title: Cost-effectiveness of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation at high risk of bleeding and normal kidney function.
abstract: BACKGROUND
  The comparative cost-effectiveness of all oral anticoagulants approved up to date has not been evaluated from the US perspective. The objective of this study was to compare the cost-effectiveness of edoxaban 60mg, apixaban 5mg, dabigatran 150mg, dabigatran 110mg, rivaroxaban 20mg and warfarin in stroke prevention in atrial fibrillation patients at high-risk of bleeding (defined as HAS-BLED score≥3).
  
  
  METHODS
  We constructed a Markov state-transition model to evaluate lifetime costs and quality-adjusted life years (QALYs) with each of the six treatments from the perspective of US third-party payers. Probabilities of clinical events were obtained from the RE-LY, ROCKET-AF, ARISTOTLE and ENGAGE AF-TIMI trials; costs were derived from the Healthcare Cost and Utilization Project, and other studies. Because edoxaban is only indicated in patients with creatinine clearance ≤95ml/min, we re-ran our analyses after excluding edoxaban from the analysis.
  
  
  RESULTS
  Treatment with edoxaban 60mg cost $77,565/QALY gained compared to warfarin, and apixaban 5mg cost $108,631/QALY gained compared to edoxaban 60mg. When edoxaban was not included in the analysis, treatment with apixaban 5mg cost $84,128/QALY gained, compared to warfarin. Dabigatran 150mg, dabigatran 110mg and rivaroxaban 20mg were dominated strategies.
  
  
  CONCLUSIONS
  For patients with creatinine clearance between 50 and 95ml/min, apixaban 5mg was the most cost-effective treatment for willingness-to-pay thresholds (WTP) above $115,000/QALY gained, and edoxaban 60mg was cost-effective when the WTP was between $75,000 and $115,000/QALY gained. For patients with creatinine clearance >95ml/min, apixaban 5mg was the most cost-effective treatment for WTP thresholds above $80,000/QALY gained.
authors: Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 3501 Terrace St, Pittsburgh, PA 15213, United States.
authors: Inmaculada
authors: I
authors: Hernandez
authors: Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, PA, United States.
authors: Kenneth J
authors: KJ
authors: Smith
authors: Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA 15261, United States. Electronic address: ytzhang@pitt.edu.
authors: Yuting
authors: Y
authors: Zhang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications* / Q000191:economics; D003362:Cost-Benefit Analysis; D000069604:Dabigatran / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008390:Markov Chains; D011720:Pyrazoles / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D011725:Pyridines / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D011728:Pyridones / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D000069552:Rivaroxaban / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D020521:Stroke / Q000191:economics / Q000517:prevention & control*; D013844:Thiazoles / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D014859:Warfarin / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D011720:Pyrazoles; D011725:Pyridines; D011728:Pyridones; D013844:Thiazoles; C522181:apixaban; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran; C552171:edoxaban
keywords: Anticoagulation; Atrial fibrillation; Cost-effectiveness; Non-vitamin K antagonist oral anticoagulants