1. Myocardial infarction

You attend an emergency call to the home of Robert, a 63 yearold male with a documented history of compensated congestive heartfailure (CHF), who you diagnose is currently suffering a myocardialinfarction. You prepare to administer GTN to Robert in the form ofa sublingual spray. GTN is a potent vasodilator that works by(Choose...increasing guanylate cyclase mediated degradationof cGMP, decreasing guanylate cyclase mediated production of cGMP,decreasing guanylate cyclase mediated degradation of cGMP,increasing guanylate cyclase mediated production of cGMP)in vascular endothelial smooth muscle. Prior to administering GTN,you ensure Robert has (Choose...an adequate systolic bloodpressure, a palpable JVP, an adequate diastolic blood pressure, ashockable heart rhythm) and ask if he has taken anyerectile dysfunction medication in the last 24hrs, to which Robertresponds “the only medication he has taken in the last 24hrs is hisregular Aspalgin”. On this basis you (Choose...administerdouble the dose of GTN to Robert, administer GTN and monitorRoberts haemodynamics, do not administer GTN to Robert, administerGTN and monitor Roberts respiratory rate) because(Choose...Aspalgin is a phosphdiesterase 5 inhibitor,Aspalgin will inhibit the metabolic activation of GTN, GTN willreduce Roberts blood pressure, GTN will reduce Roberts respiratorydrive) , which may cause Robert to(Choose...retain CO2 leading to respiratory failure,experience a drug interaction resulting in therapeutic failure ofGTN, become hemodynamically unstable and decompensate, experience adrug interaction resulting in uncontrolled hypotension).

2. Calculation

Following a short stay in hospital, Robert is discharged with anumber of new medications including an anti-platelet drug calledprasugrel. It is common to use dual anti-platelet therapy for atleast 6 months following a myocardial infarction in order to reducethe risk of a second myocardial infarction. For many years acombination of aspirin and clopidogrel has been used for thispurpose. However, the use of a newer anti-platelet drug prasugrelin place of clopidogrel is now being considered.

Over 12 months, it is expected that prasugrel will cost $670more per person treated than clopidogrel. It is estimated that ifprasugrel is used a person will have 13.325 QALYs on average,whereas if clopidogrel is used a person will have 13.300 QALYs onaverage. QALYs are a measure of life expectancy that has beenadjusted for quality of life.

What is the incremental cost-effectiveness ratio of prasugrel?(i.e. cost per QALY)

3. Short Answer

Ipilimumab is a new targeted therapy for metastatic melanoma andis also being considered for addition to Robert's hospital'sformulary. It has been estimated that the incrementalcost-effectiveness of ipilimumab is $100,000 per QALY.

If there is only enough funding to add either prasugrel oripilimumab to the formulary, which would you choose solely on thebasis of cost-effectiveness? Explain your reasoning (maximum of 100words).