Optimizing Treatment Choices for Venous Thromboembolism: A Cost-Effectiveness Analysis of Direct Oral Anticoagulants

This study examines the cost and effectiveness of different anticoagulants for the treatment of cancer-associated thrombosis (CAT) and finds that direct oral anticoagulants (DOACs) may offer an alternative to low-molecular-weight heparin (LMWH) and warfarin according to research published in the Annals of Internal Medicine. 

A cohort-state transition decision analytic model was used to process data sourced through network meta-analysis comparing DOACs vs LMWH. Lifetime data was used from adult patients with cancer at the time of thrombosis development. Strategies studied included enoxaparin, apixaban, edoxaban, and rivaroxaban for treatment of CAT. 

Apixaban outperformed enoxaparin and edoxaban in terms of cost and effectiveness when using drug prices from the US Department of Veterans Affairs Federal Supply Schedule, while rivaroxaban was slightly more effective than apixaban but with a higher ICER of $493,246. However, when factoring in "real-world" drug prices from GoodRx, rivaroxaban became cost-effective with an ICER of $50,053 per QALY.  

Apixaban was preferred in 80% of simulations at a willingness-to-pay threshold of $50,000 per QALY, but only remained cost-effective if monthly medication costs were below $530. However, above this threshold, rivaroxaban became cost-effective, but the assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed, nonmedical costs were not accounted for, and long-term thrombotic complications were not explicitly modeled. 

“The 3 DOACs are more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents,” said researchers. “These are important considerations for treating physicians and health policymakers.”  

Reference: 

Gulati S, Eckman MH. Anticoagulant therapy for cancer-associated thrombosis: a cost-effectiveness analysis. Annals of Internal Medicine. 2023;176(1), 1–9. doi:10.7326/M22-1258