Direct oral anticoagulants more cost-effective for cancer-associated thrombosis
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Direct oral anticoagulants showed greater efficacy and cost-effectiveness than low-molecular-weight heparin for treatment of cancer-associated thrombosis, according to data published in Annals of Internal Medicine.
However, researchers found the cost-effectiveness of the three direct oral anticoagulants (DOACs) in the analysis — apixaban (Eliquis, Bristol Myers Squibb), edoxaban (Savaysa, Daiichi Sankyo) and rivaroxaban (Xarelto, Janssen/Bayer) — varied depending on multiple factors, including the relative cost of each drug.
“Clinical trials have shown improved efficacy and a decreased risk [for] major bleeding with the DOACs, but the question is whether people will be willing to pay the additional cost to get the better outcome,” Shuchi Gulati, MD, MS, assistant professor of medicine and a clinician scientist with UC Davis Comprehensive Cancer Center, said in a press release. “Many oncologists have already adopted DOACs in their clinical practice, so this is a key issue.”
Background and methodology
Patients with cancer-associated thrombosis (CAT) are nearly two times more likely to die as a result of their diagnosis than patients with cancer without venous thromboembolism, according to study background. Heparin and low-molecular-weight heparin formulations — such as enoxaparin monotherapy — have been commonly used for the treatment of CAT; however, DOACs have come into clinical use following phase 3 clinical trials.
In this study, researchers explored the cost and effectiveness of three common DOACs (apixaban, edoxaban and rivaroxaban) and enoxaparin, a low-molecular-weight heparin, for the treatment of CAT and prevention of recurrent VTE using a Markov state transition decision analytic model the researchers constructed.
Results
A base-case scenario using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule showed apixaban to be less costly and more effective than enoxaparin and edoxaban. Rivaroxaban appeared a bit more effective than apixaban, with an incremental cost-effectiveness ratio (ICER) of $493,246.
In a scenario analysis using “real-world” drug prices from GoodRx, rivaroxaban demonstrated cost-effectiveness with an ICER of $50,053 per quality-adjusted life-year (QALY).
Results proved highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50,000 per QALY, apixaban was preferred in 80% of simulations. However, apixaban remained cost-effective only if monthly medication costs stayed below $530. When the figure rose above $530, rivaroxaban proved to be most cost-effective.
“Most importantly, all the DOACs are more effective and have a better side-effect profile than low-molecular-weight heparin,” Mark H. Eckman, MD, MS, professor emeritus of clinical medicine at University of Cincinnati, said in a press release. “Which of those is the most cost-effective is going to depend for any given patient on what the cost of those drugs will be for them. That decision can be one that is made in concert with the oncologist and the patient.”
References:
Comparing the cost-effectiveness of treatments for blood clots in cancer patients (press release). Available at: www.newswise.com/articles/comparing-the-cost-effectiveness-of-treatments-for-blood-clots-in-cancer-patients. Published Dec. 26, 2022. Accessed Feb. 9, 2023.
Gulati S, et al. Ann Intern Med. 2023;doi:10.7326/M22-1258.
Eckman reports grants or contracts to his institution from Bristol Myers Squibb/Pfizer and NIH. Gulati reports payment or honoraria for lectures, presentations, speakers bureau roles, manuscript writing or educational events from ASCO; patents planned, issued or pending related to diagnostic tools for prediction of survival and responsiveness to treatments; and participation on a data safety monitoring board of advisory board from AVEO, EMD Serono and Puma Biotechnology.
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Gulati S, et al. Ann Intern Med. 2023;doi:10.7326/M22-1258.
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