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
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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
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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)