Costs and effectiveness of ximelagatran for stroke prophylaxis in chronic atrial fibrillation

Context Recent trials have found that ximelagatran and warfarin are equally effective in stroke prevention for patients with atrial fibrillation. Because ximelagatran can be taken in a fixed, oral dose without international normalized ratio monitoring and may have a lower risk of hemorrhage, it might improve quality-adjusted survival compared with dose-adjusted warfarin. Objective To compare quality-adjusted survival and cost among 3 alternative therapies for patients with chronic atrial fibrillation: ximelagatran, warfarin, and aspirin. Design Semi-Markov decision model. Patients Hypothetical cohort of 70-year-old patients with chronic atrial fibrillation, varying risk of stroke, and no contraindications to anticoagulation therapy. Main Outcome Measures Quality-adjusted life-years (QALYs) and costs in US dollars. Results For patients with atrial fibrillation but no additional risk factors for stroke, both ximelagatran and warfarin cost more than $50000 per QALY compared with aspirin. For patients with additional stroke risk factors and low hemorrhage risk, ximelagatran modestly increased quality-adjusted survival (0.12 QALY) at a substantial cost ($116000 per QALY) compared with warfarin. For ximelagatran to cost less than $50000 per QALY it would have to cost less than $1100 per year or be prescribed to patients who have an elevated risk of intracranial hemorrhage (>1.0% per year of warfarin) or a low quality of life with warfarin therapy. Conclusion Assuming equal effectiveness in stroke prevention and decreased hemorrhage risk, ximelagatran is not likely to be cost-effective in patients with atrial fibrillation unless they have a high risk of intracranial hemorrhage or a low quality of life with warfarin.