Stroke prevention in patients with atrial fibrillation in France: comparative cost-effectiveness of new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), warfarin, and aspirin

Lanitis, Tereza; Cotté, François-Emery; Gaudin, Anne-Françoise; Kachaner, I.; Kongnakorn, Thitima; Durand‐Zaleski, Isabelle

doi:10.3111/13696998.2014.923891

Cited by 62 publications

(46 citation statements)

References 35 publications

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“…Whereas European studies yielded an incremental cost-effectiveness ratio (ICER) ranging from dominance to €20,089 per quality-adjusted life-year (QALY) [16][17][18][19][20], the ICERs of studies conducted in the US or Canada ranged from $3,200 to $55,800 per QALY [21][22][23]. However, to date, no study has evaluated the cost effectiveness of rivaroxaban compared with conventional warfarin for the German healthcare system.…”

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confidence: 92%

Cost Effectiveness of Rivaroxaban for Stroke Prevention in German Patients with Atrial Fibrillation

et al. 2014

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Our results showed that the substantially higher medication costs of rivaroxaban were offset by mitigating the shortcomings of warfarin, most notably frequent dose regulation and bleeding risk. Future health economic studies on novel oral anticoagulants should evaluate the cost effectiveness for secondary stroke prevention and, as clinical data from direct head-to-head comparisons become available, new anticoagulation therapies should be compared against each other.

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confidence: 92%

Cost Effectiveness of Rivaroxaban for Stroke Prevention in German Patients with Atrial Fibrillation

et al. 2014

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“…A small number of papers have recently reported the relative cost-effectiveness of rivaroxaban compared with warfarin or with the other approved NOACs (Table 8) (49)(50)(51)(52)(53)(54). These studies seem to show that, while all NOACs may provide improvements in quality-adjusted life-years vs. warfarin, this is associated with increased cost (49,53).…”

Section: Discussionmentioning

confidence: 99%

Stroke prevention with rivaroxaban in higher‐risk populations with atrial fibrillation

Diener¹,

Halperin

Fox

et al. 2015

Int J Clin Pract

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Background: Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. Rivaroxaban, an oral factor Xa inhibitor, is approved for the prevention of stroke in patients with non-valvular AF. In the pivotal phase III trial ROCKET AF, rivaroxaban demonstrated non-inferiority compared with warfarin for reducing the risk of stroke or systemic embolism (SE) in patients with AF (intention-to-treat analysis), without an increased risk of major bleeding. Superior efficacy vs. warfarin was achieved while patients were on study medication. Other direct oral factor Xa inhibitors have completed phase III clinical trials in this indication. Compared with warfarin, apixaban (in the ARISTOTLE trial) and edoxaban (in the ENGAGE-AF trial) were shown to be superior or non-inferior, respectively, for reduction in stroke or SE risk in patients with AF. Baseline stroke risk, as indicated by CHADS 2 scores, was lower in patients in the ARISTOTLE and ENGAGE-AF trials than in ROCKET AF. Objectives: This review discusses the main findings from ROCKET AF, specifically examining recent subgroup analyses investigating rivaroxaban use across various patient types at high risk for adverse outcomes, including those with prior stroke or transient ischaemic attack, reduced renal function, prior myocardial infarction, peripheral artery disease, heart failure or patients aged ≥ 75 years and those resident in East Asia. Conclusions: These subgroup analyses demonstrate that the treatment effect for rivaroxaban vs. warfarin is broadly consistent across a wide range of patient groups, with respect to both efficacy and safety. Review criteriaThis review summarises findings from most of the subgroup analyses published to date from ROCKET AF (1), a phase III trial comparing rivaroxaban with warfarin for stroke risk reduction in patients with atrial fibrillation, with particular emphasis on patient subgroups at increased risk of thromboembolic or haemorrhagic events. Factors associated with intracranial haemorrhage and mortality in ROCKET AF are also reviewed. Message for the clinicAlthough the risk for thromboembolic or bleeding events varies across different patient subgroups, the relative treatment effect of rivaroxaban compared with warfarin is broadly consistent across a wide range of different patient groups with respect to both efficacy and safety -a finding that supports the use of rivaroxaban across the wide range of patients encountered in clinical practice. Nonetheless, selection of therapy must always be individualised for the particular circumstances of each patient.

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“…Interestingly, apixaban exhibited a similar profile to aspirin in terms of safety (hemorrhagic events), while it was shown to be more effective in terms of efficacy (reduction of ischemic events). Even though economic evaluation studies performed in different health systems suggest that all NOACs (apixaban [Stevanović et al 2014], dabigatran [Wouters et al 2013], rivaroxaban [Kleintjens et al 2013]) are cost-effective alternatives to VKAs, apixaban was highlighted as the most economically efficient alternative to warfarin in a French study that compared together warfarin, all NOACs and aspirin for stroke prevention in NVAF patients [Lanitis et al 2014].…”

Section: Discussionmentioning

confidence: 99%

Novel oral anticoagulants for the secondary prevention of cerebral ischemia: a network meta-analysis

Katsanos

Mavridis

Parissis

et al. 2016

Ther Adv Neurol Disord

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Background: Novel oral anticoagulants (NOACs) have shown to be both safe and effective for ischemic stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). We conducted a network meta-analysis (NMA) using published data from secondary prevention subgroups of different phase III randomized clinical trials (RCTs) comparing individual NOACs with warfarin. Methods: Eligible studies were identified by searching MEDLINE and SCOPUS and the Cochrane Central Register of Controlled Trials databases. First, we conducted a pairwise meta-analysis for each pairwise comparison, and then we performed NMA to combine direct and indirect evidence for any given pair of treatments. The comparative effects of all NOACs against warfarin were ranked with the surface under the cumulative ranking (SUCRA) curve for each outcome. Results: We identified four RCTs (including 15,240 patients) comparing individual NOACs (apixaban, dabigatran, rivaroxaban) with warfarin. Using indirect evidence, dabigatran was related to a significantly lower risk of hemorrhagic stroke compared with rivaroxaban [risk ratio (RR) 0.28; 95% confidence interval (CI) 0.11-0.75], while rivaroxaban was associated with a significantly lower risk of major gastrointestinal bleeding compared with dabigatran (RR 0.14; 95% CI 0.03-0.74). We also performed clustered ranking plot for the primary efficacy and safety endpoints to identify the treatment with the probably best benefit-to-risk ratio profile. Conclusions:The three NOACs showed differences in terms of safety and efficacy for secondary stroke prevention in NVAF. Our findings can serve only as hypothesis generation and require independent confirmation in head-to-head RCTs, owing to the sparse available evidence and increased uncertainty in both indirect effect estimates and ranking of treatments.

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Stroke prevention in patients with atrial fibrillation in France: comparative cost-effectiveness of new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), warfarin, and aspirin

Cited by 62 publications

References 35 publications

Cost Effectiveness of Rivaroxaban for Stroke Prevention in German Patients with Atrial Fibrillation

Cost Effectiveness of Rivaroxaban for Stroke Prevention in German Patients with Atrial Fibrillation

Stroke prevention with rivaroxaban in higher‐risk populations with atrial fibrillation

Novel oral anticoagulants for the secondary prevention of cerebral ischemia: a network meta-analysis

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