, Volume 37, Issue 2, pp 279–289 | Cite as

Cost-Effectiveness Analysis of Direct-Acting Oral Anticoagulants for Stroke Prevention in Thai Patients with Non-Valvular Atrial Fibrillation and a High Risk of Bleeding

  • Thananan Rattanachotphanit
  • Chulaporn LimwattananonEmail author
  • Onanong Waleekhachonloet
  • Phumtham Limwattananon
  • Kittisak Sawanyawisuth
Original Research Article



The objective of this study was to assess the cost effectiveness of direct-acting oral anticoagulants for stroke prevention in Thai patients with non-valvular atrial fibrillation and a HAS-BLED score of 3.


Total costs (US$) in 2017 and quality-adjusted life-years were estimated over 20 years using a Markov model. A base-case analysis was conducted under a societal perspective, which included direct healthcare, non-healthcare and indirect costs in Thailand. Clinical events for warfarin and utilities were obtained from Thai patients whenever possible. The efficacy of direct-acting oral anticoagulants was derived from trial-based East Asian subgroups and adjusted for time in the target international normalized ratio range of warfarin.


In the base case, use of apixaban instead of warfarin incurred an additional cost of US$20,763 per quality-adjusted life-year gained. Substituting apixaban with rivaroxaban and rivaroxaban with high-dose edoxaban would incur an additional cost per quality-adjusted life-year by US$507 and US$434, respectively. Compared with warfarin, high-dose edoxaban had the lowest incremental cost-effectiveness ratio of US$9704/quality-adjusted life-year, followed by high-dose dabigatran (incremental cost-effectiveness ratio US$11,155/quality-adjusted life-year). The incremental cost-effectiveness ratios based on a payer perspective were similar. The incremental cost-effectiveness ratio was below Thailand’s cost-effectiveness threshold when high-dose dabigatran and edoxaban prices were reduced by 50%. Changes in key parameters had a minimal impact on incremental cost-effectiveness ratios.


For both societal and payer perspectives, high-dose edoxaban with a price below the country cost-effectiveness threshold should be the first anticoagulant option for Thai patients with non-valvular atrial fibrillation and a high risk of bleeding.



The authors thank Dr. Cynthia R. Gross and Dr. Jeffrey Roy Johns for providing editing assistance. The authors also thank four reviewers for valuable comments.

Author Contributions

TR provided the study concept and design, and contributed to the analysis and interpretation of the data and drafting of the paper. CL provided the study concept and design, contributed to the analysis and interpretation of the data and drafting of the paper, and critically revised the paper for intellectual content. OW contributed to the analysis and interpretation of the data. PL and KS critically revised the paper for intellectual content. All authors were involved in the final approval of the version to be published and agree to be accountable for all aspects of the work.


This study was funded by the Faculty of Pharmaceutical Sciences, Khon Kaen University.

Compliance with Ethical Standards

Conflicts of interest

Thananan Rattanachotphanit, Chulaporn Limwattananon, Onanong Waleekhachonloet, Phumtham Limwattananon, and Kittisak Sawanyawisuth have no conflicts of interest that are directly relevant to the contents of this study.

Data Availability

All data generated or analyzed during this study are included in this published article and its Electronic Supplementary Material.

Supplementary material

40273_2018_741_MOESM1_ESM.docx (262 kb)
Supplementary material 1 (DOCX 261 kb)


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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of Clinical Pharmacy, Faculty of PharmacyMahasarakham UniversityMahasarakhamThailand
  2. 2.Division of Clinical Pharmacy, Faculty of Pharmaceutical SciencesKhon Kaen UniversityKhon KaenThailand
  3. 3.Neurosurgery Residency Program, Department of Surgery, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
  4. 4.Department of Internal Medicine, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand

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