Cost-effectiveness of apixaban for stroke prevention in non-valvular atrial fibrillation in Saudi Arabia

Abstract

BACKGROUND: Apixaban, an oral anticoagulant for stroke and systemic embolism prevention in non-valvular atrial fibrillation (NVAF), was superior to warfarin in prevention of stroke and systemic embolism, bleeding outcomes and mortality (ARISTOTLE trial), and substantially reduced stroke risk, with no significant increase in major or intracranial bleeding risk versus aspirin (AVERROES trial).OBJECTIVE: Estimate cost-effectiveness of apixaban versus other anticoagulants for NVAF treatment in Saudi Arabia.DESIGN: Lifetime Markov model.SETTING: A published model was adapted from the United Kingdom (UK) to the Saudi Arabia setting.PATIENTS AND METHODS: The model enabled pairwise comparisons of apixaban against other anticoagulants, aspirin, and aspirin+clopidogrel. Apart from warfarin and aspirin, comparisons were indirect. Subpopulations included vitamin K antagonist (VKA) suitable and unsuitable patients. Medication and physician visit costs were from published lists. A cost ratio (0.533), from comparison of UK and Saudi physician visit costs, was applied to UK model inputs to estimate local event costs. Background life expectancy was from Saudi life tables. Model structure, treatment comparators, patient characteristics, event rates, and utilities were unchanged. Costs and health benefits were discounted by 3.5% annually.MAIN OUTCOME MEASURE: Incremental cost-effectiveness ratio of cost per quality-adjusted life-year (QALY) gained.SAMPLE SIZE: Model cohort of 1000 NVAF patients, for VKA suitable and VKA unsuitable populations.RESULTS: Apixaban was dominant versus warfarin (VKA suitable) and rivaroxaban (VKA suitable and unsuitable). Compared against dabigatran (110mg, 150 mg, 110/150mg), the cost/QALY gained for apixaban was $5166, $11 143, $10 849 (VKA suitable) and $5 157, $14 424, $14 134 (VKA unsuitable), respectively. Cost/QALY for apixaban versus aspirin and aspirin+clopidogrel was $14 805 and $5784 (VKA suitable); and $10 564 and $4203 (VKA unsuitable), respectively. Sensitivity analyses demonstrated consistency of findings across varying inputs.CONCLUSIONS: Apixaban was found to be cost-effective for stroke prevention among Saudi NVAF patients, when assessed using a US$20 000 willingness-to-pay threshold.LIMITATIONS: Lack of robust local clinical, cost and utility data for model inputs. Lack of head-to-head clinical trial data for rivaroxaban, dabigatran, and clopidogrel plus aspirin comparators.CONFLICT OF INTEREST: Study was funded by Pfizer Inc. and Bristol Myers-Squibb. KO, RS, SAK and AAA received salaries from their respective employers, but did not receive direct financial compensation for participation in or authorship of this study.

A Systematic Review of Sources of Outcomes and Cost Data Utilized in Economic Evaluation Research Conducted in the Gulf Cooperation Council

“…Two studies did not report the perspective of the analysis. 18 , 19 The majority of the studies evaluated costs from the health-care system perspective, which refers to a variety of bodies, including hospitals (n = 8) 17 , 20 , 23 , 24 , 26 , 27 , 29 , 30 or public payers (n = 1), 28 with one additionally considering the societal perspective. 30 Societal (n = 2) 22 , 25 and patient (n = 1) 21 perspectives were also adopted.…”

Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study

“…Warfarin and DOAC are nationally approved in Saudi Arabia. Patient information leaflets were evaluated for the recommended intake regimen of all five anticoagulants (warfarin: QD only, dabigatran: BID only, apixaban: BID only, rivaroxaban: QD only, and edoxaban: QD only) [13][14][15].…”

Stroke Prevention Therapy and Prevalence of Risk Factors Among Patients With Atrial Fibrillation at King Fahad University Hospital in Al Khobar: A Retrospective, Single-Center Study

“…Moreover, NOACs are more cost-effective than Warfarin, as demonstrated by a study conducted in 2019 studying the cost-effectiveness of apixaban for stroke prevention in non-valvular atrial fibrillation in Saudi Arabia [ 9 ]. Since NOACs were released in the market they have been increasingly used to prevent stroke in atrial fibrillation patients, an observational study was conducted by (Boriani et al in 2018) to assess prevention strategies in 27 European countries, concluded that between 2013-2016 the patients who were on OACs therapy were much more than those who were on antiplatelet therapy and that NOAC accounted for 40.9% of OACs.…”