Study Compares the Cost and Efficacy of Anticoagulant Therapies

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Research conducted by UC Davis Comprehensive Cancer Center and the University of Cincinnati showed that direct oral anticoagulants (DOACs) are more effective—and more cost-effective—than low–molecular-weight heparin for treating cancer-associated thrombosis. A study published by Gulati et al in Annals of Internal Medicine examined the cost-effectiveness of the four most-utilized anticoagulation strategies for blood clots, which include low–molecular-weight heparin, apixaban, edoxaban, and rivaroxaban.

Authors of the study include oncologist and Assistant Professor of Medicine Shuchi Gulati, MD, a clinician-scientist at UC Davis, and Professor Emeritus of Clinical Medicine Mark H. Eckman, MD, of the University of Cincinnati.

“For reasons not completely understood, cancer can increase the risk of blood clots, and treatments such as chemotherapy can further increase the risk. Patients with [cancer and] cancer-associated thrombosis face double the mortality rate compared to patients [with cancer] without thrombosis. Cancer-associated thrombosis also adds a significant financial burden for these patients,” explained Dr. Gulati.

For many years, injection of low–molecular-weight heparin has been the treatment of choice in patients who have cancer-associated thrombosis. DOACs came on the scene about 8 or 9 years ago and are considered to have better safety and efficacy profiles.

“Clinical trials have shown improved efficacy and a decreased risk of major bleeding with the DOACs, but the question is whether people will be willing to pay the additional cost to get the better outcome. Many oncologists have already adopted DOACs in their clinical practice, so this is a key issue,” Dr. Gulati said.

Cost and Efficacy Comparison

These drugs were compared head-to-head using a computer model Drs. Eckman and Gulati constructed that simulates major health events that happen to a cohort of patients with cancer over time who have experienced a blood clot. The model simulates events including recurrent pulmonary emboli, recurring deep vein thrombosis without pulmonary emboli, major bleeds and clinically relevant nonmajor bleeds, as well as mortality. Then, over the course of the lifetime of the patient cohort, the study examined the accumulating lifetime costs and lifetime effectiveness measured in a metric called quality-adjusted life years (QALYs).

In the base-case analysis, using the cost of drugs purchased at a federal facility such as the Veteran’s Administration, apixaban was favored as being more effective and less costly than either low–molecular-weight heparin or edoxaban, while indicating rivaroxaban was not cost-effective. However, the study results were vastly different when analyzing average prices from GoodRx, a free online service that provides drug coupons for discounts on medications. In this scenario, if decision-makers were unwilling to spend more than $50,000 per QALY, edoxaban was favored, and using the contemporary threshold for societal willingness to pay, rivaroxaban was cost-effective, with an incremental cost-effectiveness ratio of just more than $50,000 per QALY.

Dr. Gulati said the findings demonstrate a stark difference between the real-world cost of DOACs and drug prices from the Veteran’s Administration and will likely have implications for value-based price benchmarks in the United States. She added that an individual’s insurance coverage plan can make a huge difference in the patient’s out-of-pocket costs for these medications.

“Most importantly, all DOACs are more effective and have a better side-effect profile than low–molecular-weight heparin,” Dr. Eckman concluded. “Which of those is the most cost-effective is going to depend for any given patient on what the cost of those drugs will be for them. That decision can be one that is made in concert with the oncologist and the patient.”

Disclosure: For full disclosures of the study authors, visit


The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.