• Shuchi Gulati and Mark H Eckman.
• Division of Hematology and Oncology, Department of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, California (S.G.).
• Ann. Intern. Med. 2023 Jan 1; 176 (1): 191-9.

BackgroundDirect oral anticoagulants (DOACs) offer an alternative to low-molecular-weight heparin (LMWH) and warfarin for treating cancer-associated thrombosis (CAT).ObjectiveTo determine the cost and effectiveness of DOACs versus LMWH.DesignCohort-state transition decision analytic model.Data SourcesNetwork meta-analysis comparing DOACs versus LMWH.Target PopulationAdult patients with cancer at the time they develop thrombosis.Time HorizonLifetime.PerspectiveHealth care sector.InterventionStrategies of 1) enoxaparin, 2) apixaban, 3) edoxaban, and 4) rivaroxaban for treatment of CAT.Outcome MeasuresIncremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained.Results Of Base Case AnalysisIn the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective. Rivaroxaban was slightly more effective than apixaban, with an ICER of $493 246. In a scenario analysis using "real-world" drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50 053 per QALY.Results Of Sensitivity AnalysisResults were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50 000 per QALY, apixaban was preferred in 80% of simulations. However, sensitivity analyses also demonstrated that apixaban only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective.LimitationsAn assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. Nonmedical costs such as patient and caregiver loss of productivity were not accounted for, and long-term thrombotic complications were not explicitly modeled.ConclusionThe 3 DOACs are more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers.Primary Funding SourceNone.

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