Value through Innovation31 July 2014
24 March 2011

Dabigatran etexilate is cost-effective for stroke prevention in atrial fibrillation, particularly in real-world clinical practice

Ingelheim, Germany, 24 March 2011 – A new economic analysis, published  online in Thrombosis and Haemostasis, suggested that Boehringer Ingelheim's novel oral direct thrombin inhibitor dabigatran etexilate is cost-effective compared to current treatment options, particularly in real-world clinical practice.1,2

This cost-effectiveness was driven by superior prevention of ischemic stroke alongside a reduction in devastating intracranial bleeding by dabigatran etexilate compared to well-controlled warfarin, in patients with atrial fibrillation (AF).1 When dabigatran etexilate was compared against current care, including ‘real-world' warfarin, it saved 4,733 Canadian dollars (CAD) on average per patient for prevention of events, such as stroke, and the subsequent associated follow-on costs.

Dr Stuart Connolly, principal investigator of the RE-LY® trial and co-author of the economic evaluation commented, "We want to do the best for patients and dabigatran is the medically preferred treatment for stroke prevention. From the analyses reported today, we now know that it is cost-effective too - good value to our scarce healthcare budget."

The economic model evaluated patients in Canada who were treated with dabigatran etexilate compared to those treated with warfarin in both 'trial-like' conditions (using the RE-LY® trial results) and in a "real-world" clinical practice setting, where patients either received warfarin, aspirin or no treatment. In the "real-world" clinical practice setting, dabigatran etexilate was shown to be particularly cost-effective compared to current care.1

In a 'real-world' setting, many patients are not being treated adequately for stroke prevention.3,4 This is primarily due to the well-documented limitations of warfarin. Dabigatran etexilate also does not require routine coagulation monitoring or dose adjustments, is not affected by food and has a low potential for drug-drug interactions.

The model showed that over a lifetime, dabigatran etexilate treated AF patients experienced fewer ischemic strokes and intracranial bleeds compared to current care, which largely offsets the acquisition cost of dabigatran etexilate compared to current treatment options.

The results showed:1

  • Patients treated with dabigatran etexilate suffered less ischemic strokes than patients treated with current care ("trial-like" warfarin or "real-world" warfarin, aspirin or no treatment)
  • Patients treated with dabigatran etexilate had less than half the number of intracranial bleeds compared to current care (0.49 dabigatran etexilate vs. 1.13 warfarin vs. 1.05 2 "real-world" prescribing)
  • Overall, dabigatran etexilate was cost-effective, especially when compared to ‘real world’ care 
                   o The incremental cost-effectiveness ratio (ICER) of 
                      dabigatran etexilate was $10,440/quality adjusted life year 
                      (QALY) versus "trial-like" warfarin and $3,962/QALY versus 
                      "real-world" warfarin, aspirin or no treatment).

Willingness to pay threshold for additional health benefits is an important element in healthcare decision makers' assessment of whether new therapies represent good value for money. In Canada, a willingness to pay threshold of CAD 30,000 per QALY-gained is considered acceptable while being conservative.1 The results for dabigatran etexilate fall well below this threshold.

AF is a leading cause of stroke5, which in turn is associated with higher mortality and costlier hospital stays than stroke in patients without AF.6-8 Additionally AF is associated with an increased risk of systemic embolism which may result in major damage to limbs and organs (e.g. embolism (blood clot) to the renal artery).9 While the economic cost of a stroke can be exorbitant, often entailing years of rehabilitation and supervised care, the emotional impact on patients and their families is also devastating.

This economic study modelled AF patients at risk of stroke while tracking clinical events (primary and recurrent ischemic strokes, systemic embolism, transient ischemic attack , haemorrhage (bleeds), acute MI (heart attack) and death) and resulting functional disability. Dabigatran etexilate dosing approved in Canada was used: 150 mg bid for patients <80 years and 110 mg bid for patients' ≥ 80 years.1

This analysis uses the results from the RE-LY® trial, the largest AF trial completed to date. In RE-LY®, dabigatran etexilate 150 mg bid significantly reduced the risk of stroke and systemic embolism by 35 percent beyond the reduction achieved with well-controlled warfarin (median TTR 67%) in addition to reductions in life-threatening and intracranial bleeding. These groundbreaking results were shown in RE-LY®, a PROBE (prospective, randomized, open-label with blinded endpoint evaluation) trial designed to compare two fixed doses of the oral direct thrombin inhibitor dabigatran (110 mg and 150 mg bid) each administered in a blinded manner, with open label warfarin.4,5 Pradaxa® 110 mg bid was shown to be as effective as warfarin. 10,11

NOTES TO EDITORS

Disclaimer
Recently, dabigatran etexilate has been approved for clinical use in stroke risk reduction in non-valvular AF in the USA, the prevention of stroke, and systemic embolism in adults with AF in Canada and the prevention of ischemic stroke and systemic embolism in patients with non-valvular AF in Japan , South Korea, Columbia and Indonesia.

About AF and stroke
AF is the most common heart rhythm condition,12 affecting nearly one in four people over the age of 4013 and 1% of the total population, rising to 10% in people over the age of 80.12 People with AF are more likely to experience blood clots, which increases the risk of stroke by five-fold.14,15 Up to three million people worldwide suffer strokes related to AF each year,5,16,17 which are typically severe and disabling, with one half of this population dying within one year.18 Strokes due to AF tend to be severe, with an increased likelihood of death (20%), and disability (60%).18 Many AF-related strokes can be prevented with appropriate antithrombotic therapy.19

About RE-LY®
RE-LY® (Randomized Evaluation of Long term anticoagulant therapY) was a global, phase III, randomised trial of 18,113 patients enrolled in over 900 centres in 44 countries. The PROBE (prospective, randomized, open-label with blinded endpoint evaluation) trial was designed to compare two fixed doses of the oral direct thrombin inhibitor dabigatran (110mg and 150mg bid) each administered in a blinded manner, with open label warfarin (target INR of 2.0-3.0). Patients were followed-up in the study for a median of 2 years with a minimum of 1 year follow-up.10,11

The primary endpoint of the trial was incidence of stroke (including haemorrhagic) or systemic embolism. Secondary outcome measures included all-cause death, incidence of stroke (including haemorrhagic), systemic embolism, pulmonary embolism, acute myocardial infarction, and vascular death (including death from bleeding).
Compared to well controlled warfarin, dabigatran etexilate showed in the trial:10,11

  • Significant reduction in the risk of stroke and systemic embolism – including haemorrhagic strokes with dabigatran etexilate 150mg bid
  • Significantly lower major bleeding events with dabigatran etexilate 110mg bid
  • Comparable rates of stroke/systemic embolism with dabigatran etexilate 110mg bid
  • Significantly lower life threatening and intracranial bleeding with both doses
  • Significant reduction in vascular mortality with dabigatran etexilate 150mg bid.

About dabigatran etexilate
Dabigatran etexilate is at the forefront of a new generation of oral anticoagulants/direct thrombin inhibitors (DTIs)2 targeting a high unmet medical need in the prevention and treatment of acute and chronic thromboembolic diseases.

Potent antithrombotic effects are achieved with direct thrombin inhibitors by specifically blocking the activity of thrombin (both free and clot-bound), the central enzyme in the process responsible for clot (thrombus) formation. In contrast to vitamin-K antagonists, which variably act via different coagulation factors, dabigatran etexilate provides effective, predictable and consistent anticoagulation with a low potential for drug-drug interactions and no drug-food interactions, without the need for routine coagulation monitoring or dose adjustment.

Dabigatran etexilate has already been approved in 75 countries under the trademark Pradaxa® (in Canada: Pradax®) for the primary prevention of venous thromboembolic events (blood clots) in adults who have undergone elective total hip or elective total knee replacement surgery.

About the dabigatran etexilate clinical trial programme
Boehringer Ingelheim’s clinical trial program to evaluate the efficacy and safety of dabigatran etexilate encompasses studies in:

  • Primary prevention of venous thromboembolism (VTE) in patients undergoing elective total hip and knee replacement surgeries
  • Treatment of acute VTE
  • Secondary prevention of VTE
  • Stroke prevention in AF.

Boehringer Ingelheim
The Boehringer Ingelheim group is one of the world’s 20 leading pharmaceutical companies. Headquartered in Ingelheim, Germany, it operates globally with 142 affiliates in 50 countries and more than 41,500 employees. Since it was founded in 1885, the family-owned company has been committed to researching, developing, manufacturing and marketing novel products of high therapeutic value for human and veterinary medicine.

In 2009, Boehringer Ingelheim posted net sales of 12.7 billion euro while spending 21% of net sales in its largest business segment Prescription Medicines on research and development.
For more information please visit www.boehringer-ingelheim.com

Please be advised
This release is from Boehringer Ingelheim Corporate Headquarters in Germany. Please be aware that there may be national differences between countries regarding specific medical information, including licensed uses. Please take account of this when referring to the information provided in this document. This press release is not intended for distribution within the USA or Canada.

References
1Sorensen SV, Kansal AR, Connolly S, et al. Cost-effectiveness of Dabigatran etexilate for the Prevention of Stroke and Systemic Embolism in Atrial Fibrillation: A Canadian payer perspective. Thromb Haemost 2011 Mar 22; [Epub ahead of print].
2Di Nisio M, et al. Direct Thrombin Inhibitors. N Engl J Med 2005; 353: 1028-40. 3van Walraven C, Jennings A, Oake N, et al. Effect of study setting on anticoagulation control: a systematic review and metaregression. Chest 2006 May; 129 (5): 1155-66.
4Dolan G, Smith LA, Collins S, et al. Effect of setting, monitoring intensity and patient experience on anticoagulation control: a systematic review and meta-analysis of the literature. Curr Med Res Opin 2008 May; 24 (5): 1459-72.
5Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991 Aug; 22 (8): 983-8.
6Diringer MN, Edwards DF, Mattson DT, et al. Predictors of acute hospital costs for treatment of ischemic stroke in an academic center. Stroke 1999 Apr; 30 (4): 724-8.
7Dulli DA, Stanko H, Levine RL. Atrial fibrillation is associated with severe acute ischemic stroke. Neuroepidemiology 2003 Mar-Apr 22 (2): 118-23.
8Slot KB, Berge E, Dorman P, et al. Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies. BMJ 2008 Feb 16; 336 (7640): 376-9.
9Frost L, Engholm G, Johnsen S, et al. Incident thromboembolism in the aorta and the renal, mesenteric, pelvic, and extremity arteries after discharge from the hospital with a diagnosis of atrial fibrillation. Arch Intern Med 2001 Jan 22; 161 (2): 272-6.
10Connolly SJ, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009; 361:1139-51.
11Connolly SJ, Ezekowitz MD, Yusuf S, Reilly PA, Wallentin L: Newly identified events in the RE-LY® trial. N Engl J Med 2010; 363(19): 1875-1876 (November 4th, 2010).
12Stewart S, Murphy N, Walker A, et al. Cost of an Emerging Epidemic: an Economic Analysis of Atrial Fibrillation in the UK. Heart 2004; 90:286-92.
13Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation. Circulation 2004; 110: 1042-6.
14Fuster V, Rydn LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation – executive summary. Circulation 2006; 114: 700-52.
15Kannel WB, et al. Final Draft Status of the Epidemiology of Atrial Fibrillation. Med Clin North Am. 2008; 92 (1): 17–ix.
16Atlas of Heart Disease and Stroke, World Health Organization, September 2004. Viewed July 2009 at http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf.
17Marini C, De Santis F, Sacco S, et al. Contribution of atrial fibrillation to incidence and outcome of ischaemic stroke: results from a population-based study. Stroke 2005; 36: 1115-9.
18Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation: the Framingham study. Stroke 1996; 27: 1760-4.
19Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med 1999; 131: 492-501.

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    Boehringer Ingelheim

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Media contact

  • Malin
    Boehringer Ingelheim

    Media & PR
    Dr Reinhard Malin
    Binger Strasse 173
    55216 Ingelheim am Rhein

    GERMANY

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