The economic impact of enoxaparin versus unfractionated heparin for prevention of venous thromboembolism in acute ischemic stroke patients

ClinicoEconomics and Outcomes Research, Apr 2012

The economic impact of enoxaparin versus unfractionated heparin for prevention of venous thromboembolism in acute ischemic stroke patients Graham F Pineo1, Jay Lin2, Lieven Annemans31Department of Medicine, University of Calgary, Calgary, Alberta, Canada; 2Novosys Health, Flemington, NJ; 3Department of Medicine, Ghent University, Ghent and Brussels University, Brussels, BelgiumAbstract: Venous thromboembolism (VTE) is a common complication after acute ischemic stroke that can be prevented by the use of anticoagulants. Current guidelines from the American College of Chest Physicians recommend that patients with acute ischemic stroke and restricted mobility receive prophylactic low-dose unfractionated heparin or a low-molecular-weight heparin. Results from clinical studies, most recently from PREVAIL (PREvention of Venous Thromboembolism After Acute Ischemic Stroke with LMWH and unfractionated heparin), suggest that the low-molecular-weight heparin, enoxaparin, is preferable to unfractionated heparin for VTE prophylaxis in patients with acute ischemic stroke and restricted mobility. This is due to a better clinical benefit-to-risk ratio, with the added convenience of once-daily administration. In line with findings from modeling studies and real-world data in acutely ill medical patients, recent economic data indicate that the higher drug cost of enoxaparin is offset by the reduction in clinical events as compared with the use of unfractionated heparin for the prevention of VTE after acute ischemic stroke, particularly in patients with severe stroke. With national performance measures highlighting the need for hospitals to examine their VTE practices, the relative costs of different regimens are of particular importance to health care decision-makers. The data reviewed here suggest that preferential use of enoxaparin over unfractionated heparin for the prevention of VTE after acute ischemic stroke may lead to reduced VTE rates and concomitant cost savings in clinical practice.Keywords: acute ischemic stroke, cost savings, enoxaparin, unfractionated heparin, venous thromboembolism

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The economic impact of enoxaparin versus unfractionated heparin for prevention of venous thromboembolism in acute ischemic stroke patients

ClinicoEconomics and Outcomes Research The economic impact of enoxaparin versus unfractionated heparin for prevention of venous thromboembolism in acute ischemic stroke patients Graham F Pineo 2 Jay Lin 1 Lieven Annemans 0 0 Department of Medicine, Ghent University, Ghent and Brussels University , Brussels , Belgium 1 Novosys Health , Flemington, NJ , USA 2 Department of Medicine, University of Calgary , Calgary, Alberta , Canada Venous thromboembolism (VTE) is a common complication after acute ischemic stroke that can be prevented by the use of anticoagulants. Current guidelines from the American College of Chest Physicians recommend that patients with acute ischemic stroke and restricted mobility receive prophylactic low-dose unfractionated heparin or a low-molecular-weight heparin. Results from clinical studies, most recently from PREVAIL (PREvention of Venous Thromboembolism After Acute Ischemic Stroke with LMWH and unfractionated heparin), suggest that the low-molecular-weight heparin, enoxaparin, is preferable to unfractionated heparin for VTE prophylaxis in patients with acute ischemic stroke and restricted mobility. This is due to a better clinical benefit-to-risk ratio, with the added convenience of once-daily administration. In line with findings from modeling studies and real-world data in acutely ill medical patients, recent economic data indicate that the higher drug cost of enoxaparin is offset by the reduction in clinical events as compared with the use of unfractionated heparin for the prevention of VTE after acute ischemic stroke, particularly in patients with severe stroke. With national performance measures highlighting the need for hospitals to examine their VTE practices, the relative costs of different regimens are of particular importance to health care decision-makers. The data reviewed here suggest that preferential use of enoxaparin over unfractionated heparin for the prevention of VTE after acute ischemic stroke may lead to reduced VTE rates and concomitant cost savings in clinical practice. acute ischemic stroke; cost savings; enoxaparin; unfractionated heparin; venous - n w o d h c r a e s e R s e m o c t u O d n a s c i m o n o c E o c i n il C open access to scientific and medical research Introduction Worldwide, stroke is the second leading cause of death1 and its impact is expected to increase with the westernization of lifestyles in developing countries. In addition to high rates of mortality, stroke is responsible for significant long-term morbidity, with permanent disability experienced by 15%–30% of stroke patients and 20% of patients requiring institutional care at 3 months after onset.2 There is also a considerable health care burden associated with long-term morbidity due to stroke, such that the total (direct and indirect) costs of stroke were estimated to be $73. 9 billion in 2010 in the United States alone.2 Approximately 85% of all strokes are ischemic events2,3 that usually occur as a result of thrombosis or embolism. Venous thromboembolism (VTE) is also a common, yet highly preventable, complication following stroke.4 To reduce the incidence of VTE in patients with acute ischemic stroke and restricted mobility, guidelines from the American College of Chest Physicians recommend prophylaxis with low-dose unfractionated heparin or a low-molecular-weight heparin (LMWH).5 Although none of the LMWHs is indicated for thromboprophylaxis specifically in patients with acute ischemic stroke, these patients are often categorized as medical patients with reduced mobility, a group of patients for which the LMWHs dalteparin and enoxaparin are indicated for thromboprophylaxis. This review discusses the risk of VTE in stroke patients, describes studies evaluating the efficacy and safety of VTE prophylaxis after acute ischemic stroke, and details the relative costs of different thromboprophylaxis regimens, with particular emphasis on data from the PREVAIL (PREvention of Venous Thromboembolism After Acute Ischemic Stroke with LMWH and UFH) study.6–8 Thromboembolic risk in stroke patients ltdedaoohm lrspeoonaF trFhiosrlkolomwobfionasgisfaufiorrrtshtpesurtlrmtohkoreon,ampraybtoieetmnictsbeoavlrieesnmatt,)s,iigeren,ciVfiucrTarEenntlt(ydsietnrecoprkeeva,seeoidnr fr r myocardial infarction. A recent study of 1,150,336 adult hospitalizations with ischemic stroke in the United States using data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, demonstrated that although inhospital mortality decreased from 1998–1999 to 200 6–2007 , the largest increase in medical complications in these patients was observed for deep vein thrombosis (0.46% versus 0.79%) and pulmonary embolism (0.11% versus 0.27%).9 In the absence of thromboprophylaxis, 20%–75% of stroke patients may develop deep vein thrombosis, with the wide range depending on the methods used to detect deep vein thrombosis and the degree of lower limb paralysis.10,11 Pulmonary embolism is f (...truncated)


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Graham F Pineo, Jay Lin, Lieven Annemans. The economic impact of enoxaparin versus unfractionated heparin for prevention of venous thromboembolism in acute ischemic stroke patients, ClinicoEconomics and Outcomes Research, 2012, pp. 99-107, DOI: 10.2147/CEOR.S30857