In a potentially practice-changing study, direct oral anticoagulants (DOACs) were determined to be both more effective in terms of cost and clinical results than low-molecular-weight heparin (LMWH) for treating cancer-associated thrombosis (CAT).

The analysis, published in Annals of Internal Medicine, notes that CAT is associated with an almost twofold increase in mortality compared with cancer patients who do not have thrombosis. Patients with CAT also remain at a higher risk for recurrent venous thromboembolism (VTE), which can be costly—as much as 80% more spent on healthcare costs.

Researchers from the University of California (UC) Davis Comprehensive Cancer Center in Sacramento and the University of Cincinnati Medical Center point out that LMWH has been the go-to medication for the treatment of CAT, although DOACs have been increasingly used in recent years.

The study team conducted a cost-effectiveness analysis of four possible interventions for the treatment of CAT over the lifetime of a 63-year-old patient. The goal was to determine the cost and effectiveness of DOACs versus LMWH. The cohort-state transition decision analytic model involved a network meta-analysis comparing DOACs versus LMWH.

Interventions studied were enoxaparin, apixaban, edoxaban, and rivaroxaban for the treatment of CAT, with their incremental cost-effectiveness ratio (ICER) calculated in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained.

“In the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective,” according to the report. “Rivaroxaban was slightly more effective than apixaban, with an ICER of $493 246. In a scenario analysis using 'real-world' drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50 053 per QALYj.”

The researchers point out that their results were highly sensitive to monthly drug costs. At a willingness-to-pay threshold of $50 000 per QALY, according to the analysis, apixaban was preferred in 80% of simulations. Yet, sensitivity analyses also suggested that apixaban only remained cost-effective if monthly medication costs were below $530. At higher costs, rivaroxaban became cost-effective, they advise.

The study was limited in that assumptions were made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. It also did not take into account nonmedical costs, such as patient and caregiver loss of productivity.

“The three DOACs are more effective and more cost-effective than LMWH,” the authors conclude. “The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers.”

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