OBJECTIVES: New oral anticoagulants (NOACs) are recommended as preferred options for stroke prevention in patients with atrial fibrillation (AF) compared to warfarin by guidelines of high-income countries. Cost-effectiveness studies (CEA) performed in those countries support such recommendation. This study aimed to evaluate the CEA of NOACs in Thailand, an upper middle-income country.

METHODS: A lifetime Markov model was created from Thai societal perspective. The model consisted of 19 health states separated into 2 cycles as event cycle and consequence cycle. The consequences of AF included in the model were ischemic stroke, intracranial & extracranial hemorrhage and myocardial infarction. Dabigatran 150 mg and 110 mg twice daily, rivaroxaban 20 mg once daily, apixaban 5 mg twice daily, and edoxaban 60 mg and 30 mg once daily were assessed using warfarin as the reference. Inputs were a combination of published literature and local data when available. A willingness-to-pay of 160,000 THB/QALY was used as the threshold of being cost-effective. Incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves of all NOACs were estimated and compared.

RESULTS: All NOACs were not cost-effectiveness strategies for Thai AF population. The ranking of ICER from lowest to highest were apixaban 5 mg twice daily (692,136 THB) followed by edoxaban 60 mg once daily (911,772 THB), edoxaban 30 mg once daily (913,749 THB), dabigatran 150 mg twice daily (1,102,106 THB), dabigatran 110 mg twice daily (1,195,347 THB) and rivaroxaban 20 mg once daily (1,347,650 THB). Cost-effectiveness acceptability curve indicated that apixaban had the highest potential to be a cost-effective strategy

CONCLUSIONS: Our findings indicated that, at the current pricing, all NOACs were not cost-effective in Thai healthcare system. Among NOACs, apixaban may have the most likelihood to be cost effective with adjusted pricing. These data may be helpful to policy makers to perform formulary decision and pricing negotiation.