Cost-effectiveness of non-vitamin K antagonist oral anticoagulants for stroke prevention in non-valvular atrial fibrillation: a systematic and qualitative review

Abstract

The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) into clinical practice represented a major change in the treatment of non-valvular atrial fibrillation (NVAF); drugs as effective as the gold standard were available, rapidly functioning and without major interferences with drugs and foods. However, a huge increase in the economic burden of NVAF was predicted, and many cost-effectiveness analyses were developed to aid policy makers and clinicians in implementing strategies for the prevention of stroke in NVAF. The present systematic review identified 54 studies from 21 different countries, reporting the incremental cost-effectiveness of dabigatran, apixaban, rivaroxaban and edoxaban. A critical appraisal of the studies was conducted in order to highlight consolidated results and biases.

KEYWORDS:

• Cost-effectiveness analysis
• decision analysis
• critical appraisal
• health economics
• atrial fibrillation
• dabigatran
• apixaban
• rivaroxaban
• edoxaban
• anticoagulant therapy

Key issues

• Compared to VKA, big clinical trials demonstrated NOACs non-inferiority in the prevention of stroke and systemic embolism in NVAF, and their superiority in term of ICH complications.

• Thanks to the valuable clinical benefit provided, the cost-effectiveness of NOACs proved good in several countries, independently from differences in terms of health system, drug price, and costs.

• Baseline results are mainly influenced by time horizon and degree of INR control, which should be taken into account when considering NOACs adoption.

• Sponsored studies show a lower quality and a more favorable cost-effectiveness, therefore, unsponsored studies, especially those including data from the real-world setting, are to be preferred by decision makers.

Financial & competing interests dislcosure

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.