Apixaban for the prevention of venous thromboembolism in people ...

xxxxxxx xxxxxxxx xxxxxxxxx xxxxxxx xxxxxxxx xxxxxxxxx xxxxxxxxxxx xxxxxxxxxxxx
xxxxxxxxx xxxxxxxxxxx xxxx. These results were the same for THR and TKR.
The results of the indirect comparisons showed that apixaban:
when compared to rivaroxaban showed no significant differences in terms of xxxxxxx xxxxx
xxxxxxxxxxx any DVT, xxxxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxx xxxxxxx xxxxxxxxx
xxxxxxx xxxxxxxx xxxxxxxxx xxxxxxxxxx.
when compared to dabigatran was significantly superior in terms of xxxxxxx xxxxxxx
xxxxxxxx xxxxxxx xxxxxxxxxxx any DVT; xxxxx xxxxxxx xxxxxx xxxxxxx xxxxxx xxxxxx
xxxxxxxx xxxxxxx xxxxxxx xxxxxxxxx xxxxxxxxx xxxxxxx. These results were the same for
THR and TKR.
when compared to fondaparinux in THR showed no significant differences in terms of any
DVT, xxxxxxxx xxxxxxxxx xxxxxxx. Other main outcomes (Total VTE and all-cause
mortality, Major VTE, and Any bleeding) were not reported using indirect comparisons;
although, for the total VTE and all-cause mortality the MTC showed no significant differences.
For TKR an indirect comparison with enoxaparin, 40mg od was not possible.
There are no differences of opinion between the manufacturer and the ERG that might influence the
size of the ICER in a way that it would alter general conclusions. The full incremental analyses
indicate that in THR the ICER of rivaroxaban versus apixaban amounts to £21,661/QALY. In TKR
apixaban is dominated by rivaroxaban. These results are robust.
The strengths of the submission are:
- In general, the submission appeared to present a thorough and well performed analysis.
- The submission includes an overview of all available evidence.
- Errors identified in the economic model and report by the ERG were all relatively minor, and did
not substantially impact the results and conclusions.
Weaknesses are:
- The submission was not concise and lacked transparency. Therefore, the ERG cannot guarantee
that no errors are still undiscovered.
- The effectiveness and safety of apixaban, and therefore its cost-effectiveness, are based on a single
trial that included a population that is not entirely representative for the NHS.
8.1 Implications for research
Further trials of apixaban compared to other LMWHs in both THR and TKR would serve to lessen the
uncertainty surrounding the effectiveness and cost-effectiveness of these treatments. Head to head
trials of apixaban versus rivaroxaban, dabigatran and fondaparinux would strengthen the evidence
base for these comparisons.
The key parameters that drive cost-effectiveness are the relative risks for ‘total VTE and all-cause
death’ and ‘bleeding events’. These were derived from single trials. Additional trials that support
these results could be valuable.
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