Rivaroxaban plus aspirin for the prevention of ischaemic events in patients with cardiovascular disease: a cost-effectiveness study

Abstract

Background Dual pathway inhibition with 2.5 mg rivaroxaban twice daily plus 100 mg aspirin once daily may be a promising alternative to 100 mg aspirin antiplatelet therapy for the prevention of cardiovascular events in patients with coronary artery disease and/or peripheral arterial disease. However, treatment costs and bleeding risks are higher, and there is another treatment option for peripheral arterial disease, 75 mg clopidogrel. A comprehensive assessment of benefits, risks and costs of dual pathway inhibition versus standard of care is needed. Methods We used a state transition model including cardiovascular, ischaemic limb and bleeding events to compare dual pathway inhibition to aspirin antiplatelet therapy in coronary artery disease, and additionally to clopidogrel antiplatelet therapy in peripheral arterial disease patients. We calculated the incremental cost-effectiveness ratio from costs and quality-adjusted life-years of lifelong treatment, and the cost-effectiveness probability at a €50,000/quality-adjusted life-year threshold. Results Quality-adjusted life-years and costs of dual pathway inhibition were highest, the incremental cost-effectiveness ratios versus aspirin were €32,109 in coronary artery disease and €26,381 in peripheral arterial disease patients, with 92% and 56% cost-effectiveness probability, respectively (clopidogrel was extendedly dominated). Incremental cost-effectiveness ratios were below €20,000 in comorbid peripheral arterial disease patients and coronary artery disease patients younger than 65 years, incremental cost-effectiveness ratios were above €50,000 in carotid artery disease patients and coronary artery disease patients older than 75 years. Conclusion Lifelong preventive treatment of coronary artery disease and peripheral arterial disease patients at risk of cardiovascular events with dual pathway inhibition improves health outcomes and seems overall cost-effective relative to aspirin antiplatelet therapy and also to clopidogrel antiplatelet therapy for peripheral arterial disease, particularly in comorbid patients, but not in older patients and in carotid artery disease patients. These findings may warrant a targeted approach.

Cost-Effectiveness Analysis of Rivaroxaban Plus Aspirin Compared with Aspirin Alone in Patients with Coronary and Peripheral Artery Diseases in Italy

“…These findings mirrored previous economic analyses of rivaroxaban plus aspirin compared with aspirin alone in patients with CAD or PAD conducted in other countries such as Australia, Canada, The Netherlands, and the UK [10][11][12][13][14]. For instance, the two researches conducted from the Australian perspective provided strong evidence that rivaroxaban in combination with aspirin was cost effective compared with aspirin alone in the prevention of recurrent CVD events and major adverse limb events in populations of patients with CAD or PAD [12,13].…”

Cost-effectiveness of rivaroxaban plus aspirin (dual pathway inhibition) for prevention of ischaemic events in patients with cardiovascular disease: on top optimisation of secondary prevention medication in the context of COVID-19 pandemia

“…In contrast, DPI was neither cost-effective in patients with carotid artery disease nor in older CAD patients more than 75 years of age. 9 This ambitious costeffectiveness evaluation therefore confirms the baseline beneficial prognostic impact of DPI in patients with stable CAD and stable PAD, but also demonstrates well-defined limitations of this therapeutic regimen to be considered in clinical all day care and future research.…”

“…Against this background and based on data from the COMPASS trial 7,8 and a willingness to pay of e50,000, Petersohn et al tested the cost effectiveness of DPI compared to aspirin alone in CAD, and clopidogrel alone in PAD patients following a sophisticated state transition model thereby including cardiovascular, ischaemic limb and bleeding events. 9 The costeffectiveness probability of DPI was 92% in CAD patients, but only 56% in patients with PAD. DPI was especially cost-effective in young CAD patients and in PAD patients with existing comorbidities.…”

Plasma Biomarkers to Predict Cardiovascular Outcome in Patients With Peripheral Artery Disease

“…A recent cost-effectiveness analysis identified subgroups of patients with varying benefit of dual pathway inhibition, indicating that there could be added value in better selection of patients. 81 It could be expected that markers of coagulation such as d -dimer, and possibly fibrinogen, might be useful to identify hypercoagulable patients who could benefit most from this intensified antithrombotic therapy. Fibrinogen is, apart from its role in coagulation, also an inflammatory marker associated with atherosclerotic plaque formation.…”