Systematic Review Reveals Emicizumab Cost-Effectiveness Varies by Patient Population and Comparator in Hemophilia A Treatment
Key Insights
A comprehensive systematic review of 17 pharmacoeconomic studies found that emicizumab prophylaxis is more cost-effective than bypassing agents (search) in hemophilia A (search) patients with inhibitors across multiple countries.
The cost-effectiveness of emicizumab compared to recombinant factor VIII varies significantly across different healthcare systems and economic settings, with mixed results depending on local pricing and GDP levels.
Emicizumab demonstrated lower cost-effectiveness compared to newer treatments including recombinant factor VIII Fc fusion protein (search) and gene therapy valoctocogene roxaparvovec in patients without inhibitors.
A comprehensive systematic review analyzing the cost-effectiveness of emicizumab for hemophilia A (search) treatment has revealed significant variations in economic outcomes depending on patient populations and comparator therapies. The study, published in Frontiers in Public Health, examined 17 pharmacoeconomic studies conducted between 2020 and 2025 across diverse healthcare systems worldwide.
Clear Cost Advantage in Inhibitor Patients
The review found consistent evidence that emicizumab prophylaxis offers superior cost-effectiveness compared to bypassing agents (search) (BPAs) in patients with hemophilia A (search) who have developed factor VIII (search) inhibitors. Eight studies demonstrated this advantage across multiple countries including Peru, Brazil, Italy, South Korea, France, Iran, India, and Thailand.
In Peru, emicizumab saved USD 14.6 to 16.0 million per child and USD 11.8 million per adult compared to current BPA prophylaxis from the Ministry of Health perspective. The treatment increased quality-adjusted life years (QALYs) by 0.36 per child and 0.56 per adult while reducing costs, establishing emicizumab as a dominant strategy.
Similarly, in Italy, emicizumab prophylaxis proved more effective with 0.94 additional QALYs and cost savings of EUR 19.4 to 24.4 million (USD 22.89 to 28.79 million) per patient lifetime compared to BPA prophylaxis in patients who failed immune tolerance induction.
Mixed Results Against Factor VIII Replacement
The cost-effectiveness comparison between emicizumab and recombinant factor VIII (rFVIII) showed variable results across different studies and healthcare settings. Four studies found emicizumab more cost-effective, while two studies reached different conclusions.
From the US payer and societal perspective, the Institute for Clinical and Economic Review (search) found emicizumab prophylaxis had lower costs with equivalent bleeding outcomes and QALYs, saving USD 1.506 million compared to rFVIII. In Canada, emicizumab proved cost-saving among 2-year-old males with severe hemophilia A (search), resulting in 29 and 16 fewer lifetime bleeds compared to standard half-life and extended half-life FVIII, respectively.
However, a US study examining mild or moderate hemophilia A (search) patients without inhibitors found emicizumab more effective with 0.4 additional QALYs but significantly more costly, with an incremental cost-effectiveness ratio of USD 14.5 million per QALY, exceeding typical willingness-to-pay thresholds.
Challenges Against Newer Therapies
Two studies comparing emicizumab with recombinant factor VIII Fc fusion protein (search) (rFVIIIFc) consistently favored the latter in patients without inhibitors. In the United Kingdom, rFVIIIFc prophylaxis demonstrated lower costs, greater QALYs, and fewer bleeds over 23.23 life years. Total costs were GBP 5,978,424 (USD 7,592,598) for rFVIIIFc compared to GBP 10,593,306 (USD 13,453,498) for emicizumab.
The emergence of gene therapy presents additional challenges for emicizumab's economic position. A Netherlands study comparing emicizumab with valoctocogene roxaparvovec found the gene therapy more effective and cost-saving over a 10-year horizon, with 7.03 versus 6.90 QALYs and EUR 2,839,210 (USD 3,037,954) versus EUR 4,252,167 (USD 4,549,818) in total costs.
Clinical Context and Global Impact
Hemophilia A (search) affects approximately 218,800 people globally according to the World Federation of Hemophilia's 2023 survey, with 80-85% classified as hemophilia A cases. The development of factor VIII (search) inhibitors represents a major treatment complication, affecting up to one-third of patients with severe hemophilia A receiving prophylaxis.
Emicizumab, a recombinant humanized bispecific monoclonal antibody, offers distinct advantages through its subcutaneous administration and reduced dosing frequency. Clinical trials demonstrated significant bleeding reduction, with annual bleeding rates of 2.9 events in the emicizumab prophylaxis group compared to 23.3 events without prophylaxis, representing an 87% reduction (p<0.001).
Study Quality and Limitations
The systematic review evaluated study quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist, finding generally good reporting quality with an average score of 79.64%. However, significant gaps were identified: 76.47% of studies insufficiently described stakeholder engagement, 58.82% lacked subgroup analysis methods, and 47.06% failed to provide contextual information influencing findings.
These quality gaps undermine external validity and limit the generalizability of findings across different healthcare systems and patient populations. The authors emphasized the need for more comprehensive stakeholder input and region-specific cost estimations in future pharmacoeconomic evaluations.
Implications for Clinical Decision-Making
The review's findings suggest that treatment selection should consider patient-specific factors, particularly inhibitor status, alongside local healthcare economics. For patients with inhibitors, emicizumab consistently demonstrates cost-effectiveness advantages over bypassing agents (search). However, for patients without inhibitors, the choice between emicizumab and factor replacement therapies requires careful consideration of local pricing, healthcare infrastructure, and patient preferences.
The authors concluded that emicizumab represents a valuable addition to the hemophilia A (search) treatment armamentarium, particularly for inhibitor patients, while acknowledging that optimal treatment selection requires individualized assessment considering both clinical and economic factors in specific healthcare contexts.