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Is dabigatran cost effective compared with warfarin for stroke prevention in atrial fibrillation? A critically
Amelia K Adcock1, Joyce K Lee-Iannotti, Maria I Aguilar
1Department of Neurology, Mayo Clinic, Phoenix, Arizona 85054, USA.
Insights
Dabigatran 150 mg bid is a cost-effective alternative to warfarin for preventing stroke in nonvalvular atrial fibrillation (NVAF) patients aged 65+. This new oral anticoagulant offers stroke protection with reduced hemorrhage risk.
Area of Science:
- Pharmacoeconomics
- Vascular Neurology
- Internal Medicine
Background:
- Warfarin has been the standard for cardioembolic stroke prevention in nonvalvular atrial fibrillation (NVAF) for decades.
- Dabigatran, a direct thrombin inhibitor, offers potential for similar or superior stroke protection with a lower risk of intracranial hemorrhage.
- The cost-effectiveness of widespread dabigatran adoption remains a key consideration.
Observation:
- A cost-effectiveness analysis (CEA) compared dabigatran with warfarin in a hypothetical cohort of NVAF patients (age ≥65, CHADS2 ≥1).
- The analysis evaluated lifetime costs and quality-adjusted life years (QALYs) gained.
- Key variables included drug cost and patient risk profiles for stroke and hemorrhage.
Findings:
- At a willingness-to-pay threshold of $50,000/QALY, high-dose dabigatran (150 mg twice daily) was found to be cost-effective compared to warfarin.
- Sensitivity analyses indicated that dabigatran's cost-effectiveness improves with a daily cost of ≤$13 or in high-risk patient populations.
- The base case analysis estimated dabigatran's cost at $12,286 per QALY.
Implications:
- Dabigatran 150 mg bid represents a cost-effective treatment option for ischemic stroke prevention in elderly NVAF patients.
- The findings support the use of dabigatran in specific patient groups where its economic benefits are most pronounced.
- This evidence can inform clinical guidelines and healthcare policy regarding anticoagulation choices in NVAF.
Background:
Warfarin has provided protection against cardioembolic stroke in the setting of nonvalvular atrial fibrillation (NVAF) for the past 60 years. Dabigatran, the first oral direct thrombin inhibitor to be approved in the United States, promises to provide the same or better stroke protection with reduced risk of intracranial hemorrhage. However, it remains to be seen whether grand-scale adoption of dabigatran will be cost effective.
Objective:
To critically assess current evidence regarding the cost effectiveness of dabigatran for preventing stroke in patients with NVAF compared with warfarin.
Methods:
The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular neurology.
Results:
A cost-effectiveness analysis (CEA) that followed a hypothetical cohort of NVAF patients 65 years of age or older and CHADS2≥1 over their lifetime comparing dabigatran with adjusted-dose warfarin was reviewed. Assuming a willingness to pay a threshold of $50,000 per quality-adjusted life year (QALY), base case results favored high-dose (150 mg bid) dabigatran as a cost-effective alternative to warfarin. Sensitivity analysis asserted that the cost effectiveness of dabigatran improved if it could be obtained for ≤$13/d or if it was used in populations with high risk of stroke or intracranial hemorrhage.
Conclusions:
Dabigatran 150 mg bid ($12,286 per QALY) is a cost-effective alternative to International Normalized Ratio-adjusted warfarin for the prevention of ischemic stroke in patients 65 years of age or older with NVAF.
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