Study provides valuable comparison of anticoagulants

New research published by the University of Cincinnati and the University of California-Davis shows that direct oral anticoagulants (DOACs) are more effective and more cost-effective than low-molecular-weight heparin for the treatment of thrombosis. related to cancer.

The study was published in the journal Chronicle of internal medicine.

“For reasons that are not completely understood, cancer is a pre-thrombotic state. In other words, in cancer patientMark Eckman, MD, professor emeritus in the Department of Internal Medicine at UC School of Medicine and lead author of the study.

“This is still an area of ​​investigation, but we know from decades of experience and clinical trials that cancer patients are at increased risk blood clots. In particular, cancer patients who already have blood clots have an even higher risk of developing the disease,” Eckman said.

The seeds for research were sown when former UC faculty member Shuchi Gulati, MD, worked on an important project while taking a course at UC on Jan. Decision analysis and cost analysis taught by Eckman. Gulati, formerly of the UC School of Medicine and now an oncologist at the University of California, Davis, was the study’s lead author.

“For many years, low molecular weight injections heparin “The long-standing anticoagulant that we’ve been taking for decades, warfarin, is associated with a higher risk of re-clotting in cancer patients who have had a history of pulmonary embolism or blood clots,” Eckman said. deep vein thrombosis (DVT), which is why injection of heparin is the cornerstone of treatment.Direct oral anticoagulants became available about 8 or 9 years ago, and they have an efficacy and safety profile. better.”

This study used several recently published meta-analyses that combined DOACs into one group and compared them to low-molecular-weight heparin, says Eckman. Several analyzes have shown improved efficacy and reduced risk of major bleeding with the DOAC group compared with the low-molecular-weight heparin group. While he said that was indicative of DOAC’s higher efficiency, they also wanted to check the cost factor.

“Even if you have a treatment that is more effective and has fewer side effects, the question is whether people are willing to pay the extra cost to get that benefit in outcomes,” says Eckman. or not. “Can we now use these oral agents much more conveniently and what are the cost-effectiveness implications? That’s an important clinical question right now and a lot of oncologists have start using DOAC instead of low molecular weight heparin.”

The next step was to directly compare three DOACs—rivaroxaban, apixaban, edoxaban—and low molecular weight heparin, using a computer model that Eckman and Gulati built to simulate the major health events that occur with the disease. multiplied over time. a blood clot.

The model simulated events including recurrent pulmonary embolism, recurrent DVT without pulmonary embolism, clinically relevant major bleeding and non-major bleeding, as well as death. Then, over the lifetime of the group of patients, the study examined cumulative lifetime costs and lifetime effects as measured by a metric they call “quality-adjusted life years” or QALY.

“QALY is essentially the number of years lived by group members but adjusted for the quality of life in the different health states they experienced during that time,” Eckman said. “For example, if you have severe bleeding, your quality of life will decrease. In terms of data, one of the advantages of a model like this is that we can pull data from multiple sources because it’s all not available wrapped up in a neat ribbon in a clinical trial.”

When discussing such a cost-effectiveness analysis, they consider not only the cost of the drug, but also the costs accrued or saved due to the drug’s effectiveness or the risk of complications, says Eckman.

Another complicating factor in analyzing monthly drug costs, he said, is whether the drug was purchased through a federal facility like the Department of Veterans Affairs or at a brick-and-mortar or online pharmacy. An individual’s insurance plan can make a big difference in a patient’s out-of-pocket costs for these drugs.

“Most importantly, all DOACs are more effective and have better side-effects profiles than low-molecular-weight heparin,” says Eckman. “Which of these is most cost-effective will depend on any particular patient as to how much those drugs will cost them. That decision is likely to be one made in conjunction with the physician. oncologists and patients.”