OBJECTIVES: Apixaban presents as an alternative to warfarin in the primary and secondary stroke prevention in patients with atrial fibrillation, demonstrating improvements in outcomes such as stroke recurrence. Despite this, warfarin remains the standard treatment for patients within Brazil’s Public Healthcare System (SUS). We aim to evaluate the cost-utility of apixaban vs. warfarin for secondary stroke prevention in the SUS from a societal perspective.

METHODS: A Markov model was developed to compare apixaban with warfarin following hospital admission with ischemic stroke associated with atrial fibrillation. Effectiveness and safety were sourced from the ARISTOTLE study, while follow-up transition probabilities and resource utilization were derived from the 8,231 patients in the population-based Joinville Stroke Registry (Joinvasc). Additionally, Joinvasc supplied health-related quality of life after stroke from a previously published study and time-driven activity-based costing of 830 patients for hospital admissions, follow-up visits, home care services, and rehabilitation. Drug prices were obtained from the Drug Market Regulation Chamber, with an 18% tax included. Results were reported in 2023 Brazilian Reais (purchasing power parity: U$ 1.00 = R$ 2.66), and discounted at 5% yearly. A probabilistic sensitivity analysis (PSA) included 1,000 bootstrapping simulations.

RESULTS: Warfarin treatment resulted in 7.24 life years (LY) and 4.97 quality-adjusted life-years (QALYs), while apixaban led to 7.35 LY and 5.11 QALYs (incremental 0.11 LY and 0.14 QALYs). Total costs were R$ 67,208 with warfarin and R$ 64,347 with apixaban (incremental savings of R$ 2,861). The most substantial cost differences with apixaban vs. warfarin were medication acquisition (R$ 16,379), hospital costs (-R$ 12,518), medical visits (-R$ 5,300), blood tests (-R$ 698), and transportation (-R$ 523). In PSA, apixaban remained dominant in 70.2% simulations.

CONCLUSIONS: Apixaban was associated with both lower costs and superior outcomes, making it a dominant choice for secondary stroke prevention in Brazil.