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Apixaban, Dabigatran, and Rivaroxaban Versus Warfarin for Stroke Prevention in Non-Valvular Atrial Fibrillation: A Cost-Effectiveness Analysis

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Abstract

Background and objective

Non-valvular atrial fibrillation (NVAF) increases the risk of systemic thromboembolic events; therefore, anticoagulant treatment with vitamin K antagonists is widely prescribed. Recently, new oral anticoagulants (NOAs) directly inhibiting thrombin (dabigatran) or factor Xa (rivaroxaban and apixaban) demonstrated their non-inferiority with respect to warfarin in reducing the thromboembolic risk. The aim of this study was to estimate the cost effectiveness of NOAs in an Italian setting.

Methods

A Markov decision model including ten health states and death was developed, and a 3-month Markov cycle and lifetime horizon were adopted. Transition probabilities and quality of life were estimated from three randomized trials and from additional reports in the literature. Analysis was performed in the context of the Italian National Health System. First- and second-order sensitivity analyses were made to test the robustness of the results. The mean European cost of dabigatran (€2.58/day) was assigned to each NOA.

Results

The incremental cost-utility ratio was below €25,000/quality-adjusted life-year (QALY) gained for each NOA and each CHADS2 level, but differences among drugs were found. This result was sensitive to the time in (warfarin) therapeutic range and time horizon.

Conclusions

Our analysis suggests that NOAs are a cost-effective treatment for the prevention of stroke in patients with NVAF in the Italian healthcare setting.

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Acknowledgments

No sources of funding were used to assist in the conduct of this study. The authors have no potential conflicts of interest that are directly relevant to the content of this study.

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Authors and Affiliations

  1. Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy

    Carla Rognoni & Silvana Quaglini

  2. Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy

    Carla Rognoni

  3. Hematology Unit, Cardinal Massaia Hospital, Asti, Italy

    Monia Marchetti

  4. Department of Medicine, Azienda Ospedaliera della Provincia di Pavia, Casorate Primo (PV), Italy

    Nicola Lucio Liberato

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  1. Carla Rognoni
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  2. Monia Marchetti
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Correspondence to Nicola Lucio Liberato.

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Rognoni, C., Marchetti, M., Quaglini, S. et al. Apixaban, Dabigatran, and Rivaroxaban Versus Warfarin for Stroke Prevention in Non-Valvular Atrial Fibrillation: A Cost-Effectiveness Analysis. Clin Drug Investig 34, 9–17 (2014). https://doi.org/10.1007/s40261-013-0144-3

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