Cost-effectiveness of apixaban and rivaroxaban in thromboprophylaxis of cancer patients treated with chemotherapy in Spain

Apixaban and rivaroxaban are two direct-acting oral anticoagulants (DOACs) recommended for thromboprophylaxis in cancer patients treated with chemotherapy in an ambulatory setting. We aimed to assess the cost-utility of thromboprophylaxis with apixaban and rivaroxaban vs no thromboprophylaxis in ambulatory cancer patients starting chemotherapy with an intermediate-to-high risk of venous thromboembolism (VTE), Khorana score ≥ 2 points. A cost-effectiveness analysis was performed from the perspective of Spain’s National Health System (NHS) using an analytical decision model in the short-term (180 days) and a Markov model in the long-term (5 years). Transition probabilities were obtained from randomized, double-blind, placebo-controlled clinical trials of apixaban and rivaroxaban in adult ambulatory patients with cancer at risk for VTE, treated with chemotherapy (AVERT and CASSINI trials). The costs (€2,021) were taken from Spanish sources. The utilities of the model were obtained through the EQ-5D questionnaire. Deterministic (base case) and probabilistic (second-order Monte Carlo simulation) analyses were conducted. In the probabilistic sensitivity analysis, apixaban generated a cost per patient of €1,082 ± 187, with a 95% confidence interval (CI) of €713–1,442, while no prophylaxis produced a cost per patient of €1,146 ± 218, with a 95% CI of €700–1,491, with a saving of €64 per patient and a gain of 0.008 QALYs. Likewise, rivaroxaban provided a cost per patient of €993 ± 133, with a 95% CI of €748–1,310, while no prophylaxis produced a cost per patient of €872 ± 152, with a 95% CI of €602–1,250, with an additional expense of €121 per patient and a gain of 0.008 QALYs. In thromboprophylaxis of cancer patients, the use of apixaban and rivaroxaban generated similar costs compared to non-prophylaxis, without the difference found being statistically significant, with a clinically insignificant QALY gain.

阿哌沙班与利伐沙班是两类直接口服抗凝药（direct-acting oral anticoagulants, DOACs），被推荐用于门诊接受化疗的癌症患者的血栓预防。本研究旨在评估在起始化疗、静脉血栓栓塞症（venous thromboembolism, VTE）中高危（Khorana评分≥2分）的门诊癌症患者中，使用阿哌沙班、利伐沙班行血栓预防对比无血栓预防方案的成本效用。本研究从西班牙国家医疗体系（National Health System, NHS）的视角开展成本效果分析，短期（180天）采用分析决策模型，长期（5年）采用马尔可夫模型。转移概率来源于针对伴静脉血栓栓塞症风险、接受化疗的成人门诊癌症患者开展的阿哌沙班与利伐沙班随机双盲安慰剂对照临床试验（AVERT与CASSINI试验）。成本数据（2021欧元）取自西班牙本土来源。模型的效用值通过EQ-5D量表获取。本研究开展了确定性（基准情形）与概率性（二阶蒙特卡洛模拟）分析。在概率敏感性分析中，阿哌沙班组每位患者的成本为1082±187欧元，95%置信区间（confidence interval, CI）为713~1442欧元；无预防组每位患者的成本为1146±218欧元，95%置信区间为700~1491欧元，阿哌沙班组可节省每位患者64欧元，且获得0.008个质量调整生命年（Quality-Adjusted Life Years, QALYs）。同样，利伐沙班组每位患者的成本为993±133欧元，95%置信区间为748~1310欧元；无预防组每位患者的成本为872±152欧元，95%置信区间为602~1250欧元，利伐沙班组需额外花费每位患者121欧元，但同样获得0.008个QALYs。在癌症患者的血栓预防中，与无预防方案相比，使用阿哌沙班与利伐沙班的成本相近，组间差异无统计学意义，且QALYs增益无临床意义。