Cost-effectiveness of apixaban and rivaroxaban in thromboprophylaxis of cancer patients treated with chemotherapy in Spain

Background Apixaban and rivaroxaban are two direct-acting oral anticoagulants (DOACs) recommended for thromboprophylaxis in cancer patients treated with chemotherapy in an ambulatory setting. We aimed to assess the cost-utility of thromboprophylaxis with apixaban and rivaroxaban vs no thromboprophylaxis in ambulatory cancer patients starting chemotherapy with an intermediate-to-high risk of venous thromboembolism (VTE), Khorana score & GE; 2 points.Methods A cost-effectiveness analysis was performed from the perspective of Spain's National Health System (NHS) using an analytical decision model in the short-term (180 days) and a Markov model in the long-term (5 years). Transition probabilities were obtained from randomized, double-blind, placebo-controlled clinical trials of apixaban and rivaroxaban in adult ambulatory patients with cancer at risk for VTE, treated with chemotherapy (AVERT and CASSINI trials). The costs (euro2,021) were taken from Spanish sources. The utilities of the model were obtained through the EQ-5D questionnaire. Deterministic (base case) and probabilistic (second-order Monte Carlo simulation) analyses were conducted.Results In the probabilistic sensitivity analysis, apixaban generated a cost per patient of euro1,082 & PLUSMN; 187, with a 95% confidence interval (CI) of euro713-1,442, while no prophylaxis produced a cost per patient of euro1,146 & PLUSMN; 218, with a 95% CI of euro700-1,491, with a saving of euro64 per patient and a gain of 0.008 QALYs. Likewise, rivaroxaban provided a cost per patient of euro993 & PLUSMN; 133, with a 95% CI of euro748-1,310, while no prophylaxis produced a cost per patient of euro872 & PLUSMN; 152, with a 95% CI of euro602-1,250, with an additional expense of euro121 per patient and a gain of 0.008 QALYs.Conclusions In thromboprophylaxis of cancer patients, the use of apixaban and rivaroxaban generated similar costs compared to non-prophylaxis, without the difference found being statistically significant, with a clinically insignificant QALY gain.