OBJECTIVES:

To assess cost-effectiveness of direct oral anticoagulants (DOACs) for patients with venous thromboembolism (VTE) in Thailand.

METHODS:

A cohort-based state transition model was constructed under a societal perspective with lifetime horizon. All available DOACs; apixaban, rivaroxaban, edoxaban, and dabigatran were compared to warfarin. A 6-month cycle length was used to capture all costs and health outcomes. The model consisted of 9 health states including VTE on treatment, VTE off treatment, recurrent VTE, clinically relevant non-major bleeding, gastrointestinal bleeding, intracranial bleeding, post intracranial bleeding, chronic thromboembolic pulmonary hypertension, and death. All inputs were based on a comprehensive literature review. The model outcomes included total cost and quality-adjusted life-years (QALYs) with a 3% annual discount rate. A fully incremental cost-effectiveness analysis and the incremental cost-effectiveness ratio (ICER) per QALY gained were calculated at the willingness-to-pay (WTP) of THB 160,000/QALY. The robustness of findings was assessed using deterministic and probabilistic sensitivity analyses.

RESULTS:

All DOACs were associated with a decreased risk of VTE recurrence and intracranial haemorrhage complications. In our base-case analysis, apixaban could increase 0.16 QALYs compared to warfarin. An ICER for apixaban was 280,274 Thai baht (THB)/QALY. Rivaroxaban had better QALY than warfarin of 0.09 QALYs with an ICER of 779,509 THB/QALY. Edoxaban and dabigatran could also increase 0.10 QALYs with an ICER of 714,709 and 711,790 THB/QALY, respectively. Our probabilistic sensitivity analyses indicated that warfarin had 99.8% possibility of being cost-effective, while apixaban had 0.2% possibility of being cost-effective. Other DOACs had no possibility of being cost-effective at current WTP.

CONCLUSIONS:

All DOACs were not cost-effective for VTE treatment at current WTP in Thailand. Apixaban is likely to be the best option among DOACs.