Clopidogrel hydrogen sulfate, tablet, 75 mg (base), Iscover®, Plavix®, March 2009

Public summary document for Clopidogrel hydrogen sulfate, tablet, 75 mg (base), Iscover®, Plavix®, March 2009

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Public Summary Document

Product: Clopidogrel hydrogen sulfate, tablet, 75 mg (base), Iscover®, Plavix®
Sponsors: Bristol-Myers Squibb Pharmaceuticals, Sanofi-Aventis Australia Pty Ltd
Date of PBAC Consideration: March 2009

1. Purpose of Item

To allow the PBAC to consider the report reviewing the clinical and cost-effectiveness evidence available for clopidogrel’s use in preventing atherothrombotic events following coronary artery stenting, and provide advice to Government.

2. Background

At the June 1999 meeting, the PBAC recommended the listing of clopidogrel for the secondary prevention of ischaemic stroke, transient cerebral ischaemic events, myocardial infarction and unstable angina in patients with a history of cardiac ischaemic events or cerebrovascular ischaemic episodes while on therapy with low-dose aspirin. Listing was effective from 1 November 1999.

At the March 2008 meeting, the PBAC recommended extending clopidogrel’s restriction to include as an Authority Required (Streamlined) listing, the treatment of acute coronary syndromes (myocardial infarction or unstable angina) in combination with aspirin to prevent early and long-term atherothrombotic events on the basis of an acceptable cost-effectiveness ratio compared to aspirin therapy alone. Listing was effective from 1 February 2009.

The Committee noted that not all appropriate clinical use of clopidogrel may be covered by the restrictions applying to clopidogrel’s PBS listing. The use of clopidogrel following coronary artery stenting procedures was of most interest. This indication is not PBS subsidised unless the patient undergoing stenting qualifies through one of the current PBS listing restrictions, but preliminary clinical advice indicates that anti-blood clotting therapy (using both clopidogrel and aspirin) is a requirement following stenting procedures to prevent blood clots reforming later. It is likely that some patients with stents may not access PBS subsidised prescriptions, creating an inequitable arrangement whereby some patients pay the full cost of a necessary treatment whilst others do not. The PBAC requested the Department initiate a cost effectiveness review of clopidogrel with the objective of finding the best clinical place of clopidogrel as supported by evidence of efficacy, safety and cost effectiveness, and to ensure that the PBS indications reflect this use.

At the November 2008 meeting, the PBAC recommended the listing of a fixed dose combination product containing clopidogrel 75 mg with aspirin 100 mg as an Authority Required (Streamlined) item on a cost-minimisation basis compared with clopidogrel alone.

The sponsors were invited to contribute to this review, and did provide information.

3. Registration Status

From 5 August 2008, clopidogrel was TGA registered for:

  • Prevention of vascular ischaemia associated with atherothrombotic events (myocardial infarction, stroke and vascular death) in patients with a history of symptomatic atherosclerotic disease.
  • Acute Coronary Syndrome. Clopidogrel is indicated in combination with aspirin for patients with the following:

- Unstable angina or non-ST-elevation myocardial infarction in order to prevent early and long-term atherothrombotic events (myocardial infarction, stroke, vascular death or refractory ischaemia). Clopidogrel is indicated for the treatment of acute coronary syndrome whether or not patients undergo cardiac revascularisation (surgical or PCI, with or without stent);
- ST-segment elevation acute myocardial infarction in order to prevent atherothrombotic events. In this population, clopidogrel has been shown to reduce the rate of death from any cause and the rate of a combined endpoint of death, re-infarction or stroke in medically treated patients eligible for thrombolytic therapy.

4. Summary of the Review and Findings

The Clopidogrel Therapy in Current Clinical Practice report consisted of:

  • a summary of previous PBAC considerations
  • an international comparison of registration, reimbursement and clinical guidance for clopidogrel,
  • a systematic review of the clinical evidence; not previously considered by the PBAC,
  • a systematic review of the economic evidence not previously considered by the PBAC; and
  • data on the utilisation of clopidogrel in Australia.

The focus of the report was on the evidence of effectiveness and cost-effectiveness of clopidogrel in patients with stable angina undergoing stenting.

Guidelines for clinical practice for the use of clopidogrel therapy in Percutaneous Coronary Intervention (PCI)
Recommendations from national and international guidelines regarding the appropriateness and duration of clopidogrel treatment following stent insertion were reviewed as follows:

  • Australian/New Zealand guidelines, Cardiac Society of Australia and New Zealand (CSANZ)/National Heart Foundation (NHF) ACS (2006)
  • Veteran’s Medicines Advice and Therapeutic Education Services (MATES) program
  • United States, American College of Cardiology (ACC)/American Heart Association (AHA)/SCAI 2007
  • Europe, European Society of Cardiology (ESC) NSTEACS 2007

In summary, in relation to the use of clopidogrel in patients undergoing stenting all the guidelines recommend that it be used in conjunction with aspirin for 12 months or long term for those patients implanted with drug-eluting stents (DES), although new evidence is still emerging regarding the optimal duration of therapy.

Clinical Evidence for clopidogrel use in stenting
A review of the medical literature was performed to identify systematic reviews of clopidogrel as monotherapy or as dual therapy with aspirin in the intervention arm.

In one of the two reviews found, Bowry et al (2008) conducted a systematic review to clarify the role of clopidogrel and aspirin as dual-antiplatelet therapy for patients with vascular diseases. Three studies (PCI-CURE, PCI-CLARITY, and CREDO) assessed patients who underwent PCI (PCI-CURE and PCI-CLARITY were sub-studies of the CURE and CLARITY trials of dual therapy versus aspirin). The time to follow-up ranged from 28 days to 18 months. The meta-analysis showed that in patients who underwent PCI, use of clopidogrel plus aspirin significantly reduces the odds of major coronary events and fatal or non-fatal MI, compared with aspirin monotherapy.

PCI-CURE: Percutaneous Coronary Intervention-CURE (Mehta et al 2001)
PCI-CURE was a randomised double-blind trial which measured the benefit of clopidogrel plus aspirin therapy compared to aspirin monotherapy in non ST elevation myocardial infarction (NSTEMI) acute coronary syndrome (ACS) patients who underwent a PCI. A total of 2,658 patients were randomised to: clopidogrel 300 mg loading dose, followed by a 75 mg clopidogrel/day maintenance dose plus aspirin (n=1,313) versus a loading dose of placebo prior to PCI, followed by aspirin monotherapy (n=1,345). In the patients receiving clopidogrel pre-treatment, 1,080 (82%) patients received a stent compared to 1,092 (81%) in the aspirin monotherapy group. The follow-up was for a period of 12 months. The primary outcome was the composite of urgent target-vessel revascularisation, MI or vascular death within 30 days of receiving a PCI. Cardiovascular deaths or MI prior to receiving a PCI and during the follow-up period were also assessed. The safety-related outcomes were bleeding complications, which were categorised as life-threatening, major or minor.

The incidence of the combined primary outcome was significantly lower in the clopidogrel plus aspirin group (4.5%) versus the aspirin monotherapy group (6.4%), RR 0.70 (95% CI, 0.50 to 0.97); p=0.03. The relative risk for the combined endpoint of CV death and MI from the time of PCI to end of study was 0.75 (95% CI, 0.56 to 1.0); p=0.047. The overall results (events before and after PCI) for CV death and MI were RR 0.69 (95% CI, 0.54 to 0.87, p=0.002). No difference was observed between the treatment groups for major and life-threatening bleeding. A higher event rate for minor bleeding was observed in the clopidogrel group (3.5%) than for the placebo group (2.1%) at follow-up (p=0.03). The combined endpoint of cardiovascular death and myocardial infarction at follow-up in patients who received a stent was statistically significant in favour of clopidogrel, RR 0.73, (95% CI, 0.56 to 0.95).

The study authors concluded that pre-treatment with clopidogrel in addition to aspirin in patients with ACS undergoing a PCI is beneficial in reducing major ischaemic events up to 30 days after receiving a PCI.

For PBAC’s view, see Recommendation and Reasons.

PCI-CLARITY: Percutaneous Coronary Intervention-CLARITY (Sabatine et al 2005)
PCI-CLARITY was a randomised double-blind trial which assessed the benefit of clopidogrel therapy plus aspirin compared with aspirin monotherapy in patients (ST segment elevation MI) undergoing PCI in the CLARITY study. A total of 1,863 patients were randomised to: clopidogrel 300 mg loading dose prior to PCI, followed by a 75 mg/day maintenance dose plus aspirin (n=933) versus a loading dose of placebo prior to PCI, followed by aspirin monotherapy (n=930), and were followed-up for a period of 30 days. All the patients received aspirin at a dose ranging from 150 mg to 325 mg on the first day and then 75 mg to 162 mg daily thereafter. The primary efficacy outcome for patients who underwent angiography was the composite of CV death, stroke or recurrent MI. Secondary outcomes included recurrent MI or stroke before PCI and the composite of cardiovascular death, recurrent MI, or stroke during the period from randomisation up to 30 days. The safety-related outcomes were evaluated for thrombolysis in myocardial infarct (TIMI) major and minor bleeding.

The rates of the primary efficacy end point were 7.5% in the clopidogrel plus aspirin group and 12.0 % in the aspirin monotherapy group, OR 0.59 (95 % CI, 0.43 to 0.81; p=0.001). The rates for cardiovascular death or MI were 7.2 % in the clopidogrel plus aspirin group and 11% in the aspirin monotherapy group, OR 0.62 (95 % CI, 0.45 to 0.86; p=0.004). There were no significant increases in the rates of TIMI major bleeding (0.5% vs. 1.1%), TIMI minor bleeding (1.4% vs. 0.8%), or the combination (2.0% vs. 1.9%) following PCI in patients who received clopidogrel pre-treatment compared to the placebo patient group. The efficacy results for the sub-group of patients whom received a stent were not provided in the publication of the trial.

The study authors concluded that clopidogrel pre-treatment significantly reduced the incidence of cardiovascular death or ischaemic complications in STEMI patients, both before and after receiving a PCI, without significantly increasing major or minor bleeding.

CREDO: Clopidogrel for the Reduction of Events During Observation (Steinhubl 2002)
CREDO was a randomised double-blind placebo controlled trial that assessed the efficacy of clopidogrel therapy for a 12-month period. A total of 2,116 patients referred for PCI were randomised into two groups: clopidogrel 300 mg loading dose prior to PCI, followed by a 75mg/day maintenance dose plus aspirin (n=1,053) versus a loading dose of placebo prior to PCI, followed by aspirin monotherapy (n=1,063), and were followed-up for a period of 12 months. In the patient group receiving clopidogrel pre-treatment, 807 (90%) patients received a stent compared to 808 (88%) patients in the placebo arm. The primary outcome was the composite of stroke, MI or death. The other outcomes included stroke, MI or death, as separate outcomes and incidence of major bleeding.

The relative risk reduction for the primary outcome was 27% (95% CI, 3.9 to 44.4, p=0.02) and was statistically significant. Non-statistically significant differences were observed in the relative risk reduction for death 25% (95% CI, -38.9 to 59.1), MI 22% (95% CI, -7.1 to 42.7) and stroke 25% (95% CI, -77.9 to 68.4). The relative risk reduction for the primary endpoint in patients who received a stent was 28.8% (95% CI: 3.6 to 47.4) and is statistically significant (p-value not provided in publication) favouring clopidogrel. Patients treated with clopidogrel therapy for one year had non-statistically significant higher incidences of major bleeding (8.8% clopidogrel plus aspirin versus 6.7% aspirin monotherapy; p= 0.07).

The study authors concluded that following PCI, long-term (1-year) clopidogrel therapy significantly reduced the risk of adverse ischaemic events.

The CREDO trial included a different population to those in the PCI-CURE and PCI-CLARITY trials. About 33% of patients in each arm of the CREDO trial had stable angina, which is the population currently unable to access PBS subsidised clopidogrel.

For PBAC’s view, see Recommendation and Reasons.

Clopidogrel use in bare metal stents compared to drug-eluting stents
The review noted that patients in both PCI-CURE and CREDO were implanted with bare metal stents (BMS), as these studies were conducted prior to the widespread uptake of drug-eluting stents (DES). The claim for DES is that they reduce the risk of restenosis compared to BMS (evidence for this claim is beyond the scope of this report), although patients receiving either DES or BMS remain at risk of stent thrombosis.

The most recent guidelines on the duration of use of clopidogrel have recommended use for at least 12 months following implantation of DES, and recent case reports of late stent thrombosis in patients who have received DES have recommended caution in ceasing clopidogrel at all. All the literature advises that the optimal duration of clopidogrel use in DES is unknown and requires further investigation and monitoring, with some suggesting PCI patient registers as the mechanism by which to do this.

The PBAC noted in the Sponsor’s response the report from Eisenstein et al (2007) which involved a cohort study in 3165 patients with BMS and 1501 with DES. In patients who had DES and were event free at six months or at 12 months, clopidogrel use predicted a statistically significant lower death rate and death or MI rate at 24 months. However, among patients who had a BMS there were no statistical differences in death rate or MI.

The PBAC also noted the recent technology appraisal guidance from the National Institute of Clinical Excellence (NICE), Drug-eluting stents for the treatment of coronary artery disease (July 2008) which included relevant information in relation to clopidogrel therapy for patients receiving a DES.

The PBAC noted that the use of DES would have implications for the extent of increase in clopidogrel prescribing should its restriction be extended. Exact data on the ratio of DES to BMS implantation in Australia was unknown.

New evidence of factors that may adversely affect clopidogrel efficacy

The review advised of several recent retrospective studies which have linked the genetic variant CYP2C19 with a decrease in the effectiveness of clopidogrel. As the evidence is conflicting, prospective studies are being conducted, and the results will be included in updated Product Information for clopidogrel.

5. Economic Analysis

A summary of analyses of cost effectiveness of PCI/stent insertion are presented in the following table. They have generally concluded that PCI plus clopidogrel and aspirin is cost-effective. However, the cost effectiveness of clopidogrel beyond 12 months is uncertain.

Cost effectiveness in percutaneous coronary intervention (PCI)

Author Source of Clinical data Country of analysis Incremental Health Outcome(s) Incremental Cost ICER (95%CI clinical outcome)
Lindgren 2005 [42] PCI-CURE RIKS-HIA Sweden LYG: 0.04 Direct costs:
€449 € 10,993/LYG
Total costs
€332 € 8,127/LYG
Mahoney [43] (2005) PCI-CURE SASK USA All PCI patients
LYG: 0.0885 US$253 to $423 US$2,856 - US$4,775
PCI at initial hospitalisation
LYG: 0.0962 -US$181 to US$90 Dominant to US$935
Beinart [40] (2005) CREDO FRAM SASK USA & Canada Framingham
LYG: 0.1526 US$563 - US$664 US$3,684 - $4,353/LYG
LYG: 0.1920 US$563 - US$664 US$2,929 - US$3,460/LYG
Cowper [41] CREDO, DISCC, FRAM USA MI rate: -2.56% LYG: 0.056 US$896 US$34,336/MI prevented US$15,696/LYG low risk: US$26,568/LYG high risk: US$10,333/LYG
Ringborg [44] CREDO Swedish databases Sweden LYG: 0.072 QALY: 0.066 Direct:
€537 €7,492/LYG €8,184/QALY
Total costs:
€217 €3,022/ LYG €3,301/QALY

PCI-CURE: Percutaneous Coronary Intervention- Clopidogrel in Unstable angina to prevent Recurrent Events; CREDO: Clopidogrel for the Reduction of Events During Observation; LYG: Life-Years Gained; QALY: Quality-Adjusted Life Years; ICER: Incremental Cost-Effectiveness Ratio; USA: United States of America; FRAM, Framingham Heart Study; SASK: Saskatchewan Health database; DISCC: Duke Information System for Cardiovascular Care; RISK-HIA: Swedish Register of Information and Knowledge about Swedish Heart Intensive care Admissions.

For PBAC’s view, see Recommendation and Reasons.

6. Estimated PBS Usage and Financial Implications

Utilisation of clopidogrel in stenting
The review advised there was considerable uncertainty around the number of patients who do not have ACS and who are therefore not currently eligible for clopidogrel PBS subsidy but who are implanted with cardiac stents. The examination of the available utilisation data, which includes stenting data as well as clopidogrel data, particularly sought to estimate this proportion of patients. It should be noted that the ACS indication for clopidogrel prescribing was available only on 1 February 2009; therefore the available data does not yet reflect any change in clopidogrel utilisation as a result of this listing.

The PBAC noted from the Medicare Australia data provided in the report that there had been a consistent growth in dispensing since clopidogrel was first listed, although the rate of growth in dispensing is declining. Data for the period July 2004 to June 2007 from the Drug Utilisation Sub-Committee database indicated that most of the prescribing was under the PBS/RPBS for use in patients who are unable to tolerate aspirin. A relatively small number of scripts were private or below co-payment (~0.3%). Of interest is that more than 100,000 separations for cardiac stent insertion occurred over the same period.
However, the number of scripts dispensed for the pre- or post-angioplasty for RPBS patients has declined over this period, and the percentage of these scripts prescribed privately has increased from 1.1% in 2004/2005 up to 25.8% in 2007/2008.

BEACH (Bettering the Evaluation And Care of Health) utilisation data for clopidogrel were obtained for a 24 month period from April 2005 until March 2007.

In terms of health conditions associated with clopidogrel use, the BEACH data found the majority of the health conditions treated with clopidogrel (38%) were classified as ischaemic heart disease, 21% were classified as ‘other’ conditions, and all other described conditions were each less than 10% of the total. The dataset did not contain a specific category for cardiac stenting so therefore patients with stents potentially could be included in all described health conditions.

Ostini et al explored the utilisation of clopidogrel therapy in Australia, in relation to age, geographical location, gender and cardiac stenting rates and found the factors likely to have increased the supply of clopidogrel were age, male gender and living in a major city. The authors noted that these are the same demographic variables which are important predictors of cardiac stenting, and postulated that currently between one third and three quarters of the clopidogrel use is for cardiac stenting. To enhance clopidogrel utilisation, they recommended a PBS subsidy be sought for cardiac stenting and suggested that a time limit should be applied to clopidogrel therapy for this indication, based on best clinical evidence.

The Sponsors provided data from the Melbourne Interventional Group (MIG) Register, which looked at the use of clopidogrel in patients undergoing PCI in Victoria. Recently, a publication in the Medical Journal of Australia, presented related information from this Registry, and around 32% of their patients underwent stenting procedures for stable angina. They showed that when a PCI procedure is undertaken, 99.5% of all patients receive clopidogrel at baseline.

Their data also showed that patients with DES were more likely to be receiving clopidogrel than patients with BMS at both 30 days and 12 months. It was observed at the 12 month follow-up that patients still taking clopidogrel at day 30 had significantly better outcomes than patients who had ceased taking clopidogrel prior to day 30:

  • Fewer re-admissions to hospital (relative risk ratio (RRR) 16.7%, p=0.007)
  • Decreased 12 month mortality (RRR 71.7%, p<0.0001)
  • Decreased 12 month major adverse cardiac events (MACE) (RRR 28.1%, p=0.019).

Premature cessation of clopidogrel at 30 days was associated with increased hospital re-admission rates, mortality and MACE at 12 months:

  • Increased readmissions to hospital (RRR 23.0%, p=0.004)
  • Increased 12 month mortality (RRR 80.5%, p<0.0001)
  • Increased 12 month MACE (RRR 39.4%, p=0.006).

A PES addendum examining Casemix data on stenting concluded that the proportion of cardiac stenting patients who would be eligible for clopidogrel benefits under a cardiac stenting PBS restriction was potentially large, and their requirement for ongoing therapy, should DES predominate over BMS, may be long term. However, the impact on utilisation of clopidogrel as a result of extending the PBS restriction to cover cardiac stenting was uncertain.

7. Recommendation and Reasons

The PBAC recommended the listing of clopidogrel on the PBS for use following stent insertion in patients without a prior history of Acute Coronary Syndrome (ACS) in combination with aspirin. The PBAC considered that there is evidence that this is best clinical practice and noted that any increase in use is likely to be minimal following this listing. Clopidogrel is already being prescribed for at least 4 – 6 weeks in a majority of patients with stents. The PBAC expressed concern over the lack of clarity around the optimal duration of therapy and noted that further discussion with relevant experts will be needed to progress this issue.

The PBAC considered the evidence presented from the Clopidogrel Review, which had been undertaken at the PBAC’s request following the recommendation to list clopidogrel in combination with aspirin for patients with ACS at the March 2008 meeting. That decision noted that not all clinically appropriate use of clopidogrel may be subsidised by the current restrictions applying to its PBS listing, and that the use of clopidogrel following coronary artery stenting was of most interest. The PBAC observed that a coverage gap occurs in patients who have a stent inserted without a prior history of ACS. It was noted from the review that clopidogrel use is rising but at a decreasing rate, and that although stent use is high it also appears to be plateauing.

The PBAC considered the evidence presented in the CREDO trial of most relevance, as most of the participants who underwent percutaneous coronary intervention (PCI) received stents. The objectives of the trial were to compare the long-term use (one year compared with one month) of clopidogrel post- PCI. Patients were considered eligible for enrolment in the study if they had symptomatic coronary artery disease with objective evidence of ischemia. Patients were randomly assigned to receive a 300-mg clopidogrel loading dose (n=1053) or placebo (n=1063) 3 to 24 hours before PCI. Thereafter, all patients received clopidogrel, 75 mg/d, through day 28. From day 29 through 12 months, patients in the loading-dose group received clopidogrel, 75 mg/d, and those in the control group received placebo. Both groups received aspirin throughout the study. At 1 year, it showed that long term clopidogrel therapy was associated with a 26.9% relative reduction in the combined risk of death, MI, or stroke (95% confidence interval, 3.9%-44.4%; P=.02; absolute reduction, 3%), although the loading dose did not significantly reduce the combined risk of death, MI, or urgent target vessel revascularization at 28 days.

The PBAC also considered the evidence presented in the CURE trial, in which 12,562 pts with ACS were randomised to clopidogrel or placebo, both in combination with aspirin. 36% of trial participants had a percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The results at 30 days showed early effect of clopidogrel in reducing the hazard ratio, and demonstrated a 20% relative risk reduction (p= 0.00009) in first primary endpoints of myocardial infarction (MI), stroke or cardiovascular death at 12 months. The PBAC considered that CURE did not provide evidence that PCI with or without stenting is a treatment effect modifier for clopidogrel, but noted that there is no direct randomised controlled trial data to provide more certainty on this.

The PBAC noted that the systematic review of the economic evidence shows that clopidogrel plus aspirin when compared to aspirin alone has generally been interpreted as cost-effective for all patients undergoing a PCI. However there is uncertainty regarding the optimal duration of clopidogrel therapy after PCI and uncertainty regarding the effectiveness, and hence cost-effectiveness, beyond 12 months. The Committee noted that they had previously accepted the incremental cost effectiveness ratio (ICER) presented by the sponsor for the ACS listing, where the data included patients both who had and had not undergone PCI. The incremental cost per LYG was estimated to be at the lower end of the range between $15,000 and $45,000, and the incremental cost per QALY was estimated to be less than $15,000. The Committee also noted the recent guidance on Drug Eluting Stents for the treatment of coronary artery disease from the National Institute for Health and Clinical Excellence (NICE) which advised that the ICER in a cost effectiveness model submitted was highly sensitive to the duration of clopidogrel use.

The PBAC noted that mortality rates are very low in stent populations, and agreed that while the clinical trials data does not show statistical significance in mortality alone, survival trends in the literature consistently favour clopidogrel; however, the data do not provide a clear answer on the question on how long treatment should continue. The Committee agreed that evidence indicates that 6-12 months of treatment results in a better outcome than shorter treatment, and noted a very recent observational study from Kimura et al (AntiPlatelet Therapy and Stent Thrombosis after Sirolimus-Eluting Stent Implantation, Circulation 2009; 119:987-995) which looked at the influence of antiplatelet therapy discontinuation on the risk of stent thrombosis which concluded that there was no apparent clinical benefit of thienopyridine use beyond six months following sirolimus-eluting stent implantation.

The PBAC noted that the duration of clopidogrel use for patients with drug-eluting stents (DES) was of particular concern because of recent reports of late stent thrombosis, a rare but catastrophic event in DES patients who ceased clopidogrel. It was also noted that a history of ACS prior to stent implantation seems not to affect these late events.

The PBAC noted that there is considerable uncertainty in estimating the number of patients who do not have ACS or are not otherwise currently eligible for clopidogrel and who require a stent. The PBAC also accepted that the proportion of patients with stable angina, who receive a stent, may change in the future but the direction of this change is highly uncertain. However, the Committee accepted that available utilisation data suggest that currently the majority of these patients are receiving subsidised PBS clopidogrel and therefore it is likely that changing the listing to include this restriction will have only a small impact on overall PBS expenditure on clopidogrel.

Extend the listing as follows:

Authority required (STREAMLINED)
Treatment in combination with aspirin following cardiac stent insertion

Max Qty: 28
Repeats: 5

8. Context for Decision

The PBAC helps decide whether and, if so, how medicines should be subsidised in Australia. It considers submissions in this context. A PBAC decision not to recommend listing or not to recommend changing a listing does not represent a final PBAC view about the merits of the medicine. A company can resubmit to the PBAC or seek independent review of the PBAC decision.

9. Sponsor’s Comment

The Sponsors appreciated the opportunity to participate in this review and welcome the recommendation from the PBAC to allow equitable access to clopidogrel for all patients receiving a cardiac stent.