A cost-effectiveness analysis (CEA) favors direct oral anticoagulants (DOACs) over low-molecular-weight heparin (LMWH) for treating patients with cancer-associated thrombosis (CAT). Using VA pricing to compare the DOACs, apixaban was more effective and less costly than enoxaparin or edoxaban, and rivaroxaban was not cost-effective.
The comparison was based on a cohort-state transition decision analytic model and clinical data from a network meta-analysis comparing DOACs and LMWH. Adult patients with cancer at the time they developed thrombosis were the target population, the time horizon was lifetime, the perspective was that of the healthcare sector, and the outcome measure was the incremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained.
“In the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective,” the authors report. “Rivaroxaban was slightly more effective than apixaban, with an ICER of $493,246. In a scenario analysis using ‘real-world’ drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50,053 per QALY.” The sensitivity analysis showed that “results were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50,000 per QALY, apixaban was preferred in 80% of simulations. However, sensitivity analyses also demonstrated that apixaban only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective.”
Editorial: “We commend [the authors] for showing the cost-effectiveness of oral factor Xa inhibitors over LMWH,” editorialists write. “However, a limitation of this study in the context of CAT is reliance on data from only randomized clinical trials for model assumptions. A recent, well-executed, pharmacoepidemiologic study of 37,236 propensity score–matched, commercially insured incident users of apixaban and rivaroxaban showed significantly decreased risk for bleeding with apixaban in the subset of patients with a cancer diagnosis, suggesting that all available trial data that [the authors] used in their analysis might underestimate the cost-effectiveness of apixaban in the real world. This is particularly notable given the opposition from patients and physicians that led CVS Caremark to reverse its decision to pull apixaban from its national commercial formulary.”