Universal Versus Genotype-Guided Use of Direct Oral Anticoagulants in Atrial Fibrillation Patients: A Decision Analysis

Abstract

Aim: This study aims to compare clinical and economic outcomes of CYP2C9 and VKORC1 genotype-guided (PG-DOAC) versus universal use of direct oral anticoagulant (DOAC) for stroke prevention in patients with atrial fibrillation (AF). Methods: Outcomes of oral anticoagulation therapy were simulated using life-long Markov modeling. In PG-DOAC, patients with genotype of high or low warfarin sensitivity were treated with DOAC, and patients with normal warfarin sensitivity genotype received warfarin. Results: Expected quality-adjusted life-years (QALYs) and cost of DOAC were higher than PG-DOAC. Incremental cost per QALY (ICER) of DOAC versus PG-DOAC was 314,129 USD/QALY, exceeding willingness-to-pay threshold (50,000 USD/QALY). Conclusion: Using individual genotype to guide the use of DOAC versus warfarin appears to be the preferred strategy.

Keywords::

• atrial fibrillation
• cost–effectiveness analysis
• CYP2C9
• direct oral anticoagulant
• genotype-guided therapy
• VKORC1
• warfarin

Financial & competing interests disclosure

This study was supported by the General Research Fund from the Research Grants Council of the Hong Kong Special Administrative Region, China (Project no. CUHK477612). The funding source had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit an article for publication. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research

The author obtained appropriate institutional review board approval or has followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.

Additional information

Funding

This study was supported by the General Research Fund from the Research Grants Council of the Hong Kong Special Administrative Region, China (Project no. CUHK477612). The funding source had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit an article for publication. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.