DOACs more effective, cost-effective than LMWH for cancer-associated thrombosis

For patients with cancer-related thromboembolism, direct oral anticoagulants (DOACs) are more effective and cost-effective than low-molecular-weight heparin (LMWH), an analysis found.

The meta-analysis used effectiveness data from a recently published network meta-analysis of four clinical trials to compare individual DOACs (apixaban, edoxaban, and rivaroxaban) to LMWH. Drug prices from the Department of Veterans Affairs Federal Supply Schedule (VA-FSS) were used to assess cost-effectiveness. Results were published by Annals of Internal Medicine on Dec. 27, 2022.

Apixaban was less costly and more effective than enoxaparin and edoxaban. Rivaroxaban was slightly more effective than apixaban, but it had an incremental cost-effectiveness ratio (ICER) of $493,246, the analysis found. However, using drug prices from GoodRx instead of the VA, the analysis found that rivaroxaban was cost-effective, with an ICER of $50,053 per quality-adjusted life-year (QALY). Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50,000 per QALY, apixaban was preferred in 80% of simulations, but the drug only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective.

“These findings are important as we notice a stark difference in the cost-effectiveness between the VA-FSS setting and the real-world setting, and this could have implications for value-based price benchmarks in the United States,” said the authors. Limitations include that the study assumed patients would continue anticoagulation indefinitely and that nonmedical costs and costs of potential complications of treatment were not included.

“Nevertheless, our analysis is important as the DOACs are unlikely to be compared head-to-head in phase 3 clinical trials,” the authors said. They concluded that apixaban, edoxaban, and rivaroxaban are more effective and cost-effective than LMWH for patients with cancer-associated thrombosis. “Depending on clinical characteristics, location of cancer, and side effects, patients may be better suited to 1 agent over another in clinical practice and this analysis should help policymakers and clinicians with making these decisions,” the authors wrote.

An accompanying editorial noted another limitation—the study's reliance on randomized clinical trials. A recent epidemiologic study found lower risk of bleeding with apixaban than previously reported, “suggesting that all available trial data that Gulati and Eckman used in their analysis might underestimate the cost-effectiveness of apixaban in the real world,” the editorialists said.