Routine use of the drug, called clopidogrel, either with aspirin or by itself would prevent 400,000 second heart attacks and prolong hundreds of thousands of lives over a 25-year period compared with aspirin alone. But the price is steep: On a daily basis, clopidogrel is 80 times as expensive as aspirin.
Clopidogrel is sold as Plavix by Sanofi-Synthelabo and as Iscover by Bristol-Myers Squibb. The drug prevents blood cells called platelets from sticking together and encouraging clots.The authors of a new study consider the routine use of clopidogrel "unattractive" at its current price. At about $3.22 a day, the researchers said, clopidogrel is only cost-effective for people at very high risk of second heart attacks and strokes and in the nearly 6 percent of people who can't take aspirin. The price of aspirin is four cents a day, the study says.
On the other hand, if the price of the drug were slashed to $1 a day or even 60 cents a day, its appeal would grow significantly, concluded the study, which appears in tomorrow's New England Journal of Medicine.
"If you have to pay for the medications out of pocket, it would be appropriate for a doctor to say to someone, 'Here's what you're buying,'" said Dr. Lee Goldman, chairman of the department of medicine at the University of California, San Francisco and a co-author of the study. "In all sorts of arenas people make these sorts of choices."
Goldman said clopidogrel's cost-benefit profile compares unfavorably to every other heart therapy, from drugs like ACE inhibitors and beta-blockers to bypass surgery. And it's between two and three times more expensive on a year-of-life-gained basis than kidney dialysis, which some experts consider a benchmark therapy for such analyses.
"We're not saying you shouldn't use it. We're saying it's unattractive," Goldman said. "If we ignore these cost issues, then there will be no pressure in the system for [companies] to compete on a price basis. In every other part of our lives in a capitalist society, price is one thing we consider."
Goldman conducted the study with colleagues in Europe and the United States. They ran computer simulations to determine the benefits and costs of aspirin and clopidogrel in every American 35 or older with coronary heart disease who would take the pills between 2003 and 2027.
Dr. Paul Heidenreich, a Stanford University cardiologist and an expert in cost-benefit analyses, said the study will be more relevant to policy makers in government and the health insurance industry than it is to patients, for whom the idea of saving society money is cast aside by their desire to get the best possible care.
"The individual patient rarely sees the full cost of their medical care. Through work, taxes, or other mechanisms, most of our health care is subsidized," Heidenreich said. "As patients, we're not that interested in the cost because someone else is paying for it."
But in the long run that indifference, however understandable, will lead to shortages in other areas of health care which society won't be able to afford, Heidenreich added.
Dr. Charles Davidson, a Northwestern University physician, said knowing the high cost of clopidogrel relative to aspirin should prompt doctors to raise the issue with their patients. "I think they'd have to advise their patients that there are therapies" that cost less and that may have fewer or different side effects, he said.
However, not all experts agreed with the conclusions of Goldman's group. In an editorial accompanying the journal article, Dr. Alastair J.J. Wood of Vanderbilt University School of Medicine wrote that the study's implications were "deeply troubling."
Giving up on new therapies solely because they cost more than older treatments would be an "enormous disservice to our patients" that would put health care in a category unique among other consumer items like cars, stereos and computers, he wrote.
"Surely the search for better drug therapy is at least as important as the search for improved audio performance?" he added.
"The question for all of us," Wood wrote, "is what to do with this information -- these additional years look good to me if they are mine, but others may think the price is too high."
What To Do
For more on the economics of health care, try the Agency for Healthcare Research and Quality.