Use and costs of P2Y12 inhibitors after myocardial infarction in germany and the US

Background Dual antiplatelet therapy is a cornerstone of secondary prevention after acute myocardial infarction. In randomized trials, the potent P2Y12 inhibitors ticagrelor and prasugrel reduced ischemic events compared with clopidogrel. However, ticagrelor’s clinical advantage over clopidogrel has been debated, and head-to-head comparisons suggest that prasugrel is noninferior and potentially superior to ticagrelor. Contemporary patterns of P2Y12 inhibitor use and associated treatment costs across countries are not well characterized. Purpose To describe temporal trends in P2Y12 inhibitor use and associated treatment costs in Germany and the United States from 2011 through 2024. Methods Cohort study using longitudinal, nationwide health care claims data from Germany and the US. Country-specific cohorts included adults aged 18 years or older who newly initiated P2Y12 inhibitor therapy within 30 days after hospitalization for acute myocardial infarction. Annual proportions of patients initiating clopidogrel, ticagrelor, or prasugrel and absolute changes over time were assessed. 12-month treatment costs were estimated using net price estimates accounting for average manufacturer rebates, and potential savings associated with substitution of lower-cost alternatives were calculated. Results From 2011 to 2024, the proportion of patients initiating clopidogrel after acute myocardial infarction decreased by 39% in Germany and 13% in the US. Ticagrelor use increased through 2018 (+41% in Germany; +40% in the US), coinciding with guideline recommendations favoring potent P2Y12 inhibitors (Europe, 2011; US, 2014). After results of the ISAR-REACT 5 randomized trial in 2019 showed lower ischemic event rates with prasugrel than with ticagrelor, and subsequent European guideline updates favored prasugrel, use of prasugrel in Germany increased by 18%, without an observed increase in major adverse cardiovascular events. In contrast, uptake in the US remained limited, with continued predominant use of ticagrelor. Following generic entry of prasugrel in the US in 2017, the 12-month treatment cost declined from $4,518 to $115, whereas ticagrelor costs remained largely unchanged at $2,843. If patients had initiated prasugrel instead of ticagrelor from Q4 2019 through 2024, estimated drug spending would have been up to $3 billion lower in the US. Conclusions Despite similar patient populations, prescribing patterns diverged between Germany and the United States. Earlier and greater adoption of prasugrel in Germany after 2019 contrasted with continued predominant use of ticagrelor in the US after randomized trials suggested prasugrel’s superiority over ticagrelor. Greater uptake of prasugrel in the US may have reduced drug spending without compromising post-myocardial infarction care.