Abstract
BackgroundApixaban was shown to be superior to adjusted-dose warfarin in preventing stroke or systemic embolism in patients with atrial fibrillation (AF) and at least one additional risk factor for stroke, and associated with reduced rates of hemorrhage. We sought to determine the cost-effectiveness of using apixaban for stroke prevention.MethodsBased on the results from the Apixaban Versus Warfarin in Patients with Atrial Fibrillation (ARISTOTLE) trial and other published studies, we constructed a Markov model to evaluate the cost-effectiveness of apixaban versus warfarin from the Medicare perspective. The base-case analysis assumed a cohort of 65-year-old patients with a CHADS2 score of 2.1 and no contraindication to oral anticoagulation. We utilized a 2-week cycle length and a lifetime time horizon. Outcome measures included costs in 2012 US$, quality-adjusted life-years (QALYs), life years saved and incremental cost-effectiveness ratios.ResultsUnder base case conditions, quality adjusted life expectancy was 10.69 and 11.16 years for warfarin and apixaban, respectively. Total costs were $94,941 for warfarin and $86,007 for apixaban, demonstrating apixaban to be a dominant economic strategy. Upon one-way sensitivity analysis, these results were sensitive to variability in the drug cost of apixaban and various intracranial hemorrhage related variables. In Monte Carlo simulation, apixaban was a dominant strategy in 57% of 10,000 simulations and cost-effective in 98% at a willingness-to-pay threshold of $50,000 per QALY.ConclusionsIn patients with AF and at least one additional risk factor for stroke and a baseline risk of ICH risk of about 0.8%, treatment with apixaban may be a cost-effective alternative to warfarin.
Highlights
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States (US), affecting about 2.7 million people [1]
Based upon the results of ARISTOTLE, apixaban 5 mg twice daily is currently recommended as ‘‘a relatively safe and efficacious alternative to warfarin in patients with nonvalvular atrial fibrillation (AF) deemed appropriate for vitamin K antagonist therapy who have at least 1 additional risk factor and no more than 1 of the following characteristics: Age .80 years, weight,60 kg, or serum creatinine .1.5 mg/dL
While assessing the cost of a new therapy based purely on its acquisition costs may provide some insight, the costs or savings associated with such therapies often extend far beyond these baseline figures, especially considering anticoagulation therapy is warranted for a lifetime in patients with AF
Summary
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States (US), affecting about 2.7 million people [1]. Warfarin has been shown to prevent up to 64% of strokes in patients AF; despite recommendations for its use by consensus guidelines (Class I; Level of Evidence A) [2], warfarin is prescribed in only about half of eligible AF patients [3]. The Apixaban versus Warfarin in Patients with Atrial Fibrillation (ARISTOTLE) trial compared apixaban with adjusted-dose warfarin for the prevention of stroke or systemic embolism in patients with AF and at least one additional risk factor for stroke. Apixaban was shown to be superior to adjusted-dose warfarin in preventing stroke or systemic embolism in patients with atrial fibrillation (AF) and at least one additional risk factor for stroke, and associated with reduced rates of hemorrhage. We sought to determine the cost-effectiveness of using apixaban for stroke prevention
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