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Comparing the Cost Effectiveness of Non-vitamin K Antagonist Oral Anticoagulants with Well-Managed Warfarin for Stroke Prevention in Atrial Fibrillation Patients at High Risk of Bleeding

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Abstract

Background

Several studies have compared the cost effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin using results from clinical trials evaluating NOACs. However, the time in therapeutic range (TTR) of warfarin groups ranged across clinical trials, and all were below the therapeutic goal of 70%. We compared the cost effectiveness of edoxaban 60 mg, apixaban 5 mg, dabigatran 150 mg, dabigatran 110 mg, rivaroxaban 20 mg, and well-managed warfarin with a TTR of 70% in preventing stroke among patients with atrial fibrillation at high risk of bleeding.

Methods

For the six treatments, we used a Markov state-transition model to quantify lifetime costs in $US and effectiveness in quality-adjusted life-years (QALYs). We simulated relative risk ratios of clinical events with each NOAC versus warfarin with a TTR of 70% using published regression models that predict how the incidence of thrombotic or hemorrhagic events changes for each unit change in TTR. We re-ran our analysis for two other estimates of TTR: 65 and 75%.

Results

Treatment with edoxaban 60 mg cost $US127,520/QALY gained compared with warfarin with a TTR of 70% and cost $US41,860/QALY gained compared with warfarin with a TTR of 65%. However, warfarin with a TTR of 75% was more effective and less expensive than all NOACs. For three levels of TTR, apixaban 5 mg, dabigatran 150 mg, dabigatran 110 mg, and rivaroxaban 20 mg were dominated strategies.

Conclusions

The comparative cost effectiveness of edoxaban and warfarin is highly sensitive to TTR. At the $US100,000/QALY willingness-to-pay threshold, our results suggest that warfarin is the most cost-effective treatment for patients who can achieve a TTR of 70%.

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Fig. 1

Reproduced from Hernandez et al. [7] with permission

Fig. 2
Fig. 3

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Authors and Affiliations

  1. Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 3501 Terrace St, Pittsburgh, PA, 15261, USA

    Alexa R. Hospodar & Inmaculada Hernandez

  2. Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA, 15261, USA

    Yuting Zhang

  3. Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    Kenneth J. Smith

Authors
  1. Alexa R. Hospodar
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Correspondence to Inmaculada Hernandez.

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Conflicts of interest

Alexa R. Hospodar, Kenneth J. Smith, Yuting Zhang, and Inmaculada Hernandez have no conflicts of interest that are directly relevant to the content of this manuscript.

Funding

No sources of funding were used to conduct this study or prepare this manuscript.

Prior Postings

The authors presented this study in the Academy of Managed Care Specialty Pharmacy Annual Meeting 2017, Denver, CO, USA, on March 28, 2017.

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Hospodar, A.R., Smith, K.J., Zhang, Y. et al. Comparing the Cost Effectiveness of Non-vitamin K Antagonist Oral Anticoagulants with Well-Managed Warfarin for Stroke Prevention in Atrial Fibrillation Patients at High Risk of Bleeding. Am J Cardiovasc Drugs 18, 317–325 (2018). https://doi.org/10.1007/s40256-018-0279-y

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