title: Cost-effectiveness of apixaban, dabigatran, rivaroxaban, and warfarin for stroke prevention in atrial fibrillation.
abstract: OBJECTIVE
  To estimate the cost-effectiveness of stroke prevention in patients with nonvalvular atrial fibrillation by using novel oral anticoagulants apixaban 5 mg, dabigatran 150 mg, and rivaroxaban 20 mg compared with warfarin.
  
  
  METHODS
  A Markov decision-analysis model was constructed using data from clinical trials to evaluate lifetime costs and quality-adjusted life-years of novel oral anticoagulants compared with warfarin. The modeled population was a hypothetical cohort of 70-year-old patients with nonvalvular atrial fibrillation, increased risk for stroke (CHADS2 ≥ 1), renal creatinine clearance ≥ 50 mL/min, and no previous contraindications to anticoagulation. The willingness-to-pay threshold was $50 000/quality-adjusted life-years gained.
  
  
  RESULTS
  In the base case, warfarin had the lowest cost of $77 813 (SD, $2223), followed by rivaroxaban 20 mg ($78 738 ± $1852), dabigatran 150 mg ($82 719 ± $1959), and apixaban 5 mg ($85 326 ± $1512). Apixaban 5 mg had the highest quality-adjusted life-years estimate at 8.47 (SD, 0.06), followed by dabigatran 150 mg (8.41 ± 0.07), rivaroxaban 20 mg (8.26 ± 0.06), and warfarin (7.97 ± 0.04). In a Monte Carlo probabilistic sensitivity analysis, apixaban 5 mg, dabigatran 150 mg, rivaroxaban 20 mg, and warfarin were cost-effective in 45.1%, 40%, 14.9%, 0% of the simulations, respectively.
  
  
  CONCLUSIONS
  In patients with nonvalvular atrial fibrillation and an increased risk of stroke prophylaxis, apixaban 5 mg, dabigatran 150 mg, and rivaroxaban 20 mg were all cost-effective alternatives to warfarin. The cost-effectiveness of novel oral anticoagulantss was dependent on therapy pricing in the United States and neurological events associated with rivaroxaban 20 mg.
authors.affiliation: Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ 85721-0202, USA.
authors.forename: Amanda R
authors.initials: AR
authors.lastname: Harrington
authors.forename: Edward P
authors.initials: EP
authors.lastname: Armstrong
authors.forename: Paul E
authors.initials: PE
authors.lastname: Nolan
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Malone
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications*; D001562:Benzimidazoles / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D000069604:Dabigatran; D004305:Dose-Response Relationship, Drug; D006801:Humans; D008390:Markov Chains; D015233:Models, Statistical; D009025:Morpholines / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use; D011720:Pyrazoles / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use; D011728:Pyridones / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D000069552:Rivaroxaban; D020521:Stroke / Q000453:epidemiology* / Q000517:prevention & control*; D013876:Thiophenes / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use; D014481:United States; D014859:Warfarin / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use; D015091:beta-Alanine / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D009025:Morpholines; D011720:Pyrazoles; D011728:Pyridones; D013876:Thiophenes; D015091:beta-Alanine; C522181:apixaban; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran
keywords: Markov model; anticoagulation; atrial fibrillation; cost-effectiveness; intracranial hemorrhage; stroke