Cost-effectiveness of New Oral Anticoagulants for the Prevention of Stroke in Patients with Atrial Fibrillation in Low and Middle-Income Countries: A Systematic Review

Background: Low- and middle-income (LMICs) countries are facing with a high incidence of cardiovascular diseases and limited resources for confronting these diseases. Atrial fibrillation(AF) is the most common cardiac arrhythmia in the world that is associated with significant morbidity and mortality. This study assessed cost-effectiveness studies of novel oral anticoagulants(NOACs) compared to Warfarin for the prevention of stroke in patients with AF in LMICs. Methods: In this systematic review study, electronic databases were searched for economic evaluation studies about NOACs cost-effectiveness conducted in LMICs between 2008 and 2019. The selection of studies for review was also based on the PICO (population, intervention, comparison, and outcomes) guidelines. In this study, the population was restricted to patients with atrial fibrillation living in LMICs. We identified three types of drugs (apixaban, rivaroxaban, dabigatran, and edoxaban) as interventions and warfarin as the comparison therapy. Quality of Health Economic Studies checklist was used to evaluate the quality of the included articles. Results: Sixteen articles were extracted, including four cost-effectiveness analyses and two cost-utility analyses. QHES scores ranged from 58 to 87.5 out of a possible 100 points, with a mean score of 77.34. The results of the study showed that from a social perspective, Edoxaban is the most cost-effective therapeutic option compared to warfarin and other NOACs, but Warfarin was much more cost-effective than Rivaroxaban and Apixaban. Furthermore, NOACs were more cost-effective than warfarin from the payer perspective, but from the health system perspective, all NOACs were dominated by warfarin. Conclusion: The present systematic review demonstrates that from a social perspective, Edoxaban is the optimal alternative to warfarin other NOACs for stroke prevention in patients with AF in (LMICs). one study was found on the economic evaluation of NOACs and warfarin in patients with AF in low-income countries, so further research on the economic evaluation of these drugs is recommended.