Τίτλος:
Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation
Γλώσσες Τεκμηρίου:
Αγγλικά
Περίληψη:
Objective: Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. Methods: CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. Results: Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient’s lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953–£7018 per patient (UK), €6683–€7368 (Netherlands), €4933–€9378 (Spain), AUD$5353–6539 (Australia) and $26,768–$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468–$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). Conclusions: Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients. © 2021, The Author(s).
Συγγραφείς:
Witte, K.K.
Tsivgoulis, G.
Reynolds, M.R.
Tsintzos, S.I.
Eggington, S.
Ismyrloglou, E.
Lyon, J.
Huynh, M.
Egea, M.
de Brouwer, B.
Ziegler, P.D.
Franco, N.
Joglekar, R.
Rosemas, S.C.
Liu, S.
Thijs, V.
Περιοδικό:
BMC Cardiovascular Disorders
Εκδότης:
BioMed Central Ltd.
Λέξεις-κλειδιά:
acetylsalicylic acid; anticoagulant agent; dabigatran; rivaroxaban; warfarin; acetylsalicylic acid; anticoagulant agent; dabigatran; rivaroxaban, adult; anticoagulation; Article; atrial fibrillation; Australia; brain ischemia; cardioembolic stroke; CHADS2 score; controlled study; cost benefit analysis; cost control; female; health care cost; health care system; human; major clinical study; male; Markov chain; medicare; Netherlands; patient monitoring; priority journal; risk factor; risk reduction; Spain; United States; bleeding; brain ischemia; clinical trial (topic); comparative study; drug cost; economic model; economics; oral drug administration; prevention and control; recurrent disease; retrospective study; risk assessment; secondary prevention; time factor; treatment outcome, Administration, Oral; Anticoagulants; Aspirin; Clinical Trials as Topic; Cost-Benefit Analysis; Dabigatran; Drug Costs; Embolic Stroke; Hemorrhage; Humans; Ischemic Stroke; Models, Economic; Recurrence; Retrospective Studies; Risk Assessment; Risk Factors; Rivaroxaban; Secondary Prevention; Time Factors; Treatment Outcome
DOI:
10.1186/s12872-021-01967-x
