Heart, Lung and Circulation (2015) 24, 860–868 ORIGINAL ARTICLE

1443-9506/04/$36.00
http://dx.doi.org/10.1016/j.hlc.2015.02.018

Cost-Effectiveness Analysis of
Fondaparinux vs Enoxaparin in Non-ST
Elevation Acute Coronary Syndrome in
Thailand§
Unchalee Permsuwan, PhD a*,
Nathorn Chaiyakunapruk, PharmD, PhD b,c,d,e,
Surakit Nathisuwan, PharmD, BCPS f, Apichard Sukonthasarn, MD g
a
Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
b
School of Pharmacy, Monash University Malaysia, Malaysia
c
Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
d
School of Population Health, University of Queensland, Brisbane, Australia
e
School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
f
Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
g
Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Received 27 August 2014; received in revised form 2 February 2015; accepted 20 February 2015; online published-ahead-of-print 14 March 2015

Background Non-ST elevation acute coronary syndrome (NSTE-ACS) imposes a significant health and economic burden
on a society. Anticoagulants are recommended as standard therapy by various clinical practice guidelines.
Fondaparinux was introduced and evaluated in a number of large randomised, controlled trials. This study
therefore aimed to determine the cost-effectiveness of fondaparinux versus enoxaparin in the treatment of
NSTE-ACS in Thailand.
Methods A two-part construct model comprising a one-year decision tree and a Markov model was developed to
capture short and long-term costs and outcomes from the perspective of provider and society. Effectiveness
data were derived from OASIS-5 trial while bleeding rates were derived from the Thai Acute Coronary
Syndrome Registry (TACSR). Costs data were based on a Thai database and presented in the year of 2013.
Both costs and outcomes were discounted by 3% annually. A series of sensitivity analyses were performed.

Results The results showed that compared with enoxaparin, fondaparinux was a cost-saving strategy (lower cost
with slightly higher effectiveness). Cost of revascularisation with major bleeding had a greater impact on the
amount of cost saved both from societal and provider perspectives. With a threshold of 160,000 THB
((4,857.3 USD) per QALY in Thailand, fondaparinux was about 99% more cost-effective compared with
enoxaparin.

Conclusion Fondaparinux should be considered as a cost-effective alternative when compared to enoxaparin for
NSTE-ACS based on Thailand’s context, especially in the era of limited healthcare resources.
Keywords Fondaparinux  Enoxaparin  NSTE-ACS  Cost-Effectiveness  Thailand

§
All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
*Corresponding author at: Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand. Tel.: +66 54944355;
fax: +66 53222741, Email: unchalee.permsuwan@gmail.com
© 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier
Inc. All rights reserved.
Cost-Effectiveness Analysis of Fondaparinux vs Enoxaparin
Introduction
Acute coronary syndrome (ACS) encompasses a range
of conditions from unstable angina (UA) to ST-segment-
elevation myocardial infarction (STEMI). ACS associated
with non-ST segment elevation includes UA and non-ST
segment elevation MI (NSTEMI). ACS presents a unique
challenge to clinicians due to the high rate of mortality
and morbidity associated with these conditions [1]. UA
and NSTEMI share similar pathophysiology and clinical
presentations, but NSTEMI is characterised by an increase
in the biochemical markers of myocardial injury; hence, non-
ST elevation acute coronary syndrome (NSTE-ACS) has
become the preferred diagnosis for UA/NSTEMI [2].
NSTE-ACS imposes a health and economic burden on soci-
ety. Patients with NSTE-ACS are also at high risk of death.
According to the NICE clinical guideline 2010 for NSTE-ACS
[3], treatment with anticoagulants in addition to anti-platelet
agents such as aspirin and clopidogrel is recommended.
Although low-molecular-weight heparins (LMWHs) have
been demonstrated to reduce coronary events, they are asso-
ciated with an increased risk of bleeding, which can be
associated with an increased risk of death [1,4–6]. Appropri-
ate management of NSTE-ACS is challenging, as the benefit
of treatments in reducing cardiovascular associated mortality
must be balanced against a risk of bleeding.
Fondaparinux is a synthetic pentasaccharide that can
inhibit Factor Xa leading to inhibition of thrombin generation
[7]. Compared to LMWHs, this new agent possesses favour-
able pharmacokinetic and pharmacodynamic profiles
including high selectivity and specificity against Factor Xa,
complete absorption through subcutaneous injection and
long half-life allowing simple once daily fix dosing. This
agent has been tested and approved in a variety of conditions
such as prevention and treatment of venous thromboembo-
lism and acute coronary syndrome. Clinical effectiveness
data for fondaparinux in acute coronary syndrome is primar-
ily based on a large multi-centre pivotal trial (OASIS-5) [8]
which compared fondaparinux with enoxaparin for the treat-
ment of NSTE-ACS. Fondaparinux was demonstrated to be
non-inferior to enoxaparin in preventing death, MI, and
refractory ischaemia at nine days. Importantly, fondaparinux
was associated with a significant reduction in the rate of
major bleeding over both short- and longer term. The
short-term efficacy and the reduction in the number of cases
of bleeding with fondaparinux, translated to a reduction in
the longer-term mortality and morbidity of patients.
For Thailand, LMWHs have been the anticoagulant of
choice in the ACS setting especially enoxaparin. Enoxaparin
has to be administered twice daily and requires dose adjust-
ment for weight of individual patients. This not only increases
the cost of drug administration but also requires diligent effort
by clinicians to measure the patient’s weight and monitor the
drug dose accordingly. With limited healthcare resources in
Thailand, such issues can lead to problems in care of patients.
In addition, a reduction of bleeding associated with enoxa-
parin would provide a large cost saving to a developing
861
healthcare system. While data on cost-effectiveness of fonda-
parinux exists, such studies were done in the countries that
have vast differences in healthcare environment from
Thailand; hence, the application of data might be limited.
Therefore, the aim of our study was to conduct a cost-effec-
tiveness analysis comparing fondaparinux and enoxaparin in
patients with NSTE-ACS in Thailand using parameters and
data that reflect the local context, when available.
Methods
Overall Description
We used a Markov model to simulate NSTE-ACS patients
receiving fondaparinux compared to enoxaparin, which was
a standard treatment. We performed a cost-utility analysis
with incremental cost per quality-adjusted life year (QALY)
gained. The model simulated the life-time horizon to capture
long-term costs and effectiveness incurred. As recommended
by Thailand’s health technology assessment guidelines, the
study applied an annual discount rate of 3.0% to costs and
benefits [9] and was undertaken from a societal perspective
[10]. Costs included drug cost, cost of major bleeding, cost of
ACS first year after hospitalisation, cost of ACS in second and
subsequent years, and direct non-medical costs such as trans-
portation, care-giver time. Indirect cost was excluded to
avoid double-counting since QALY already counted morbid-
ity and mortality effect as a recommendation of Thailand’s
health technology assessment guidelines [11]. We also per-
formed analysis based on provider perspective, in which
only direct medical costs were included. All above costs were
adjusted with CPI [12] and presented in the year 2013. The
costs were converted at a rate of 32.94 baht per USD as the
average rate for 2013 [13].
Intervention and Comparators
We compared fondaparinux (at a dose of 2.5 mg once daily)
with enoxaparin (at a dose of 1 mg/kg body weight twice
daily) for six days in the treatment of patients with NSTE-
ACS. Due to the report from the OASIS-5 trial [8] regarding a
few cases of coronary and catheter-related thrombosis in
patients who underwent PCI, patients receiving fondapar-
inux who underwent revascularisation would receive
100 IU/kg of unfractionated heparin (UFH) to flush the
catheters. Enoxaparin is the most commonly prescribed
LMWH in Thailand. It is therefore considered to be the most
appropriate comparator as the treatment most likely to be
displaced by fondaparinux.
Study Cohort
The study cohort included only patients with NSTE-ACS.
The mean age of patients recruited in the OASIS-5 trial [8]
was 66.6 years so that we assumed our study cohort with age
started at 60 years and older. We also excluded the patients
with creatinine clearance (CrCl) < 30 ml/min. The dose of
medications was calculated based on 60 kg body weight for
our Thai patients.
862 U. Permsuwan et al.

Economic Model
The model in this study was a two-part construct with a
one-year decision tree, based effectiveness data on the
OASIS-5 trial [8], and a Markov model for capturing long-
term costs and benefits (Figure 1). A one-year decision tree
model was used in the first part because the efficacy of
fondaparinux in terms of the reduction of major bleeding
occurs rapidly after treatment. The OASIS-5 trial [8] provided
the safety outcome at day 9, day 30, and day 180. The result at
day 9 was used in this analysis owing to the clinical evidence
from the TACSR which demonstrated the average hospital-
isation of 8.6 days for UA patients and 11.8 days for NSTEMI
patients [14].
A decision tree began with cohort patients with NSTE-
ACS. Patients would receive either fondaparinux or
enoxaparin. After receiving medication, they underwent
revascularisation or continued receiving conservative medi-
cation treatment. The revascularisation included percutane-
ous coronary intervention (PCI) or/and coronary artery
bypass graft (CABG). Patients would further have a

Survive
No major bleeding
Die
No revascularization Death
Survive
Major bleeding
Die
Fondaparinux Death
Survive
No major bleeding
Die
Death
Revascularization
Survive
Major bleeding
Die
Death
NSTE-ACS
Survive
No major bleeding
Die
No revascularization Death
Survive
Major bleeding
Die
Death
Enoxaparin
Survive
No major bleeding
Die
Death
Revascularization
Survive
Major bleeding
Die
Death
A A one-year decision tree model

ACS Death

B A long-term Markov model

Figure 1 Model structure comparing fondaparinux and enoxaparin in non-ST elevation acute coronary syndrome patients.
Cost-Effectiveness Analysis of Fondaparinux vs Enoxaparin 863

possibility of major bleeding occurrence. At the end of one Likelihood of Events

year, patients would be either alive or dead. After the first
year, fondaparinux or enoxaparin treatment was discon-
tinued. We assumed that there was no remaining treatment
effect in the subsequent years. Therefore, each treatment
arm had similar transition probabilities in a Markov model
which comprised only two health states (ACS or death).
The difference occurred directly from the number of
patients entering into a Markov model. Patients might
continue staying in ACS health state or pass to death.
The model was run until patients aged 100 years or 40
cycles. The cycle length was one year.
Input Parameters
Effectiveness data were obtained from the OASIS-5 trial [8].
Costs were based on the Thai database. Major bleeding rates
and mortality were derived from the Thai Acute Coronary
Syndrome Registry (TACSR). The TACSR is a multi-centre
prospective project of nationwide registration in Thailand. A
total of 17 tertiary care hospitals located in different regions in
Thailand initially participated in the registry. The enrolment of
the patients started in August 2002. After three years, records
of 9,373 patients had been collected. Of those, 59.1% were
NSTE-ACS patients [14]. All input parameters and sources
of information used in the model are shown in Table 1.
We derived the probability of revascularisation and major
bleeding from the TACSR which was the largest cohort
study ever conducted in Thailand [2,15]. The probability
of major bleeding in patients undergoing revascularisation
was 5.8% which was very consistent with the report of 6% in
the OASIS-5 trial. In the case of no revascularisation, the
probability of major bleeding was still close to that from
OASIS-5 trial (4.2% vs 3%) respectively. Based on the safety
data from the OASIS-5 trial [8], the fondaparinux group had
a significantly lower rate of major bleeding at nine days than
the enoxaparin group (2.2% vs 4.1% respectively; hazard
ratio 0.52; 95%CI 0.44-0.61; p<0.001). We used the finding
from the OASIS-5 trial [8] to calculate the probability of
major bleeding for the fondaparinux arm in a decision tree
model.
The finding from the OASIS-5 trial [8] and the TACSR [2]
showed that patients who had major bleeding during hos-
pitalisation had higher rates of death. However, the mortality
rate with major bleeding reported in the TACSR was double
compared with the OASIS-5 trial (27.9% vs 13.2%). In the
same way, without major bleeding the mortality rate was
higher in the TACSR than that from the OASIS-5 trial (8.6% vs
2.8%). We decided to choose the data based on Thai database
because it reflected current clinical practice in Thailand.

Table 1 Input parameters.

Parameters Base case Range Source

Probabilities
Revascularisation 0.274 0.267-0.282 [15]
Major bleeding after revascularisation 0.058 0.052-0.064 [15]
Major bleeding without revascularisation 0.042 0.038-0.045 [15]
Death with major bleeding 0.279 0.251-0.308 [2]
Death without major bleeding 0.086 0.082-0.090 [2]
Effectiveness of fondaparinux (RR)
On major bleeding 0.52 0.44-0.61 [8]
Costs (THB, year of costing: 2013)
Fondaparinux1 1,320 352-2,112 GSK
Enoxaparin2 2,712 723.2-4,339.2 [18]
Heparin3 128 102.4-153.6 [18]
Revascularisation with major bleeding 386,130 295,536-1,067,795 [19]
Revascularisation with no major bleeding 315,422 305,612-325,232 [19]
No revascularisation with major bleeding 75,377 54,721-96,033 [19]
No revascularisation with no major bleeding 55,826 53,726-57,924 [19]
Direct non-medical cost 1st year 3,382 2,706-4,059 [20]
Direct non-medical cost 2nd year 4,4892 3,913-5,870 [20]
Cost of ACS 1st year 59,405 47,524-71,286 [20]
Cost of ACS 2nd year 13,584 10,867-16,300 [20]
Utility
ACS 0.605 0.509-0.920 [21]

1
Unit cost of fondaparinux sodium prefill syringe 2.5 mg/0.5 ml was 220 THB; Total six day treatment was 1,320 (220*6).
2
Unit cost of enoxaparin sodium 60 mg/0.6 ml was 226 THB; Total six day treatment was 2,712 (226*2*6).
3
Unit cost of heparin 5000 IU/ml was 128 THB.
864
Long-term mortality rate in the Markov model was based
on the age- and sex-specific mortality rate (ASMR) for the
Thai population [16]. However, ACS is a serious medical
condition associated with high morbidity and mortality
[14]. The additional mortality risk in ACS patients was quan-
tified in terms of a relative risk compared to the general Thai
population. This relative risk was based on a secondary
analysis of the Prospective Registry of Acute Ischaemic
Syndromes in the UK (PRAIS) study which followed-up
490 ACS patients for four years [17]. Therefore, we calculated
transition probability for ACS to death by multiplying ASMR
of Thai population by 1.8.
Healthcare Resources and Costs Parameters
Drug costs comprised fondaparinux, enoxaparin, and hepa-
rin. The unit price was 220 THB (6.68 USD)/2.5 mg/0.5 ml
tube, obtained from GSK. The reference prices of enoxaparin
and heparin were obtained from Drug and Medical Supply
Information Center (DMSIC), Ministry of Public Health
(http://dmsic.moph.go.th/price.htm) [18]. The standard
price of enoxaparin sodium 60 mg/0.6 ml was 226 THB
(6.86 USD) and heparin 5,000 IU/ml were 128 THB (3.88
USD). Based on the OASIS-5 trial [8], the treatment duration
lasted for six days. Enoxaparin was administered twice daily
while fondaparinux was once daily. Therefore, total costs of
enoxaparin and fondaparinux treatment were 2,712 THB
(82.33 USD) and 1,320 THB (40.07 USD) respectively. Patients
receiving fondaparinux who underwent revascularisation
would receive UFH 100 IU/kg to flush the catheters.
Costs of major bleeding were derived from the study by
Saokaew S. [19] which used the database of a University-
affiliated hospital in Bangkok. This study was a retrospective
cohort study of hospitalised patients with acute
coronary syndrome (n=346) comparing cost and length of
stay between those with and without bleeding. The cost of
major bleeding for patients who underwent revascularisation
and not revascularisation was 386,130 THB (SD=75,870) and
75,377 THB (SD=12,980), respectively. Patients who under-
went revascularisation, but did not have major bleeding
incurred 315,422 THB (SD=49,946), while the medical care
cost of those patients who did not undergo revascularisation
and no major bleeding was 55,826 THB (SD=10,523). The
attributable cost of major bleeding among those with revas-
cularisation was 70,708 THB (SD=25,923) and those without
revascularisation was 19,552 THB (SD=2,458).
Costs of ACS first year, second year, and direct non-medi-
cal costs were obtained from the study by Anukoolsawat P.
[20]. The first year ACS cost accounted for the costs incurred
after hospitalisation. Since this cost was not actually reported
in the study, we used the difference between the first year
average cost and the first year average admission cost. For the
second year and onward, we assumed the indifferent costs
were due to a paucity of cost data beyond the second year.
Utility
Due to the lack of direct utility elicitation from the Thai
population, we derived a utility based on the disability
weight of ACS patients used in a study by Tamteerano Y.
U. Permsuwan et al.
[21] from the Health Intervention and Technology Assess-
ment Program (HITAP). The utility was 0.605 with a range
from 0.509 to 0.92.
Analyses
The two alternatives were compared on the basis of the
increments in costs and effectiveness. The ICER was calcu-
lated by incremental cost divided by incremental effective-
ness yielding cost per QALY.
Sensitivity Analyses
A series of sensitivity analyses were performed. One-way
sensitivity analysis was carried out by varying each variable
while keeping other variables constant. Those varied varia-
bles were costs, relative risks, probabilities, and utility value.
Number of days that patients received either fondaparinux
or enoxaparin was also varied. This was due to the fact that
the treatment would last only three days for the treatment of
patients with NSTE-ACS as the routine clinical practice in
Thailand. For cost variables, we used 20% for upper and
lower range except for costs of major bleeding, for which data
were available [19]. For probability parameters, the range
would be mean  standard error. For other variables, the
study provided the base case value and its range. The results
of one-way sensitivity analysis were displayed as the tornado
diagram.
In addition, probabilistic sensitivity analysis (PSA) was
undertaken to address uncertainty in the assumptions under-
lying the model by allowing all of the input parameters’
values to vary simultaneously over their respective feasible
ranges within the model. All input parameters were assigned
a probability distribution to reflect their feasible range of
values. A beta distribution was chosen for probability and
utility parameters. A log-normal distribution was used for
RRs’ parameters. A gamma distribution, which ensures pos-
itive values, was assigned for all cost parameters. A thousand
iterations were performed. The results were displayed as a
cost-effectiveness acceptability curve which illustrates the
relationship between the willingness to pay for a unit of
outcome and the probability of favouring each strategy [22].
Results
Base Case Analysis
We found that fondaparinux treatment was a cost saving
strategy compared to enoxaparin treatment in both perspec-
tives. This was the result from less total cost of 962 THB (29.2
USD) and 1,286 THB (39.0 USD) from the perspectives of society
and provider respectively. Furthermore, NSTE-ACS patients
who received fondaparinux gained 0.04 more QALY than those
who received enoxaparin from both perspectives (Table 2).
Sensitivity Analyses
A series of one-way sensitivity analyses from both provider
and societal perspectives (Figure 2 and 3) showed that fon-
daparinux treatment was still a cost-saving strategy com-
pared with enoxaparin treatment. This was the result from
Cost-Effectiveness Analysis of Fondaparinux vs Enoxaparin 865

Table 2 Base case analyses.

Variable Societal Perspective Provider Perspective

Fondaparinux Enoxaparin Fondaparinux Enoxaparin

Costs (THB) 451,070 452,031 379,122 380,408

QALY 9.03 8.99 9.03 8.99
ICER (THB/QALY) Cost saving Cost saving

-1,60,000.00 -1,20,000.00 -80,000.00 -40,000.00 0.00

Cost of revas with bleeding (295,536-

1,067,795)

Discount rate (0-6)

Unit cost of enoxaparin (181-271)

Death with major bleeding (0.251-0.308)

Using the lower value

Cost of no revas with bleeding (54,721-96,033)

Unit cost of fondaparinux (176-264) Using the upper value

Utility (0.509-0.920)

RR of major bleeding (0.44-0.61)

RR of death from ACS (1.233-2.367)

Figure 2 One-way sensitivity analyses considering societal perspective.

ACS: acute coronary syndrome; bleeding: major bleeding; RR: relative risk; revas: revascularisation.

-1,60,000.00 -1,20,000.00 -80,000.00 -40,000.00 0.00

Cost of revas with bleeding (295,536-

1,067,795)

Discount rate (0-6)

Unit cost of enoxaparin (181-271)

Utility (0.509-0.92)

Death with major bleeding (0.251-0.308)

Using the lower value
Cost of no revas with bleeding (54,721-96,033)

Using the upper value

Unit cost of fondaparinux (176-264)

RR of major bleeding (0.44-0.61)

RR of death from ACS (1.233-2.367)

Figure 3 One-way sensitivity analyses considering provider perspective.

ACS: acute coronary syndrome; bleeding: major bleeding; RR: relative risk; revas: revascularisation.
866 U. Permsuwan et al.

the less incremental cost with a slightly higher gain in QALY.
Among 22 varied parameters, cost of revascularisation with
major bleeding had the high impact on cost saving. When it
was increased, fondaparinux treatment was more likely to be
a cost-saving strategy.
The result of PSA showed that at a 160,000 THB (4,857.3
USD) per QALY threshold in Thailand, fondaparinux treat-
ment was approximately 99% cost-effective compared with
enoxaparin from both provider and societal perspectives as
shown in Figures 4 and 5.

1.2

Fondaparinux
1
Probability of being cost-effective

0.8

0.6

0.4

0.2
Enoxaparin
0

Willingness to pay per QALY

Figure 4 Cost-effectiveness acceptability curve from societal perspective.

1.2

Fondaparinux
1
Probability of being cost-effective

0.8

0.6

0.4

0.2

Enoxaparin
0

Willingness to pay per QALY

Figure 5 Cost-effectiveness acceptability curve from provider perspective.

Cost-Effectiveness Analysis of Fondaparinux vs Enoxaparin
Discussion
Summary of Findings
Our findings demonstrate that fondaparinux is a cost-
effective strategy compared with enoxaparin in treating
patients with NSTE-ACS from both provider and societal
perspectives. We believe that the cost-effective or cost-saving
findings in our study are due mainly to two reasons. Firstly,
both medicines have no significant difference in acquisition
cost (226 vs 220 THB for enoxaparin and fondaparinux respec-
tively). Enoxaparin has a slightly higher total drug cost com-
pared with fondaparinux due to its twice daily administration.
Secondly, avoidance of costs associated with major bleeding
results in substantial saving. The study by Saokaew S. [19]
reported that the attributable cost of major bleeding among
those with revascularisation was 70,708 THB (2,146.6 USD)
and those without revascularisation was 19,552 THB (593.6
USD). Based on the result of one-way sensitivity analysis, we
found that cost of revascularisation with major bleeding was
the most influential parameter. When this cost was increased,
fondaparinux showed even better cost-saving.
In addition to our research work, another cost-effective-
ness study conducted by Pepe et al. [23] in Brazil reported
similar findings. From the Ministry of Health of Brazil, it was
found that fondaparinux resulted in cost-saving based on
less than one-year time horizon.
However, this study used a Markov model to simulate for
the life-time horizon to capture long-term costs and effective-
ness incurred. Our results are also consistent with findings of
other cost-effectiveness studies [24–26] which reported that
fondaparinux was a dominant strategy compared with enox-
aparin. However, those studies have different aspects from
this study such as differences in construct model and costs.
Strengths and Limitations
This study used clinical effectiveness based on a well-known
landmark clinical trial, the OASIS-5 trial [8], specifically
designed to evaluate non-inferiority of fondaparinux and
enoxaparin. The highly internal valid findings from this trial
suit well as inputs in our cost-effectiveness analysis. To make
our results applicable to the local context, we used local
inputs to reflect clinical practice and consequences associated
with bleeding. Most local inputs were derived from a large
registry of ACS patients receiving care in a number of hos-
pitals in Thailand. Furthermore, the cost of major bleeding
used in our model was obtained from a cohort study of 346
Thai ACS patients. This cost analysis was undertaken using a
standard generalised linear model with log-transformation
and Duan’s smearing estimator. Based on these, we believe
that our findings provide key relevant information aiding
policy makers to make informed decisions regarding
resource allocation, especially treating NSTE-ACS patients
in Thailand.
A number of key limitations of this study should be noted.
First, the study finding is limited to NSTE-ACS and may not
be applicable to all ACS patients. Second, the population
867
included in this study is those with CrCl  30 ml/min. There
remains limited evidence on the use of fondaparinux in ACS
patients with renal insufficiency. Third, costs of bleeding
were obtained from a single hospital. This would affect
overall generalisability of our findings. Fourth, we assume
lack of difference of both short- and long-term adverse effects.
Despite current evidence of no difference, clinicians and policy
makers should be aware of the changes in cost-effectiveness
value when new information related to adverse effects
becomes available.
Conclusions
In summary, our cost-effectiveness results show that, com-
pared with enoxaparin, fondaparinux is a cost-effective strat-
egy for treating only patients with NSTE-ACS in Thailand
from both provider and societal perspectives. Fondaparinux
should be considered as another cost-effective anticoagulant
alternative in Thailand during the era of limited healthcare
resources.
Funding Sources
This study was supported by GSK (Thailand). However, the
supporter did not have a role in directing the design, con-
ducting model analyses, interpreting the data, and preparing
this manuscript.
Conflict of Interest
All authors have no conflict of interest.
Acknowledgements
The authors would like to thank Dr. Surasak Saokaew
for providing assistance on cost analysis, and Dr. Naiyana
Praditsitthikorn and Ms. Pitsaphun Werayingyong for their
advice and comments on this cost-effectiveness study.
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