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Clinical Articles, Lead Article

Are NOACs more cost-effective than warfarin?

In patients with nonvalvular atrial fibrillation (AF) and an increased risk of stroke prophylaxis, apixaban 5 mg, dabigatran 150 mg, and rivaroxaban 20 mg are all cost-effective alternatives to warfarin, according to a study1 published recently in Stroke.

Researchers constructed a Markov decision-analysis model using data from clinical trials to evaluate lifetime costs and quality-adjusted life-years of novel oral anticoagulants (NOACs) compared with warfarin. The modeled population was a hypothetical cohort of 70-year-old patients with nonvalvular AF, increased risk for stroke (CHADS2 ≥1), renal creatinine clearance ≥50 mL/min, and no previous contraindications to anticoagulation. The willingness-to-pay threshold was $50,000/quality-adjusted life-years gained.

In the base case, warfarin had the lowest cost of $77,813 (SD, $2,223), followed by rivaroxaban 20 mg ($78,738±$1,852), dabigatran 150 mg ($82,719±$1,959), and apixaban 5 mg ($85,326±$1,512). Apixaban 5 mg had the highest quality-adjusted life-years estimate at 8.47 (SD, 0.06), followed by dabigatran 150 mg (8.41±0.07), rivaroxaban 20 mg (8.26±0.06), and warfarin (7.97±0.04).

In a Monte Carlo probabilistic sensitivity analysis, apixaban 5 mg, dabigatran 150 mg, rivaroxaban 20 mg, and warfarin were cost-effective in 45.1%, 40%, 14.9%, 0% of the simulations, respectively. The cost-effectiveness of NOACs was dependent on therapy pricing in the United States and neurological events associated with rivaroxaban 20 mg, the authors found.

Cost-Effectiveness of Apixaban (HEADSHOT)

Amanda Harrington MS (University of Arizona, USA)

Lead author Amanda Harrington MS (Department of Pharmacy Practice and Science, University of Arizona, USA) spoke to BJC Arrhythmia Watch on the current lack of real-world cost-effectiveness data: “To date, all of the studies evaluating the cost-effectiveness of the three NOACs have used efficacy data reported in the clinical trials to populate the models.”

“Observational studies are developed to evaluate whether the therapy will work in a real-world patient setting. There is currently a limited amount of data assessing the real-world effectiveness of these therapies. In the future, however, this type of data will offer additional information regarding the cost-effectiveness of the NOACs, such as the impact of therapy compliance and/or adherence,” she added.

On the events associated with rivaroxaban, Ms Harrington said: “Patients enrolled in the clinical trials evaluating apixaban and dabigatran (ARISTOTLE and RE-LY, respectively) had similar CHADS2 scores, a mean of 2.1 for apixaban and mean of 2.2 for dabigatran. Alternatively, patients enrolled in the ROCKET AF trial to evaluate the efficacy of rivaroxaban had a mean CHADS2 score of 3.5. Given the differences in risk for stroke prophylaxis, the results for apixaban and dabigatran relative to rivaroxaban may be skewed.”

“Additional effectiveness data of the three novel anticoagulants in similar patient populations will demonstrate whether these differences are present in real-world scenarios,” she concluded.


1. Harrington AR, Armstrong EP, Nolan PE, Malone DC. Cost-effectiveness of apixaban, dabigatran, rivaroxaban, and warfarin for stroke prevention in atrial fibrillation. Stroke 2013.​STROKEAHA.111.000402

Published on: April 26, 2013

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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