Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY, USA.
Stroke. 2012 Mar;43(3):881-3. doi: 10.1161/STROKEAHA.111.641027. Epub 2012 Feb 3.
The cost-effectiveness of dabigatran for stroke prevention in patients with atrial fibrillation and prior stroke or transient ischemic attack has not been directly assessed.
A Markov decision model was constructed using data from the Randomized Evaluation of Long-Term Therapy (RE-LY) trial, other trials of warfarin therapy for atrial fibrillation, and the published cost of dabigatran. We compared the cost and quality-adjusted life expectancy associated with 150 mg dabigatran twice daily versus warfarin therapy targeted to an international normalized ratio of 2 to 3. The target population was a cohort of patients aged ≥70 years with nonvalvular atrial fibrillation, prior stroke or transient ischemic attack, and no contraindication to anticoagulation.
In the base case, dabigatran was associated with 4.27 quality-adjusted life-years compared with 3.91 quality-adjusted life-years with warfarin. Dabigatran provided 0.36 additional quality-adjusted life-years at a cost of $9000, yielding an incremental cost-effectiveness ratio of $25,000. In sensitivity analyses, the cost-effectiveness of dabigatran was inversely related to the quality of international normalized ratio control achieved with warfarin therapy. In Monte Carlo analysis, dabigatran was cost-effective in 57% of simulations using a threshold of $50,000 per quality-adjusted life-year and 78% of simulations using a threshold of $100,000 per quality-adjusted life-year.
Dabigatran appears to be cost-effective relative to warfarin for stroke prevention in patients with atrial fibrillation and prior stroke or transient ischemic attack. Our analysis is limited by its reliance on data from a substudy of a single randomized trial, and our results may not apply in settings with uncommonly good international normalized ratio control using warfarin.
尚未直接评估达比加群预防有房颤病史且伴有既往卒中或短暂性脑缺血发作患者发生卒中的成本效益。
采用来自随机评价长期抗凝治疗（RE-LY）试验、其他华法林治疗房颤试验的数据以及达比加群的已公布成本，构建了一个马尔可夫决策模型。我们比较了 150mg 达比加群每日 2 次与目标 INR 为 2 至 3 的华法林治疗相关的成本和调整后预期寿命。目标人群为年龄≥70 岁、无抗凝禁忌证、伴有非瓣膜性房颤、既往卒中或短暂性脑缺血发作的患者队列。
在基线情况下，与华法林相比，达比加群可带来 4.27 个质量调整生命年，而华法林可带来 3.91 个质量调整生命年。达比加群带来 0.36 个额外的质量调整生命年，但成本增加 9000 美元，增量成本效益比为 25000 美元。在敏感性分析中，达比加群的成本效益与华法林治疗实现的 INR 控制质量呈反比关系。在蒙特卡罗分析中，当使用 50000 美元/QALY 和 100000 美元/QALY 作为成本效益阈值时，在 57%和 78%的模拟中，达比加群具有成本效益。
达比加群在预防房颤伴既往卒中或短暂性脑缺血发作患者发生卒中方面似乎优于华法林，具有成本效益。本分析受到其依赖于一项随机试验亚组数据的限制，且本研究结果可能不适用于华法林 INR 控制效果通常不佳的情况下。
