According to a cost-effectiveness analysis published in Blood Advances, fondaparinux costs less, confers more benefits, and averts more adverse events than argatroban in patients with suspected heparin-induced thrombocytopenia (HIT). Rivaroxaban averts the most adverse events (AEs) but is also associated with higher medical costs.

“Factor Xa inhibitors [have] gradually replace[d] approved treatment with intravenous direct thrombin inhibitors despite their off-label indication, because of easier management and favorable economic profile. Whether they are cost-effective remains unclear,” wrote Aleksandra Tuleja, MD, and colleagues of the University of Bern, Switzerland.

The researchers used census data, between 2015 and 2018, from the largest hospital in Switzerland to evaluate the cost-effectiveness of approved and off-label anticoagulants in patients with suspected HIT.

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The team constructed a model reflecting important clinical events associated with HIT. They obtained cost data from the hospital finance department or estimated it based on the Swiss-wide cost tariff. The primary outcome parameters were estimated averted AEs and an incremental cost-effectiveness ratio. To assess the robustness of the study results, the team performed sensitivity analyses using simulations.

In the base-case analysis, the researchers estimated that the total cost of averting 1 AE was 49,565 Swiss francs (CHF) for argatroban, 30,380 CHF for fondaparinux, and 30,610 CHF for rivaroxaban and, after adjusting for the 4Ts score, 41,152 CHF, 27,710 CHF, and 37,699 CHF, respectively.

The team found that fondaparinux and rivaroxaban were more clinically effective than argatroban, averting 0.82, 0.83, and 0.92 AEs for argatroban, fondaparinux, and rivaroxaban, respectively. Results of the simulations were concordant with those of the base-case analysis.

“This is the first cost-effectiveness analysis comparing argatroban with fondaparinux and rivaroxaban using primary data,” the researchers wrote in their report. “Fondaparinux and rivaroxaban resulted in more averted AEs, but fondaparinux had greater cost savings. Fondaparinux could be a viable alternative to argatroban.”

Limitations of the study included small sample sizes (54 patients and 6 AEs), which were addressed using the simulations; exclusion of costs for arterial thrombotic events and amputations; and potential confounding by indication and treatment allocation bias.

“Our study suggests that fondaparinux is a viable alternative to argatroban and should be considered. Future studies involving more participants by expanding the modeling to a national population are needed to confirm our findings,” concluded the authors.


Tuleja A, Salvador D, Muka T, et al. Cost-effectiveness analysis of alternative anticoagulation in suspected heparin-induced thrombocytopenia. Blood Adv. 2022;6(10):3114-3125. doi:10.1182/bloodadvances.2022007017