Nasseer A. Masoodi, MD, FACP
Is dabigatran cost-effective compared with adjusted-dose warfarin for preventing ischemic stroke in patients ≥ 65 years of age with nonvalvular atrial fibrillation (AF)?
Cost-effectiveness analysis using a Markov model and based on a societal perspective and a lifetime time horizon. Effectiveness data were from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial and other published studies of anticoagulation. Cost of dabigatran was estimated from UK prices. Actual US costs were later reported in a letter to the editor. See Table footnote.
Base case was a hypothetical cohort of patients ≥ 65 years of age with nonvalvular AF, who were at increased risk for stroke (CHADS2 score ≥1 or equivalent) and had no contraindications to anticoagulation.
Low-dose dabigatran, 110 mg, twice daily, or high-dose dabigatran, 150 mg, twice daily, compared with adjusted-dose warfarin, target international normalized ratio 2.0 to 3.0.
Quality-adjusted life-years (QALYs), costs in 2008 US dollars, and incremental cost-effectiveness ratios (ICERs). Costs included direct costs of inpatient and outpatient medical care and prescriptions, projected over 35 years. Future costs and life-years were discounted at 3% per year. Clinical endpoints were ischemic stroke, intracranial hemorrhage (ICH), severity of stroke and ICH, and risk for myocardial infarction.
Base-case analysis showed that high-dose dabigatran was cost-effective than warfarin (Table). Sensitivity analysis showed that cost-effectiveness estimates were most sensitive to changes in dabigatran costs.
Compared with adjusted-dose warfarin, dabigatran, 150 mg twice daily, might be considered cost-effective in some jurisdictions for preventing ischemic stroke in patients ≥ 65 years of age with nonvalvular atrial fibrillation but was sensitive to the cost of dabigatran.
Cost-effectiveness of dabigatran, 150 mg twice daily, vs adjusted-dose warfarin for preventing ischemic stroke in a hypothetical cohort of patients ≥ 65 years of age with atrial fibrillation at increased risk for stroke*
*QALY = quality-adjusted life-year; ICER = incremental cost-effectiveness ratio. Costs are in US dollars; costs and utilities discounted at 3% per year.
†Actual US cost of dagibatran, 150 mg twice daily, was $8.00. Freeman JV, Turakhia MP. Ann Intern Med. 2011;154:570-1.Findings for dagibatran, 110 mg twice daily, are not reported here because the US Food and Drug Administration did not approve that dose for this indication.
Nasseer A. Masoodi. Compared with warfarin, high-dose dabigatran might be cost-effective for preventing stroke in older patients with nonvalvular AF. Ann Intern Med. 2011;154:JC6–12. doi: 10.7326/0003-4819-154-12-201106210-02012
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Published: Ann Intern Med. 2011;154(12):JC6-12.
Geriatric Medicine, Neurology, Stroke.
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