A quantitative analysis by researchers from the UK has shown that high-dose (150 mg twice daily) dabigatran etexilate has positive net health benefits in patients with nonvalvular atrial fibrillation (AF) when compared with both low-dose (110 mg twice daily) dabigatran and warfarin.

Dabigatran is a promising alternative to warfarin. However, the benefit–harm ratio and cost effectiveness of this drug has not been established or compared with that of warfarin.

Pink et al. constructed a model using data from the RE-LY study to simulate two identical 50,000-strong cohorts of patients with AF. Over a theoretical lifetime, both low-dose and high-dose dabigatran were associated with incremental net health benefits (0.094 and 0.146 quality-adjusted life years [QALY] gained, respectively) when compared with warfarin. Incremental costs per QALY gained were UK£43,074 and £23,082, respectively. Therefore, the high dose of dabigatran was superior to the low dose, providing greater incremental benefit at a lower cost. However, the probablility of the high dose being a cost-effective alternative to warfarin at a threshold of £20,000 per QALY gained was only 45%. The researchers indicate that, in the real-world setting, high-dose dabigatran is only likely to be cost-effective compared with warfarin in patients at high risk of stroke or in whom international normalized ratio is poorly controlled.

The researchers conclude by suggesting that “a stratified approach may represent the best approach to maximize both the clinical effectiveness and cost effectiveness of anticoagualtion”.