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Research Article
21 May 2025

Cost–effectiveness and budget impact analysis of switching from apixaban to rivaroxaban treatment among patients with nonvalvular atrial fibrillation in a German healthcare setting

Authors: Rupesh Subash [email protected], Thomas Strakosch, Michelle Zhang, Melissa Hagan, Elke Dworatzek, Agnes Kisser https://orcid.org/0009-0009-1486-8795, Vasileios Vasilopoulos, Chloe Salter, Carissa Dickerson https://orcid.org/0000-0002-2450-0902, and Ewa Stawowczyk https://orcid.org/0009-0003-1446-4607Author Info & Affiliations
Volume 14, Number 6
https://doi.org/10.57264/cer-2025-0008
PDFFormats

Abstract

Aim: Direct oral anticoagulant (DOAC) switching often occurs in patients with nonvalvular atrial fibrillation (NVAF) for medical and nonmedical reasons. Limited data describe the economic consequences of DOAC switching in patients with NVAF. This study evaluates the cost–effectiveness and budget impact of initiating apixaban and switching to rivaroxaban versus initiating and continuing apixaban for patients with NVAF, from a German payer perspective. Materials & methods: Built on an existing model, a cohort-level lifetime Markov model was developed, including dynamic pricing assumptions to account for anticipated generic entry of DOACs. The modeled population (n = 1000) included German patients with NVAF, eligible for oral anticoagulation, who initiated on apixaban. The primary model outcome was the incremental cost–effectiveness ratio, assessed using cost per quality-adjusted life year (QALY) gained and a willingness-to-pay threshold of €48,750/QALY. A secondary model outcome was a 5-year budget impact analysis. Results: Switching patients from apixaban to rivaroxaban led to 285 additional events per 1000 patient years, resulting in 0.079 fewer QALYs and higher total costs per patient (€21,357 vs €16,390 for apixaban continuers). In the base case analysis (with generic pricing assumptions), switching from apixaban to rivaroxaban was dominated (i.e., less effective and more costly) by continuing apixaban. In the budget impact analysis (with generic pricing assumptions), switching from apixaban to rivaroxaban led to additional cumulative costs of €490 per patient over 5 years. Conclusion: Despite the introduction of generic discounting, switching patients with NVAF from apixaban to rivaroxaban led to higher total costs and fewer QALYs under base case assumptions, meaning apixaban switchers were dominated by apixaban continuers from a German payer perspective. Switching patients from apixaban to rivaroxaban also led to greater budget impact over 5 years.

Plain language summary: Cost impact of switching patients with nonvalvular atrial fibrillation from apixaban to rivaroxaban compared with remaining on apixaban in Germany

What is this article about?

Atrial fibrillation (AF) is a heart rhythm disorder increasing the risk of blood clots and therefore stroke. Patients with nonvalvular AF (NVAF) are commonly prescribed direct-acting oral anticoagulants (DOACs), such as apixaban and rivaroxaban, to reduce this risk. DOAC switching is common in clinical settings for medical and nonmedical reasons, but few studies describe the economic implications of DOAC-to-DOAC switching in patients with NVAF. This study evaluates the cost–effectiveness and budget impact of switching patients with NVAF from apixaban to rivaroxaban versus continuing apixaban in Germany.

How was the research carried out?

A cost–effectiveness and budget impact analysis was conducted using a mathematical model that assessed clinical event incidence, quality-adjusted life years (QALYs, a metric combining quantity and quality of life) and costs in patients switching from apixaban to rivaroxaban versus continuing apixaban. The model used dynamic pricing to account for ongoing loss of exclusivity of DOACs and generic entry.

What were the results?

Cost–effectiveness analysis indicated that switching patients from apixaban to rivaroxaban led to more clinical events, fewer QALYs, and higher total costs versus continuing apixaban over a lifetime horizon, meaning apixaban switchers were dominated (less effective and more costly) by apixaban continuers. Switching from apixaban to rivaroxaban also led to greater budget impact over 5 years.

Why is the study important?

Switching patients with NVAF from apixaban to rivaroxaban increased healthcare costs and reduced QALYs due to higher clinical event incidence.
Despite generic rivaroxaban being available before generic apixaban, the lower price savings during this period do not offset the higher medical costs from increased clinical event management in apixaban switchers.

Supplementary Material

File (supplementary materials.docx)

References

Papers of special note have been highlighted as: • of interest; •• of considerable interest
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