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Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage

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Abstract

Andexanet-alpha is a specific reversal agent for direct factor Xa inhibitors (dFXaI). We aimed to project utilization rates and cost of andexanet for reversal of dFXaI-related major hemorrhage compared to 4-factor prothrombin complex concentrates (4F-PCC). A retrospective, multicenter review was conducted between 1/1/2014 and 7/15/2018 of patients who received 4F-PCC for reversal of dFXaI-related life-threatening hemorrhages. Total hospital reimbursements/patient were calculated based on national average MS-DRG payments adjusting for Medicare discounts. The projected cost for andexanet (based on dose and insurance) and % reimbursement/patient was compared to the actual cost of 4F-PCC. Hemostasis at 24 h (excellent/good vs. poor) and 30-day thrombotic complications were assessed. Of 126 patients who received 4F-PCC to reverse dFXaI, 46 (~ 10 per-year) met inclusion criteria. The median projected cost of andexanet was $22,120/patient, compared to $5670/patient for 4F-PCC (P < 0.001). The median hospital reimbursement was $11,492/hospitalization. The projected cost of andexanet alone would exceed the entire hospital reimbursement in 74% of patients by a median of $7604, while 4F-PCC cost exceeded the total hospital payments in 7% of patients in the same cohort (P < 0.001). Hemostasis was excellent/good in 72% of patients post-4F-PCC, compared to 82% in andexanet trials. Thromboembolic events occurred in 4% of patients following 4F-PCC versus 10% in andexanet trials. The projected cost of andexanet would exceed the national average hospital reimbursement/patient in nearly 75% of patients by over $7500/hospitalization. 4F-PCC was significantly less expensive, had lower rates of thrombosis, but also lower rates of good/excellent hemostasis compared to published data for andexanet.

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Acknowledgements

This study was approved by the NYU Langone Hospitals IRB.

Author information

J.A.F, T.A., J.P., S.Y. and D.J. contributed to study concept and design. J.A.F., P.B., R.L. and D.J. contributed to data acquisition and analysis. J.A.F reviewed and finalized the statistical analysis. J.A.F. and D.J. prepared the first draft of the manuscript. J.A.F, P.B., R.L., T.A., J.P., S.Y. and D.J. contributed to drafting and finalizing the manuscript.

Correspondence to Jennifer A. Frontera.

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Frontera, J.A., Bhatt, P., Lalchan, R. et al. Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage. J Thromb Thrombolysis 49, 121–131 (2020). https://doi.org/10.1007/s11239-019-01973-z

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Keywords

  • DOAC
  • NOAC
  • Anticoagulation
  • Reversal
  • Coagulopathy
  • Hemostasis
  • Thrombosis
  • Cost
  • Intracranial hemorrhage
  • Direct factor Xa inhibitor