Benefit, risk and cost of new oral anticoagulants and warfarin in atrial fibrillation; A multicriteria decision analysis

PLoS One. 2018 May 3;13(5):e0196361. doi: 10.1371/journal.pone.0196361. eCollection 2018.

Abstract

Introduction: Warfarin and new oral anticoagulants are effective in reducing stroke in atrial fibrillation; however, the benefits and risks rates in clinical trials show heterogeneity for each anticoagulant, and is unknown the cost influence on a model considering most of the treatment consequences. We designed a benefit-risk and cost assessment of oral anticoagulants.

Design: We followed the roadmap proposed by IMI-PROTECT and the considerations of emerged good practice to perform Multi-Criteria Decision Analysis (MCDA). The roadmap defines the following steps: (1) planning, (2) evidence gathering and data preparation, (3) analyses, (4) explorations, and (5) conclusions. We defined two reference points (0-100) to allocate numerical values for scores and weights, and used an analogue numeric scale to assess physicians' preferences. As benefits of the anticoagulant therapy, we included reductions in stroke and all-cause mortality; intracranial haemorrhage, gastrointestinal haemorrhage, minor bleeding and myocardial infarction were considered risks. We also made an estimation of the annual drug cost per person.

Main results: The scores were: Apixaban 33, Dabigatrán 25, warfarin 18 and Rivaroxaban 14 this score reveals the most preferred up to the less preferred option, considering the benefit-risk ratio and drug costs altogether. The relative model weights were: 51.1% for risks, 40.4% for benefits and 8.5% for cost. The sensitivity analysis confirms the model robustness.

Conclusions: From this analysis, apixaban should be considered as the preferred anticoagulant option -due to a better benefit-risk balance and a minor cost influence- followed by dabigatran, warfarin and rivaroxaban.

MeSH terms

  • Administration, Oral
  • Anticoagulants / adverse effects
  • Anticoagulants / economics
  • Anticoagulants / therapeutic use*
  • Atrial Fibrillation / complications
  • Atrial Fibrillation / drug therapy*
  • Cost-Benefit Analysis
  • Dabigatran / adverse effects
  • Dabigatran / economics
  • Dabigatran / therapeutic use
  • Decision Support Techniques
  • Drug Costs
  • Hemorrhage / etiology
  • Humans
  • Models, Statistical
  • Pyrazoles / adverse effects
  • Pyrazoles / economics
  • Pyrazoles / therapeutic use
  • Pyridones / adverse effects
  • Pyridones / economics
  • Pyridones / therapeutic use
  • Risk Factors
  • Rivaroxaban / adverse effects
  • Rivaroxaban / economics
  • Rivaroxaban / therapeutic use
  • Stroke / etiology
  • Stroke / prevention & control
  • Warfarin / adverse effects
  • Warfarin / economics
  • Warfarin / therapeutic use*

Substances

  • Anticoagulants
  • Pyrazoles
  • Pyridones
  • apixaban
  • Warfarin
  • Rivaroxaban
  • Dabigatran

Grants and funding

The authors received no specific funding for this work.