Key Points
- To evaluate the comparative lifetime effectiveness of dabigatran, rivaroxaban, apixaban, and warfarin for the prevention of thromboembolic stroke in patients with nonvalvular atrial fibrillation.
- Conducted an indirect comparison using a discrete event simulation model adopting a lifetime analytic horizon.
- Synthesized evidence from the RE-LY, ROCKET-AF, and ARISTOTLE randomized clinical trials parameterized for the US atrial fibrillation population.
- Apixaban, dabigatran, and rivaroxaban accrued 0.130 (95% central range [CR] -0.030 to 0.264), 0.106 (95% CR -0.048 to 0.248), and 0.095 (95% CR -0.052 to 0.242) more lifetime QALYs, respectively, than warfarin.
- Apixaban demonstrated a 55% probability of yielding the highest total QALYs among all evaluated anticoagulants.
Structured PICO
Do newer oral anticoagulants (apixaban, dabigatran, rivaroxaban) improve quality-adjusted life-years compared to warfarin in patients with nonvalvular atrial fibrillation?
PPopulationSimulated cohorts of 100,000 patients per treatment (total n=400,000) representative of the stroke risk profile of the US nonvalvular atrial fibrillation population, mean age 73.0 years.
IInterventionApixaban 5 mg twice daily, dabigatran 150 mg twice daily, or rivaroxaban 20 mg once daily.
CComparatorDose-adjusted warfarin.
OOutcomeIncremental net health benefits, measured as the differences between treatments in quality-adjusted life-years (QALYs) over a lifetime horizon.patient reported
In an indirect comparison using a lifetime simulation model, apixaban appeared to be the most effective oral anticoagulant for nonvalvular atrial fibrillation, accruing the highest number of QALYs compared to dabigatran, rivaroxaban, and warfarin.
Limitations
- Differences across trials in design, patient populations, and reporting
- Assumption that risk equations derived from 2-year data apply to a lifetime horizon
- Did not consider cost-effectiveness, patient convenience, or lack of antidotes