Cost-effectiveness of edoxaban versus rivaroxaban for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF) in the US

Abstract

BackgroundUnderstanding the value of new anticoagulation therapies compared with existing therapies is of paramount importance in today’s cost-conscious and efficiency-driven health care environment. Edoxaban and rivaroxaban for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients with CHADS2 scores ≥2 have been evaluated in pivotal trials versus warfarin. The relative value of edoxaban versus rivaroxaban would be of interest to health care stakeholders and patients who prefer a once-daily treatment option for long-term stroke prevention in NVAF.ObjectiveTo evaluate the relative cost-effectiveness of two once-daily regimens of novel oral anticoagulation therapy – edoxaban (60 mg/30 mg dose-reduced) versus rivaroxaban (20 mg/15 mg dose-reduced) – for stroke prevention in NVAF patients from a US health-plan perspective.Materials and methodsA Markov model simulated lifetime risk and treatment of stroke, systemic embolism, major bleeding, clinically relevant nonmajor bleeding, myocardial infarction, and death in NVAF patients treated with edoxaban or rivaroxaban. Efficacy and safety data were derived from a network meta-analysis that utilized data from patients enrolled in ENGAGE AF-TIMI 48 and ROCKET-AF. Health care cost and utility data were obtained from published sources. Incremental cost-effectiveness ratios of <US$50,000, $50,000–$150,000, and >$150,000 per quality-adjusted life year (QALY) gained were used as thresholds for “highly cost-effective”, “cost-effective”, and “not cost-effective” treatment options, respectively, as per American Heart Association/American College of Cardiology guidelines.ResultsEdoxaban was dominant relative to rivaroxaban, such that it was associated with lower total health care costs and better effectiveness in terms of QALYs in the base-case analysis. Results were supported by probabilistic sensitivity analyses that showed edoxaban as either dominant or a highly cost-effective alternative (incremental cost-effectiveness ratio <$50,000) to rivaroxaban in 88.4% of 10,000 simulations.ConclusionResults of this study showed that the once-daily edoxaban (60 mg/30 mg dose-reduced) regimen is a cost-saving or highly cost-effective treatment relative to rivaroxaban (20 mg/15 mg dose-reduced) for stroke prevention in NVAF patients with CHADS2 ≥2.

Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective

“…The core model structure was inspired by existing studies and models developed for evaluating the diagnosis and management of patients with AF and/or cryptogenic stroke and the use of anticoagulants. These included a cost-effectiveness analysis by Diamantopolous et al based on CRYSTAL-AF for the UK setting 27 , a US analysis by Miller et al 28 on the benefits of anticoagulation in patients with nonvalvular AF and a CADTH therapeutic review on anticoagulant use in patients with AF 29 . Existing US clinical guidelines were also used to support model development 11 and details were subsequently validated with input from a local clinical expert.…”

“…Based on data used by Diamantopoulos et al 27 and Miller et al 28 , background mortality risk was increased for the poststroke health states (mild stroke HR ¼ 2.56, moderate stroke HR ¼ 4.63, severe stroke HR ¼ 13.18). Furthermore, during the acute phase patients may die as a direct result of adverse events.…”

“…Utility decrements associated with adverse events were derived from various cost-effectiveness studies 28,49,50,54 . Each time an adverse event occurred, a one-off utility decrement was taken into account to reflect the negative HRQL impact of these events in their acute phase.…”

“…A one-off cost was included for the management of the acute phase of adverse events, obtained from a US cost-effectiveness study by Miller et al 28 comparing two types of NOAC for stroke prevention in patients with nonvalvular AF. For the base-case scenario, we assigned zero cost to fatal strokes although in a sensitivity analysis we assumed the same acute costs for fatal stroke as for a severe ischemic stroke event i.e.…”

“…To reflect the longer-term cost of managing patients who have experienced stroke recurrence, health state costs were also included in the model. These longer-term expenditures for the US setting were derived from the study by Miller et al 28…”