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Aspirin with Low-Dose Ticagrelor or with Low-Dose Rivaroxaban for Secondary Prevention: A Cost per Outcome Analysis

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Abstract

Introduction

Secondary prevention of cardiovascular events among patients with diagnosed cardiovascular disease and high ischemic risk poses a significant challenge in clinical practice. The combinations of aspirin with low-dose (LD) ticagrelor or LD rivaroxaban have shown superiority in preventing major adverse cardiovascular events (MACE) compared with aspirin treatment alone. The comparative value for money of these two regimens remains unexplored.

Methods

We analyzed each regimen's annual cost needed to treat (CNT) by multiplying the annualized number needed to treat (aNNT) by the annual cost of each drug. The aNNTs were based on outcome data from PEGASUS TIMI-54 and COMPASS trials. Scenario analyses were performed to overcome variances in terms of population risk. Costs were calculated as 75% of US National Average Drug Acquisition Cost (NADAC), extracted in January 2022. The primary outcome was defined as CNT to prevent one MACE across the two regimens. Secondary value analysis was performed for myocardial infarction (MI), stroke, and cardiovascular death as separate outcomes.

Results

The aNNTs to prevent MACE with LD ticagrelor and with LD rivaroxaban were 229 [95% confidence interval (CI) 141–734] and 147 (95% CI 104–252), respectively. At an annual cost of US$3726 versus US$4533, the corresponding CNTs were US$853,254 (95% CI 525,366–2,734,884) with LD ticagrelor and US$666,351 (95% CI 471,432–1,142,316) with LD rivaroxaban.

Conclusion

Combining aspirin with LD rivaroxaban provides better value for money than with LD ticagrelor for secondary prevention of MACE.

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Author notes

  1. Gal Tsaban and Hilmi Alnsasra contributed equally to the manuscript.

Authors and Affiliations

  1. Division of Cardiology, Soroka University Medical Center, PO Box 653, 84105, Beer-Sheva, Israel

    Gal Tsaban, Hilmi Alnsasra, Aref El Nasasra, Amjad Abu-Salman, Ala Abu-Dogosh, Itay Weissberg, Yael Ben-Baruch Golan, Orit Barrett & Roi Westreich

  2. Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel

    Gal Tsaban, Hilmi Alnsasra, Aref El Nasasra, Amjad Abu-Salman, Ala Abu-Dogosh, Itay Weissberg, Yael Ben-Baruch Golan, Orit Barrett & Roi Westreich

  3. Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel

    Enis Aboalhasan & Ronen Arbel

  4. Diabetes Clinic, Central District, Maccabi Healthcare Services, Tel Aviv, Israel

    Joseph Azuri

  5. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

    Joseph Azuri

  6. Department of Pharmaceutical Technology Assessment, Clalit Health Services Headquarters, Tel Aviv, Israel

    Ariel Hammerman

  7. Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel

    Ronen Arbel

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  1. Gal Tsaban
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Corresponding author

Correspondence to Gal Tsaban.

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Funding

This work has not been funded by external grants.

Competing interests

Gal Tsaban, Hilmi Alnsasra, Aref El Nasasra, Amjad Abu-Salman, Ala Abu-Dogosh, Itay Weissberg, Yael Ben-Baruch Golan, Orit Barrett, Roi Westreich, Enis Aboalhasan, Joseph Azuri, Ariel Hammerman, and Ronen Arbel declare no competing interest related to this work or any relevant conflicts of interest.

Author contributions

GT, HA, and RA conceived the study and analysis. Material preparation and data collection were performed by GT HA, AEN, AAS, and EA. Statistical analysis was performed by EA and was reviewed by AH and JA. The first draft of the manuscript was written by GT, HA, and RA. All authors critically reviewed the manuscript. All authors read and approved the final manuscript.

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Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Tsaban, G., Alnsasra, H., El Nasasra, A. et al. Aspirin with Low-Dose Ticagrelor or with Low-Dose Rivaroxaban for Secondary Prevention: A Cost per Outcome Analysis. Am J Cardiovasc Drugs 22, 677–683 (2022). https://doi.org/10.1007/s40256-022-00543-8

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