Open Access Highly Accessed Original basic research

Dabigatran versus warfarin under standard or pharmacogenetic-guided management for the prevention of stroke and systemic thromboembolism in patients with atrial fibrillation: a cost/utility analysis using an analytic decision model

Léon Nshimyumukiza1, Julie Duplantie1, Mathieu Gagnon1, Xavier Douville2, Diane Fournier2, Carmen Lindsay3, Marc Parent3, Alain Milot34, Yves Giguère35, Christian Gagné2, François Rousseau35 and Daniel Reinharz1*

Author Affiliations

1 Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada

2 Département de génie électrique, Faculté des Sciences et de génie, Université Laval, Québec, Québec, Canada

3 Centre de recherche du centre hospitalier universitaire de Québec (CRCHUQ), Faculté de Médecine, Université Laval, Québec, Québec, Canada

4 Département de médecine, faculté de Médecine, Université Laval, Québec, Québec, Canada

5 Département de biologie moléculaire, biochimie médicale et pathologie, Faculté de Médecine, Université Laval, Québec, Québec, Canada

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Thrombosis Journal 2013, 11:14  doi:10.1186/1477-9560-11-14

Published: 17 July 2013

Abstract

Background

Atrial fibrillation (AF) is the most common form of heart arrhythmia and a leading cause of stroke and systemic embolism. Chronic anticoagulation is recommended for preventing those complications. Our study aimed to compare the cost/utility (CU) of three main anticoagulation options: 1) standard warfarin dosing (SD-W) 2) warfarin dosage under the guidance of CYP2C9 and VKORC1 genotyping (GT-W) and 3) dabigatran 150 mg twice a day.

Methods

A Markov state transition model was built to simulate the expected C/U of dabigatran, SD-W and GT-W anticoagulation therapy for the prevention of stroke and systemic thromboembolism in patients with atrial fibrillation over a period of 5 years under the perspective of the public health care system. Model inputs were derived from extensive literature search and government’s data bases. Outcomes considered were the number of total major events (thromboembolic and hemorrhagic events), total costs in Canadian dollars (1CAD$ = 1$US), total quality-adjusted life years (QALYs), costs/QALYs and incremental costs/QALYs gained (ICUR).

Results

Raw base case results show that SD-W has the lowest C/U ratio. However, the dabigatran option might be considered as an alternative, as its cost per additional QALY gained compared to SD-W is CAD $ 4 765, i.e. less than 50 000, the ICUR threshold generally accepted to adopt an intervention. At the same threshold, GT-W doesn’t appear to be an alternative to SD-W. Our results were robust to one-way and multi-way sensitivity analyses.

Conclusion

SD-W has the lowest C/U ratio among the 3 options. However, dabigatran might be considered as an alternative. GT-W is not C/U and should not currently be recommended for the routine anticoagulotherapy management of AF patients.

Keywords:
Atrial fibrillation; Simulation; Cost-utility; Dabigatran etexilate; Warfarin; Anticoagulation; CYP2C9; VKORC1