Cost-effectiveness of direct oral anticoagulants compared to low-molecular-weight-heparins for treatment of cancer associated venous thromboembolism in Spain

Abstract

Aim

Recent studies have compared the efficacy and safety of direct-acting oral anticoagulants (DOAC) and low-molecular-weight heparin (LMWH) for cancer-associated venous thromboembolism (VTE). However, there is no available cost-effectiveness analysis comparing DOAC and LMWH. The study aimed to conduct a cost-effectiveness analysis of DOAC (apixaban, edoxaban, and rivaroxaban) vs. LMWH for the treatment of cancer-associated VTE in Spain from the Spanish healthcare system perspective.

Methods

We developed a Markov model with a 12-month time horizon. The states included pulmonary embolism, deep vein thrombosis, major and non-major bleeding, chronic thromboembolic pulmonary hypertension, post-thrombotic syndrome, and death. The use of medical resources and drug costs were obtained from the 2021 Spanish Ministry of Health database, and the main references for obtaining the outcomes were derived from Caravaggio, Hokusai VTE Cancer, ADAM VTE, and SELECT-D trials. We performed a deterministic and probabilistic sensitivity analysis to validate the robustness. The Incremental Cost-Effectiveness Ratio (ICER) scores cost per life-year (€/LY) gained and cost per quality-adjusted life-year (€/QALY) gained.

Results

The 12-month cost of DOAC was 1,994€ (apixaban 1,944€, edoxaban 1,968€, rivaroxaban 2,122€) and 2,152€ for LMWH. The amount of QALY for DOAC was 0.54 (apixaban 0.55, rivaroxaban 0.53, and edoxaban 0.52) and 0.53 for LMWH. We observed similar results for LYs. ICER scores in terms both of €/LY and €/QALY show that DOAC is dominant over LMWH and apixaban showed the best profile.

Limitations

Our research is based on an indirect comparison of a short-term clinical trial.

Conclusion

Our results suggest that DOAC is cost-effective and cost-saving compared to LMWH in treating VTE.

Keywords:

• Cost-effectiveness analysis
• apixaban
• low-molecular-weight heparin (LMWH)
• major bleeding
• venous thromboembolism
• direct-acting oral anticoagulants (DOAC)

JEL CLASSIFICATION CODES:

• D61
• D6
• D
• I10
• I1
• I
• C63
• C6
• C

Transparency

Declaration of funding

This study was sponsored by Pfizer and Bristol Myers Squibb.

Declaration of financial/other relationships

GA reports personal fees from Bristol Myers Squibb, Pfizer, Bayer Healthcare, and Daichi Sankyo outside the submitted work.

AM reports personal fees and others from Celgene, personal fees and others from Sanofi, personal fees from Pfizer-BMS, personal fees and others from Leo Pharma, personal fees from Daichii Sankyo, personal fees from Bayer, personal fees from Halozyme, personal fees from AstraZeneca, personal fees from Rovi, personal fees from Merck Sharp & Dohme, personal fees and other from Roche, personal fees from Eli Lilly, personal fees from Servier, other from Merck Serono, personal fees from Incyte, other from Amgen, outside the submitted work; In addition, AM has a patent Risk assessment model in venous thromboembolism in patients with cancer issued to NO.

EG reports personal fees from Sanofi, personal fees from Pfizer, personal fees and non-financial support from Rovi, personal fees and non-financial support from Daiichi Sankyo, personal fees from Techdow, personal fees and non-financial support from Leo Pharma, personal fees from Boehringer Ingelheim, during the conduct of the study; grants from Sanofi, grants, personal fees and non-financial support from Janssen, grants and personal fees from Astellas, grants and personal fees from Bayer, grants, personal fees and non-financial support from Ipsen, grants, personal fees and non-financial support from Roche, grants from Novartis, grants, personal fees and non-financial support from Pfizer, grants, personal fees and non-financial support from Eisai, personal fees from EUSA Pharma, grants, personal fees and non-financial support from BMS, personal fees and non-financial support from AstraZeneca, personal fees from Merck, personal fees from MSD, grants from Ferrer, grants from GSK, outside the submitted work.

JS, SFC, and DA report that they are current employees at Pfizer Spain. Pfizer Spain is the owner of Apixaban.

CC and MF are employees of Axentiva Solutions who were paid consultants to Pfizer and Bristol Myers Squibb in connection with the development of this manuscript. CC was involved in projects with Novartis, Amgen, Angellini, Ferrer, Mallinkcrodt, Boehringer, Biogen, Shire, Almirall, Abbvie, Edwards, Boston Scientific, Medtronic, Dexcom, Takeda, Mundipharma, Pfizer, Fresenius Kabi, Pierre-Fabre, Roche, Vifor, and LeoPharma. CC reports personal fees from Amgen and GSK.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

JS, SFC, and DA developed the conception of the study, supervised the whole study, and were involved in its design. AM, EG, and GA provided background information based on their experience as principal investigators in this field and interpretation of data. CC and MF were involved in the study design, conducted the research and the data analysis, and drafted the manuscript. All the investigators revised the draft and contributed to the final version of the manuscript.

Acknowledgements

None reported.