An economic evaluation, based on modelling, has suggested that dabigatran may be a cost-effective first-line treatment for the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF) in the UK.

The authors of the study, published in Heart, estimated the cost-effectiveness of dabigatran versus warfarin, aspirin or no therapy in two patient cohorts with AF (starting age < 80 and ≥ 80 years). The lifetime outcome model considered clinical events, quality-adjusted life years (QALYs), total costs and incremental cost-effectiveness ratios (ICERs).

Patients treated with dabigatran had fewer ischaemic strokes, 3.74 vs 3.97 per 100 patient-years, and fewer combined intracranial haemorrhages and haemorrhagic strokes, 0.43 vs 0.99 per 100 patient-years, compared with warfarin. Larger differences were observed in comparison with aspirin or no treatment.

The authors cost analysis yielded interesting results. For patients starting treatment at < 80 and ≥ 80 years, the ICERs for dabigatran were £4,831 and £7,090/QALY gained versus warfarin with a probability of cost-effectiveness at £20,000/QALY gained of 98% and 63%, respectively.

For those patients starting treatment at < 80 years, the ICER versus aspirin was £3,457/QALY gained; and dabigatran was less costly and more effective compared with no therapy.

There is much interest in the new raft of oral anticoagulants such as dabigatran which appear to offer advantages over warfarin both in terms of efficacy and tolerability. However, as with any new drug there is debate over cost which outstrips warfarin even when the cost of INR monitoring is considered.

The authors conclude that this study supports the notion that dabigatran is a cost-effective option as a first-line treatment for the prevention of stroke and systemic embolism in UK patients with AF. However the study is based on a hypothetical model and at present the newer anticoagulants are likely to remain a second-line choice to warfarin which, in many patients, is an acceptable and effective therapy.

Nevertherless, there will be a definite subset of patients who could benefit from the ease of use of these newer drugs and studies such as this should reassure us both of their likely clinical effectiveness and allay fears over spiralling healthcare costs.

Dr Peter Savill

• Kansal A, Sorensen S, Gani R et al. Cost-effectiveness of dabigatran etexilate for the prevention of stroke and systemic embolism in UK patients with atrial fibrillation. Heart 2012;98:573-578