Cost-effectiveness of apixaban versus other oral anticoagulants and aspirin for stroke prevention in atrial fibrillation in indian subcontinent
Authors: Kulkarni N , Taur S , Tichy E , Kongnakorn T , Sharma R 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Pfizer Ltd

Background/Introduction
Non-vitamin K antagonist oral anticoagulants (NOACs) are class I recommended by various guidelines for stroke prevention in atrial fibrillation. NOACs are associated with comparable or lower risk of stroke / systemic embolism and significantly lower major bleeding as compared to VKAs. Despite the fact that NOACs have demonstrated safety and efficacy in stroke prevention in AF by various randomized clinical trials and real-world evidences, the pharmacoeconomic data of NOACs in stroke prevention is lacking in India. In view of the higher initial and long-term cost of the NOAC therapy, it is important to analyze the cost effectiveness of such therapy to ensure wider acceptance and compliance to medication since majority of population in India is self-paying.

Purpose
The aim of this study was to evaluate the cost-effectiveness of apixaban versus other NOACs available in India (dabigatran and rivaroxaban), warfarin and aspirin for stroke prevention in atrial fibrillation from the healthcare providers’ and patients’ perspectives in the government healthcare as well as the private healthcare facilities across Indian subcontinent.

Methods
A Markov model was constructed using six-week cycle length over a lifetime horizon by including the available data from RCTs and real-world analyses of all NOACs. The clinical consequences of AF included in the analysis were stroke (ischemic and hemorrhagic), systemic embolism, bleeding (intracranial hemorrhage, other major and clinically relevant non-major), myocardial infarction, mortality and morbidity associated with NVAF not on anticoagulant. Innovator brands of NOACs were considered for this analysis, as NOACs are not under price control in India unlike warfarin and aspirin. Model outputs included quality-adjusted life years (QALY), life years gained, direct medical costs and incremental cost-effectiveness ratios (ICERs). Additional sensitivity and scenario analyses were conducted to test the robustness of the outcomes.

Results
From healthcare provider’s perspective irrespective of private medical facility or the government healthcare facilities, Apixaban was dominantly associated with cost-saving over other OACs. Apixaban was cost effective as compared to warfarin from patients’ perspective at the private medical facilities. Apixaban was cost-effective compared to dabigatran and rivaroxaban from patients’ perspective in the RWE-based analysis.

Conclusion
We conclude that apixaban is cost saving (less costly and more effective) compared to warfarin, aspirin and other NOACs from healthcare providers’ perspective. Apixaban may be a cost-effective alternative to dabigatran and rivaroxaban from patients’ perspective as per the RWD-based cost-effectiveness analysis. These conclusions are based on indirect comparisons, but despite this limitation, the information is useful for healthcare professionals and decision-makers. Abstract Figure. Incremental cost-effectiveness ratios