Apixaban Provides ‘Intermediate Value’ Care, According to New Economic Analysis

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According to the researchers, the survival benefit seen in ARISTOTE outweighed the drug’s higher costs and led to a favorable economic evaluation.

Treating A-fib patients with apixaban (Eliquis, Bristol-Myers Squibb) instead of warfarin costs significantly more, but these increased costs are offset by better patient outcomes, particularly gains in life expectancy , according to a new study. These gains suggest that the non-vitamin K oral anticoagulant (NOAC) is cost-effective based on current criteria, according to the authors.

In an economic analysis of patients treated in ARISTOTLE – the large randomized trial that previously showed NOAC was superior to warfarin in preventing stroke or systemic embolism in patients with atrial fibrillation – the additional cost of anticoagulation with apixaban instead of warfarin was just under $54,000 per quality-adjusted life year (QALY) gained. That’s “within a range considered acceptable in the US healthcare system,” say the researchers led by Patricia Cowper, PhD (Duke Clinical Research Institute, Durham, NC).

“I would argue that clinicians are more interested in overall efficiency and superior patient outcomes than efficiency from an economic perspective,” said lead author Dan Mark, MD (Duke Clinical Research Institute, Durham, North Carolina), at TCTMD. “The efficacy aspect of apixaban, in that sense, is favourable. If you didn’t have a drug that doctors said would benefit the patient, you wouldn’t care about the efficacy of its use.

The cost-effectiveness study was published on March 29, 2017 in JAMA: Cardiology.

Intermediate value care based on ACC/AHA criteria

In the economic analysis, the projected healthcare costs of patients treated with apixaban and warfarin, respectively, did not differ between the two groups. Excluding the cost of the drug, health care costs including inpatient, outpatient, and emergency room visits, among other costs, were $15,686 and $15,746 in the respective arms. The cost of prothrombin time monitoring and patient care was significantly lower with apixaban, but the 2-year cumulative cost of study drug was significantly higher with apixaban compared to warfarin ($5,915 vs. $56; P

Overall, the total cost of apixaban treatment, including drug, anticoagulation monitoring, and other expenses, was $21,852 compared to $16,927 in the warfarin group (P

Given the 11% reduction in all-cause mortality observed in ARISTOTLE, the projected life expectancy of US patients was significantly longer with apixaban than with warfarin. As a result, the number of QALYs gained in the apixaban arm was 0.40 higher than in the warfarin arm (7.94 vs 7.54 QALYs; 95% CI 0.26-0.55 for the difference). Accordingly, the incremental cost of anticoagulation for a patient using apixaban instead of warfarin was $53,925 per QALY gained.

“If you save lives – and ARISTOTLE actually showed a mortality advantage – and move the ball that much across the field, you can actually balance out a bit of overhead while getting favorable cost-effectiveness,” said said Marc “If you only move a little quality of life, it’s a lot harder.”

And while pharmaceutical companies aren’t likely to be interested in discussions about lowering drug costs, downward pressure on the price of the drug would make the economics of treatment even more attractive, Mark said. In their analysis, reducing the price of apixaban to 75%, 50%, and 25% of its 2014 price improved incremental cost-effectiveness to $40,426, $26,927, and $13,427 per QALY gained, respectively.

The American College of Cardiology and the American Heart Association consider a treatment threshold of less than $50,000 per QALY gained to be high value care, while $50,000 to less than $150,000 is considered high value care. of intermediate value.

Processing costs of $10 per day versus 10 cents

In an editorial, Mark Hlatky, MD (Stanford University School of Medicine, CA), writes that the fundamental principle behind cost-effective analysis is that the higher price of a new drug – apixaban costs about $10 per day, while than warfarin is less than $0.10 — may be acceptable if clinical outcomes are sufficiently improved.

Over the 2 years of follow-up, the lower costs of anticoagulation follow-up with apixaban only offset 15% of the cost difference between NOAC and warfarin. Additionally, patients treated with apixaban had fewer strokes and hospital admissions for bleeding, but these events were infrequent and only made up 6% of the cost difference between the two drugs. However, Hlatky points out that the increase in life expectancy with apixaban – 0.4 years – is “actually quite significant in the context of cost-effectiveness analysis.

Another way to interpret this number is that it equates to one more patient surviving out of 19 patients treated, with an average life expectancy of 7.54 years,” he writes. While the use of apixaban will increase health care costs, Hlatky concludes that “clinical outcomes have been improved enough to provide reasonable value within the US system.”

Mark told TCTMD that as a general rule, the benefit side of the cost-effectiveness relationship will almost always have much more influence. “In the vast majority of cases that we’re likely to see, it’s not the cost that matters, it’s the benefit, although it’s also the relationship between the extra costs and the extra benefits,” he said. he declares.

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