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Dabigatran found cost-effective in high-risk patients with AF
Shah S. Circulation. 2011;123:2562-2570.
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For patients with atrial fibrillation who were at high risk for hemorrhage and stroke, dabigatran 150 mg twice daily was found cost-effective, unless international normalized ratio control with warfarin was considered excellent, according to a recent analysis.
Warfarin (Coumadin, Bristol-Myers Squibb), however, was found cost-effective in moderate-risk patients, unless international normalized ratio (INR) control was poor, in which dabigatran was preferred.
Shimoli V. Shah, MD, and Brian F. Gage, MD, MSc, with the department of medicine, Washington University, St. Louis, performed the analysis using the results from RE-LY, ACTIVE and other trials. They developed a decision-analysis model to compare cost and quality-adjusted survival for several antithrombotic therapies.
Using a cost-effectiveness threshold of $50,000 per quality-adjusted life-year in a hypothetical cohort of 70-year-old patients with AF and estimating cost of dabigatran (Pradaxa, Boehringer- Ingelheim) at $9 per day, they found that the most cost-effective therapy varied depending on risk.
Overall, aspirin was the only cost-effective therapy in patients with the lowest risk for stroke (CHADS2 stroke score 0), whereas for those at moderate risk (CHADS2 score 1 or 2), the cost-effective therapy was warfarin, except when the risk for hemorrhage was high or quality of INR control was poor.
However, among patients at highest risk for stroke (CHADS2 score >3), dabigatran 150 mg twice daily was the most cost-effective, with the exception of when INR control was excellent.
Additionally, dabigatran 110 mg twice daily, due to the greater efficacy with 150 mg, was not deemed cost-effective in this analysis nor was combined warfarin and aspirin use.
Shah and Gage said clinicians should not be tempted to prescribe dabigatran, even when it would not be cost-effective, because the health benefits would only be modest.
“In RE-LY, dabigatran caused more dyspepsia and possibly more MIs than warfarin, so prescribing dabigatran when not indicated could even worsen health,” they said. “Whether these adverse events are frequent and disabling enough to decrease long-term compliance with dabigatran is unknown, but because dabigatran has a 12- to 17-hour half-life, lapses of dabigatran therapy could be more problematic than lapses of warfarin.”
Disclosure: Drs. Shah and Gage report no relevant financial disclosures.
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