Cost-Effectiveness of Apixaban Versus Other New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation

Study Questions:

How cost-effective is apixaban compared to dabigatran and rivaroxaban in patients with nonvalvular atrial fibrillation (AF)?


A Markov model was used to determine the pharmacoeconomic impact of apixaban compared with the other two novel oral anticoagulants (NOACs) in a hypothetical patient population. Indirect treatment comparison of data from the three relevant trials (ARISTOTLE: apixaban at 5 mg bid vs. warfarin; RELY: dabigatran at 110 or 150 mg bid vs. warfarin; and ROCKET-AF: rivaroxaban at 20 mg qd vs. warfarin) was performed. Direct health care costs were expressed in terms of 2011 British pounds. Incremental cost-effectiveness ratio (ICER) was determined, which was expressed with respect to quality-adjusted life-year (QALY) gained.


Initiation of treatment with apixaban as opposed to either one of the other NOACs was projected to result in fewer strokes, episodes of peripheral embolism, and cardiovascular deaths. The model also predicted fewer major bleeds in patients treated with apixaban compared with dabigatran at 150 mg and rivaroxaban, but not dabigatran at 110 mg. These benefits of apixaban led to an additional 0.18, 0.12, and 0.08 undiscounted LY, and an additional 0.10, 0.07, and 0.05 discounted QALY per patient, as compared with dabigatran at 110 mg, dabigatran at 150 mg, and rivaroxaban, respectively. The ICER was £4497, £9611, and £5305 per QALY gained, respectively (£1≈$1.6).


The authors concluded that, from a British perspective, apixaban may be a cost-effective alternative to the other NOACs.


Several studies (all indirect comparisons) have demonstrated the cost-effectiveness of each NOAC compared to warfarin. These models are limited by the somewhat different patient populations and study designs of the three pivotal trials, and assumptions that may not apply to real-world users. A prior study did suggest that apixaban might be the most effective NOAC. In the absence of a definitive trial which compares these drugs in a head-to-head fashion, it is not clear whether one is superior to another. For now, clinicians will continue to use conventional criteria in selecting one NOAC over another: side effect profile, drug-drug interactions, frequency of dosing, potential of reversibility, possible mortality benefit (for apixaban), and patient copay.

Clinical Topics: Anticoagulation Management, Novel Agents

Keywords: Stroke, Morpholines, Warfarin, Pyrazoles, Health Care Costs, Drug Interactions, Benzimidazoles, Embolism, Pyridones, Quality-Adjusted Life Years

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