Cost-effectiveness of dabigatran compared with warfarin for stroke prevention in patients with atrial fibrillation and prior stroke or transient ischemic attack.
OBJECTIVE
The cost-effectiveness of dabigatran for stroke prevention in patients with atrial fibrillation and prior stroke or transient ischemic attack has not been directly assessed.


METHODS
A Markov decision model was constructed using data from the Randomized Evaluation of Long-Term Therapy (RE-LY) trial, other trials of warfarin therapy for atrial fibrillation, and the published cost of dabigatran. We compared the cost and quality-adjusted life expectancy associated with 150 mg dabigatran twice daily versus warfarin therapy targeted to an international normalized ratio of 2 to 3. The target population was a cohort of patients aged ≥70 years with nonvalvular atrial fibrillation, prior stroke or transient ischemic attack, and no contraindication to anticoagulation.


RESULTS
In the base case, dabigatran was associated with 4.27 quality-adjusted life-years compared with 3.91 quality-adjusted life-years with warfarin. Dabigatran provided 0.36 additional quality-adjusted life-years at a cost of $9000, yielding an incremental cost-effectiveness ratio of $25,000. In sensitivity analyses, the cost-effectiveness of dabigatran was inversely related to the quality of international normalized ratio control achieved with warfarin therapy. In Monte Carlo analysis, dabigatran was cost-effective in 57% of simulations using a threshold of $50,000 per quality-adjusted life-year and 78% of simulations using a threshold of $100,000 per quality-adjusted life-year.


CONCLUSIONS
Dabigatran appears to be cost-effective relative to warfarin for stroke prevention in patients with atrial fibrillation and prior stroke or transient ischemic attack. Our analysis is limited by its reliance on data from a substudy of a single randomized trial, and our results may not apply in settings with uncommonly good international normalized ratio control using warfarin.
Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY, USA. hok9010@med.cornell.edu
Hooman
H
Kamel
S Claiborne
SC
Johnston
J Donald
JD
Easton
Anthony S
AS
Kim
D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications*; D001562:Benzimidazoles / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D000069604:Dabigatran; D016208:Databases, Factual; D004305:Dose-Response Relationship, Drug; D016527:Drug Costs; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000191:economics / Q000517:prevention & control; D002546:Ischemic Attack, Transient / Q000150:complications*; D008297:Male; D008390:Markov Chains; D015233:Models, Statistical; D009010:Monte Carlo Method; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000150:complications / Q000191:economics* / Q000517:prevention & control*; D014859:Warfarin / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
D000925:Anticoagulants; D001562:Benzimidazoles; D015091:beta-Alanine; D014859:Warfarin; D000069604:Dabigatran