Janzic Andrej, Kos Mitja
Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000, Ljubljana, Slovenia.
Pharmacoeconomics. 2015 Apr;33(4):395-408. doi: 10.1007/s40273-014-0246-7.
Vitamin K antagonists, such as warfarin, are standard treatments for stroke prophylaxis in patients with atrial fibrillation. Patient outcomes depend on quality of warfarin management, which includes regular monitoring and dose adjustments. Recently, novel oral anticoagulants (NOACs) that do not require regular monitoring offer an alternative to warfarin. The aim of this study was to evaluate whether cost effectiveness of NOACs for stroke prevention in atrial fibrillation depends on the quality of warfarin control.
We developed a Markov decision model to simulate warfarin treatment outcomes in relation to the quality of anticoagulation control, expressed as percentage of time in the therapeutic range (TTR). Standard treatment with adjusted-dose warfarin and improved anticoagulation control by genotype-guided dosing were compared with dabigatran, rivaroxaban, apixaban and edoxaban. The analysis was performed from the Slovenian healthcare payer perspective using 2014 costs.
In the base case, the incremental cost-effectiveness ratio for apixaban, dabigatran and edoxaban was below the threshold of €25,000 per quality-adjusted life-years compared with adjusted-dose warfarin with a TTR of 60%. The probability that warfarin was a cost-effective option was around 1%. This percentage rises as the quality of anticoagulation control improves. At a TTR of 70%, warfarin was the preferred treatment in half the iterations.
The cost effectiveness of NOACs for stroke prevention in patients with nonvalvular atrial fibrillation who are at increased risk for stroke is highly sensitive to warfarin anticoagulation control. NOACs are more likely to be cost-effective options in settings with poor warfarin management than in settings with better anticoagulation control, where they may not represent good value for money.
维生素K拮抗剂，如华法林，是心房颤动患者预防中风的标准治疗方法。患者的治疗效果取决于华法林管理的质量，其中包括定期监测和剂量调整。最近，无需定期监测的新型口服抗凝剂（NOACs）为华法林提供了一种替代方案。本研究的目的是评估NOACs用于心房颤动中风预防的成本效益是否取决于华法林控制的质量。
我们开发了一个马尔可夫决策模型，以模拟与抗凝控制质量相关的华法林治疗结果，抗凝控制质量用治疗范围内的时间百分比（TTR）表示。将调整剂量华法林的标准治疗和通过基因型指导给药改善抗凝控制与达比加群、利伐沙班、阿哌沙班和依度沙班进行比较。分析是从斯洛文尼亚医疗保健支付方的角度使用2014年成本进行的。
在基础案例中，与TTR为60%的调整剂量华法林相比，阿哌沙班、达比加群和依度沙班的增量成本效益比低于每质量调整生命年25000欧元的阈值。华法林成为具有成本效益选择的概率约为1%。随着抗凝控制质量的提高，该百分比会上升。在TTR为70%时，华法林在一半的迭代中是首选治疗方法。
对于中风风险增加的非瓣膜性心房颤动患者，NOACs用于中风预防的成本效益对华法林抗凝控制高度敏感。在华法林管理不佳的情况下，NOACs比在抗凝控制较好的情况下更有可能成为具有成本效益的选择，在抗凝控制较好的情况下，它们可能不具有良好的性价比。
