Anticoagulant Therapy for Cancer-Associated Thrombosis A Cost-Effectiveness Analysis

Background: Direct oral anticoagulants (DOACs) offer an alternative to low-molecular-weight heparin (LMWH) and warfarin for treating cancer-associated thrombosis (CAT). Objective: To determine the cost and effectiveness of DOACs versus LMWH. Design: Cohort-state transition decision analytic model. Data Sources: Network meta-analysis comparing DOACs versus LMWH. Target Population: Adult patients with cancer at the time they develop thrombosis. Time Horizon: Lifetime.Perspective: Health care sector. Intervention: Strategies of 1) enoxaparin, 2) apixaban, 3) edoxaban, and 4) rivaroxaban for treatment of CAT. Outcome Measures: Incremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: 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. 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. Results of Sensitivity Analysis: Results were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50000 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. Limitations: An assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. Nonmedical costs such as patient and caregiver loss of productivity were not accounted for, and longterm thrombotic complications were not explicitly modeled. Conclusion: The 3 DOACs are more effective and more costeffective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers.