OBJECTIVES: Globally, atrial fibrillation (AF) is associated with increased risk of morbidity and mortality and accounts for one-third of hospitalizations. Patients with AF have a 4-5-fold increase in the risk of stroke, which is the leading cause of death in these patients. Apixaban, a novel oral anticoagulant was found to be superior to warfarin and aspirin in the prevention of stroke, systemic embolism, bleeding outcomes, and mortality in clinical trials (AVERROES and ARISTOTLE). The present study assesses the cost‑effectiveness of apixaban over warfarin in Vitamin K antagonist [VKA] suitable patient and aspirin in VKA unsuitable patients in AF patients in Iraq, treated in the private healthcare sector.

METHODS: A Markov model with 11 health states was developed to evaluate the impact of introducing apixaban from the Iraqi private healthcare payer perspective. Only direct costs (drug acquisition, routine care, monitoring visit, anticoagulation management, and event costs) were included. This study modelled only AF patients at risk of stroke and studied apixaban in comparison to warfarin and aspirin. Outcomes assessed included life-years (LYs), quality-adjusted life‑years gained (QALYs), direct healthcare costs, and incremental cost-effectiveness ratios (ICER).

RESULTS:Compared to aspirin and warfarin, the use of apixaban resulted in 0.28 QALYs and 0.29 LYs gain with an incremental cost of US Dollar (USD) 1,231; thereby generating an ICER of USD 4,329/QALY gained and USD 4,159/LY gained. The incremental cost was mainly attributed to the increase in the cost of anticoagulants, however, partially offset by the decrease in the cost associated with monitoring and adverse events management.

CONCLUSIONS:Apixaban is a cost-effective treatment option compared to warfarin and aspirin for the management of VKA suitable and unsuitable AF patients at a willingness to pay threshold of USD 25,000/QALY gained for the Iraqi private healthcare sector.