report, the concern for cost inflation fueled by personalized medicine seems justi-
fied. This has already been acknowledged. For instance, the UK NICE Diagnostics
Assessment Programme explicitly states that its purpose is to “evaluate diagnostic
technologies that have the potential to improve health outcomes but whose intro-
duction is likely to be associated with an overall increase in cost to the NHS.”^30
However, companion diagnostic technology is proving very useful, not only in
improving health outcomes but also in reducing health care costs.
For instance, a cost-effectiveness study of a companion diagnostic recently
demonstrated that genetically guided personalized medicine, traditionally consid-
ered as more expensive than traditional medical approaches, can both increase the
effectiveness of interventions and reduce their costs, hence improving the outcome
of treatment and optimizing health care resource allocation. A study by Kazi
et al. ( 2014 ) explored the most cost-effective approach for dual antiplatelet therapy
following a percutaneous coronary intervention for the acute coronary syndrome
(ACS). The study showed that personalizing treatments based on genotype infor-
mation might be very cost-effective in some settings. In particular, the study
showed that the standard antiplatelet therapy prescribed in patients recovering
from ACS should be seriously reconsidered. Following the percutaneous coronary
intervention for ACS, most patients are traditionally prescribed aspirin in combi-
nation with clopidogrel to prevent blood clotting. However, the effectiveness of
clopidogrel in preventing clotting and the recurrent cardiovascular problems
depends on the characteristics of treatment recipients and hence varies considerably
within the patient population. One cause of this variability is a genetic variation
carried by approximately 28 % of the population, known as loss-of-function
CYP2C19 alleles, which is necessary for the bioactivation of clopidogrel. Patients
with the genetic variation treated with clopidogrel experience higher rates of
cardiovascular events following ACS than patients with normal CYP2C19 function,
including myocardial infarction and stroke. Two newer drugs, prasugrel and
ticagrelor, prevent clotting more reliably than clopidogrel in most patients, but
they are considerably more expensive and can have troublesome side effects. For
instance, prasugrel can cause severe (even fatal) bleeding in some patients, and
ticagrelor can cause uncomfortable shortness of breath. The need for combining a
large amount of information on effectiveness, costs, side effects, and genetic factors
hindered on physicians’ability to decide on the right treatment for each patient,
particularly since neither the benefit of genetic testing for CYP2C19 variants nor
the relative advantages of prasugrel versus ticagrelor have been tested in random-
ized clinical trials. In their research, Kazi and colleagues showed that genotyping
for the loss-of-function CYP2C19 allele before prescribing either prasugrel or
ticagrelor would be more cost-effective than treating all patients with either of
the three drugs and that genotype-guided individual approach to treatment may
improve the cost-effectiveness of prasugrel and ticagrelor, although ticagrelor for
all patients may also be an economically reasonable alternative in some settings.
(^30) NICE DAP ( 2011 ), p. 8.
120 A. Bobinac and M. Vehovec