Economic evaluation of direct oral anticoagulants (DOACs) for venous thromboembolism with different etiologies: a systematic review

Venous thromboembolism (VTE) imposes significant clinical and economic burdens. While direct oral anticoagulants (DOACs) offer favorable efficacy and safety, their cost-effectiveness across diverse VTE etiologies remains incompletely synthesized. To systematically evaluate the cost-effectiveness of DOACs versus comparators for VTE management stratified by etiology. A PRISMA-compliant systematic search was conducted in MEDLINE, Web of Science, Scopus, and NHS EED (2020–2025). Economic evaluations reporting cost-effectiveness or cost-utility outcomes were included. Study quality was assessed using the Drummond checklist. Twenty studies were included (9 CAT, 3 post-surgical, 6 hospitalized VTE, 2 COVID-19). DOACs were cost-effective or dominant in 18/20 studies. For cancer-associated thrombosis (CAT), DOACs dominated LMWHs and were cost-effective versus placebo (ICERs: $5,794–$11,947/QALY). DOACs were also dominant for post-surgical prophylaxis and in general hospitalized VTE (ICERs: -$1,862/QALY to $125.68/QALY), while rivaroxaban was cost-effective for post-COVID-19 prophylaxis (ICER: $5,386/QALY). DOACs, particularly apixaban and rivaroxaban, are an economically dominant strategy for VTE across most etiologies. Their adoption as a first-line therapy can improve patient outcomes while significantly reducing healthcare costs.