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

Introduction: 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 60 mg, apixaban 5 mg, dabigatran 150 mg, dabigatran 110 mg, rivaroxaban 20 mgandwarfarin in stroke prevention in atrial fibrillation patients at high-risk of bleeding (defined as HAS-BLED score >= 3). Materials andmethods: Weconstructed aMarkov state-transitionmodel 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 = 95 ml/min, we re-ran our analyses after excluding edoxaban from the analysis. Results: Treatment with edoxaban 60 mg cost $ 77,565/QALY gained compared to warfarin, and apixaban 5 mg cost $ 108,631/QALY gained compared to edoxaban 60 mg. When edoxaban was not included in the analysis, treatment with apixaban 5 mg cost $ 84,128/QALY gained, compared to warfarin. Dabigatran 150 mg, dabigatran 110 mg and rivaroxaban 20 mg were dominated strategies. Conclusions: For patientswith creatinine clearance between 50 and 95 ml/min, apixaban 5 mgwas themost costeffective treatment for willingness-to-pay thresholds (WTP) above $ 115,000/QALY gained, and edoxaban 60 mg was cost-effective when the WTP was between $ 75,000 and $ 115,000/QALY gained. For patients with creatinine clearance N95 ml/min, apixaban 5 mg was the most cost-effective treatment forWTP thresholds above $ 80,000/QALY gained. (C) 2016 Elsevier Ltd. All rights reserved.