Easing the economic burden of acute coronary syndromes: cost-effectiveness of emerging therapies

Although only part of the entire treatment regimen, antithrombotic therapy represents a large portion of the total costs associated with acute coronary syndromes (ACS) treatment. Unfractionated heparin (UFH), the mainstay of antithrombotic therapy, carries the risk of bleeding and associated interventions, and must be closely monitored. UFH therapy also has an increased risk of heparin-induced thrombocytopenia (HIT) and osteoporosis. These drawbacks prompted the development of newer antithrombotic agents, particularly low molecular weight heparins (LMWH) and factor Xa inhibitors. LMWH have several clinical advantages over UFH and has been demonstrated to be more effective than UFH in ACS. Because UFH is inexpensive, newer therapies need to demonstrate economic attractiveness over UFH. In addition to acquisition costs, it is important to consider the cost of all key components throughout the continuum of care. Health economic analyses show that the clinical advantages of the LMWH enoxaparin are also likely to result in net cost-saving benefits, due to reductions in diagnostic catheterization, percutaneous transluminal coronary angioplasty, and intensive care unit length of stay. Fondaparinux, an indirect inhibitor of factor Xa, does not require routine monitoring or multiple daily dosing, and is unlikely to interact with HIT antibodies. Large randomized clinical trials have shown that fondaparinux is at least as safe and efficacious as enoxaparin or UFH in the prevention of venous thromboembolism (VTE) and treatment of deep vein thrombosis or pulmonary embolism. Data from 2 recently published trials are similarly indicating noninferiority of fondaparinux in ACS patients. Health economic analysis of fondaparinux treatment is currently limited to VTE scenarios but point to a cost benefit associated with fondaparinux compared with enoxaparin.