Cost-effectiveness of ticagrelor and generic clopidogrel in patients with acute coronary syndrome in Switzerland

QUESTION UNDER STUDY The aim of this study was to evaluate the cost-effectiveness of ticagrelor and generic clopidogrel as add-on therapy to acetylsalicylic acid (ASA) in patients with acute coronary syndrome (ACS), from a Swiss perspective. METHODS Based on the PLATelet inhibition and patient Outcomes (PLATO) trial, one-year mean healthcare costs per patient treated with ticagrelor or generic clopidogrel were analysed from a payer perspective in 2011. A two-part decision-analytic model estimated treatment costs, quality-adjusted life years (QALYs), life years and the cost-effectiveness of ticagrelor and generic clopidogrel in patients with ACS up to a lifetime at a discount of 2.5% per annum. Sensitivity analyses were performed. RESULTS Over a patient's lifetime, treatment with ticagrelor generates an additional 0.1694 QALYs and 0.1999 life years at a cost of CHF 260 compared with generic clopidogrel. This results in an Incremental Cost Effectiveness Ratio (ICER) of CHF 1,536 per QALY and CHF 1,301 per life year gained. Ticagrelor dominated generic clopidogrel over the five-year and one-year periods with treatment generating cost savings of CHF 224 and 372 while gaining 0.0461 and 0.0051 QALYs and moreover 0.0517 and 0.0062 life years, respectively. Univariate sensitivity analyses confirmed the dominant position of ticagrelor in the first five years and probabilistic sensitivity analyses showed a high probability of cost-effectiveness over a lifetime. CONCLUSION During the first five years after ACS, treatment with ticagrelor dominates generic clopidogrel in Switzerland. Over a patient's lifetime, ticagrelor is highly cost-effective compared with generic clopidogrel, proven by ICERs significantly below commonly accepted willingness-to-pay thresholds.

Newton’s Metaphysics of Space as God’s Emanative Effect

In several of his writings, Isaac Newton proposed that physical space is God’s “emanative effect” or “sensorium,” revealing something interesting about the metaphysics underlying his mathematical physics. Newton’s conjectures depart from Plato and Aristotle’s metaphysics of space and from classical and Cambridge Neoplatonism. Present-day philosophical concepts of supervenience clarify Newton’s ideas about space and offer a portrait of Newton not only as a mathematical physicist but an independent-minded rationalist philosopher.

Socrates on the Moral Mischief of Misology

In Plato’s dialogues, the Phaedo, Laches, and Republic, Socrates warns his interlocutors about the dangers of misology. Misology is explained by analogy with misanthropy, not as the hatred of other human beings, but as the hatred of the logos or reasonable discourse. According to Socrates, misology arises when a person alternates between believing an argument to be correct, and then refuting it as false. If Socrates is right, then misanthropy is sometimes instilled when a person goes from trusting people to learning that others sometimes betray our reliance and expectations, and finally not to placing any confidence whatsoever in other people, or, in the case of misology, in the correctness or trustworthiness of arguments. A cynical indifference to the soundness of arguments generally is sometimes associated with Socrates’ polemical targets, the Sophists, at least as Plato represents Socrates’ reaction to these itinerant teachers of rhetoric, public speaking and the fashioning of arguments suitable to any occasion. Socrates’ injunctions against misology are largely moral, pronouncing it ‘shameful’ and ‘very wicked’, and something that without further justification we must ‘guard against’, maintaining that we will be less excellent persons if we come to despise argument as lacking the potential of leading to the truth. I examine Socrates’ moral objections to misology which I show to be inconclusive. I consider instead the problem of logical coherence in the motivations supposedly underlying misology, and conclude that misology as Socrates intends the concept is an emotional reaction to argumentation on the part of persons who have not acquired the logical dialectical skills or will to sort out good from bad arguments. We cannot dismiss argument as directed toward the truth unless we have a strong reason for doing so, and any such argument must itself presuppose that at least some reasoning can be justified in discovering and justifying belief in interesting truths. The relevant passages from Socrates’ discussion of the soul’s immortality in the Phaedo are discussed in detail, and set in scholarly background against Socrates’ philosophy more generally, as represented by Plato’s dialogues. I conclude by offering a suggestive list of practical remedies to avoid the alienation from argument in dialectic with which Socrates is concerned.