Iris Publishers - Current Trends in Clinical & Medical Sciences (CTCMS)

Pharmacoeconomic Evaluation of Novel Oral Anticoagulants in Patients with Cardiovascular Diseases: A Systematic Review

Authored by Ahmed Ibrahim Nouri


Introduction

For decades, the oral anticoagulant warfarin remained the gold standard of medical management for many cardiovascular diseases and main pharmacological agents for the prophylaxis of venous thromboembolism [1]. Among these cardiovascular patients, the vitamin K antagonists are especially beneficial to patients with venous thromboembolism and for the prevention of stroke. In terms of clinical consideration, warfarin displays several limitations and disadvantages. The narrow therapeutic window and vast drugdrug and drug-food interactions properties of warfarin render it clinically difficult to use [2]. Precise dose adjustment and frequent dose monitoring are of utmost importance because inappropriate dose can lead to many adverse clinical events. Warfarin over-dose will increase the risk of serious bleeding while under-dose will not produce the therapeutic outcomes desired, for example stroke prevention [3].

Novel oral anticoagulants (NOACs) are becoming more important in clinical uses due to the limitations of warfarin mentioned above. NOACs can be divided into direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and direct thrombin inhibitors (dabigatran). In terms of bleeding risk, NOACs display a significantly lower risk of intracranial and intracerebral bleeding than warfarin [4]. NOACs display evidence that they are at least as effective as warfarin if not superior to warfarin in the clinical treatment of patients with systemic embolism and as a prophylaxis for stroke in atrial fibrillation patients [5-6].

Even though NOACs show a superior performance in clinical uses compared to warfarin, but the main drawback on prescribing NOACs to patients instead of warfarin is due to the high daily costs. The rising clinical importance of NOACs, as well as their higher cost, impose a question on the pharmacoeconomic performance of the NOACs. There are numerous studies done in many countries to evaluate the pharmacoeconomic profile of the NOACs.

The aim of this systematic review is to evaluate the pharmacoeconomic performance of four novel oral anticoagulants, rivaroxaban, apixaban, edoxaban and dabigatran usage in patients with cardiovascular diseases (deep vein thrombosis, pulmonary embolism, atrial fibrillation and stroke).

Methodology

A search was conducted in Google Scholar, Embase, Cochrane Library, Medline, CINAHL and Science Direct using search algorithms to identify relevant pharmacoeconomic publications of novel oral anticoagulants in patients with cardiovascular diseases. Processes throughout systematic review were carried out using Preferred Reporting Items for Systematic Reviews and Meta- Analysis (PRISMA) statement. The search identified publications with the keywords pharmacoeconomic, cost-effectiveness, novel oral anticoagulants, dabigatran, rivaroxaban, apixaban, edoxaban, cardiovascular diseases, stroke, atrial fibrillation, deep vein thrombosis or pulmonary embolism. Both cost studies and economic evaluation of novel oral anticoagulants were considered.

While cost studies estimate expenses associated with a particular treatment for cardiovascular diseases, economic evaluations assess both health costs and benefits associated with a drug against its comparator(s). Economic evaluations usually include cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses depending on how health benefits [natural units, quality-adjusted-life-years (QALYs)] and monetary terms are measured. QALYs incorporated both morbidity (as the quality of life) and mortality. Cost-effectiveness analyses looks at a single quantified effectiveness measure of the cost per unit. There are many variations in cost-effectiveness analyses that can be considered; cost consequence and cost-minimization analyses, with comparing cost outcomes due to health benefits. Economic evaluation in health care consider the resources consumed by patients, productivity losses, health sector and other sectors as well. A treatment is usually considered cost-effective if the incremental cost-effectiveness ratio (ICER) is below the commonly used threshold for the given country. Various threshold are available such as $50,000 per QALY in the United States and $20,000-$100,000 per QALY in Canada.

The title and/or abstract of articles published between 2008 and 2018 pertaining to novel oral anticoagulants were searched for the keywords. “Grey” literature (ie, material that can be referenced, but is not published in peer-reviewed, indexed medical journals) was not examined and not included in this review. From the review questions, the author concluded that the question is a therapy question. Hence, the best evidence would be a randomized controlled trial, cohort study, and case-control. Abstracts were included when all of the following were true: cost-effectiveness of different novel oral anticoagulants on patients with cardiovascular diseases and published from 2008 to 2018. Articles published in English language only were accepted; those that did not meet the pre-stated criteria were excluded. Different types of novel oral anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban) used in patients with cardiovascular diseases were included in this review. Articles that have not mentioned novel oral anticoagulants were excluded. Patients with cardiovascular diseases (stroke, deep vein thrombosis, pulmonary embolism and atrial fibrillation); any gender; any age and any severity of cardiovascular diseases were included in this review. Populations were not restricted to one country or place. All papers around the world will be examined and reviewed.

For data extraction, data extracted from included studies using data extraction from guided by standardized extraction data tool by Cochrane Collaboration. The extracted data assured to match with the review question and fulfill the review objectives. A table was used to present details of the characteristic of included studies, such as author, country, year of study; interventions, sample and study design. Data on study design, inputs, results and authors’ conclusions were extracted

To read more about this article: https://irispublishers.com/ctcms/fulltext/pharmacoeconomic-evaluation-of-novel-oral-anticoagulants-in-patients.ID.000539.php

Indexing List of Iris Publishers: https://medium.com/@irispublishers/what-is-the-indexing-list-of-iris-publishers-4ace353e4eee

Iris publishers google scholar citations: https://scholar.google.co.in/scholar?hl=en&as_sdt=0%2C5&q=irispublishers&btnG=


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