title: Is dabigatran cost effective compared with warfarin for stroke prevention in atrial fibrillation? A critically appraised topic.
abstract: BACKGROUND
  Warfarin has provided protection against cardioembolic stroke in the setting of nonvalvular atrial fibrillation (NVAF) for the past 60 years. Dabigatran, the first oral direct thrombin inhibitor to be approved in the United States, promises to provide the same or better stroke protection with reduced risk of intracranial hemorrhage. However, it remains to be seen whether grand-scale adoption of dabigatran will be cost effective.
  
  
  OBJECTIVE
  To critically assess current evidence regarding the cost effectiveness of dabigatran for preventing stroke in patients with NVAF compared with warfarin.
  
  
  METHODS
  The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular neurology.
  
  
  RESULTS
  A cost-effectiveness analysis (CEA) that followed a hypothetical cohort of NVAF patients 65 years of age or older and CHADS2≥1 over their lifetime comparing dabigatran with adjusted-dose warfarin was reviewed. Assuming a willingness to pay a threshold of $50,000 per quality-adjusted life year (QALY), base case results favored high-dose (150 mg bid) dabigatran as a cost-effective alternative to warfarin. Sensitivity analysis asserted that the cost effectiveness of dabigatran improved if it could be obtained for ≤$13/d or if it was used in populations with high risk of stroke or intracranial hemorrhage.
  
  
  CONCLUSIONS
  Dabigatran 150 mg bid ($12,286 per QALY) is a cost-effective alternative to International Normalized Ratio-adjusted warfarin for the prevention of ischemic stroke in patients 65 years of age or older with NVAF.
authors.affiliation: Department of Neurology, Mayo Clinic, Phoenix, Arizona 85054, USA.
authors.forename: Amelia K
authors.initials: AK
authors.lastname: Adcock
authors.forename: Joyce K
authors.initials: JK
authors.lastname: Lee-Iannotti
authors.forename: Maria I
authors.initials: MI
authors.lastname: Aguilar
authors.forename: Charlene R
authors.initials: CR
authors.lastname: Hoffman-Snyder
authors.forename: Dean M
authors.initials: DM
authors.lastname: Wingerchuk
authors.forename: Kay E
authors.initials: KE
authors.lastname: Wellik
authors.forename: Bart M
authors.initials: BM
authors.lastname: Demaerschalk
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications* / Q000191:economics; D001562:Benzimidazoles / Q000191:economics* / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis / Q000639:trends; D000069604:Dabigatran; D016527:Drug Costs / Q000639:trends*; D006801:Humans; D008297:Male; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology* / Q000517:prevention & control; D014859:Warfarin / Q000191:economics* / Q000627:therapeutic use*; D015091:beta-Alanine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D015091:beta-Alanine; D014859:Warfarin; D000069604:Dabigatran