Credit: CDC
A new study suggests the use of novel oral anticoagulants (NOACs) has surpassed warfarin use in the last few years, but the cost burden for NOACs is much higher than that of warfarin.
By mid-2013, the NOACs dabigatran, rivaroxaban, and apixaban accounted for 62% of all new anticoagulant prescriptions included in the study, but this represented 98% of the total anticoagulant costs.
These findings and a related commentary appear in The American Journal of Medicine.
NOAC use on the rise
To better understand NOAC use, researchers analyzed medical and prescription claims data from the insurance company Aetna. They identified 6893 patients with atrial fibrillation (AF) who were prescribed an oral anticoagulant from 2010 to 2013.
During that time, 45,472 anticoagulant prescriptions were filled—26,253 (57.7%) for warfarin, 14,922 (32.8%) for dabigatran, 4241 (9.3%) for rivaroxaban, and 56 (0.1%) for apixaban.
The researchers noted that the US Food and Drug Administration (FDA) approved dabigatran for use in AF patients in October 2010. And by October 2011, patients were as likely to receive dabigatran as warfarin.
Rivaroxaban was FDA-approved for AF in November 2011, and, by June 2013, the drug had overtaken both warfarin and dabigatran. Apixaban use increased the least, as the drug gained FDA approval for AF in December 2012.
Though NOACs appeared to be on the rise overall, the researchers found NOAC use was significantly less likely for women, patients living in lower income areas, and patients with higher CHADS2, CHA2DS2-VASC, and HAS-BLED scores (P<0.001 for each variable).
The team said this finding is significant because, in the clinical trials supporting NOAC approvals, most patients had CHADS2/CHA2DS2-VASC scores in the higher ranges.
“The greatest absolute benefit from novel anticoagulants has been shown in clinical trials to be among patients at highest baseline risk for stroke or systemic embolization,” said lead investigator Niteesh K. Choudhry, MD, PhD, of Brigham and Women’s Hospital in Boston.
“[This] is at odds with our observation of [physicians selecting] seemingly lower-risk patients for these drugs. Such a finding may reflect provider conservatism for new drug adoption, particularly given longitudinal experience with warfarin.”
Higher costs
Dr Choudhry and his colleagues also found that NOACs confer high healthcare cost consequences. The data revealed that NOACs represented 98% of the total dollars spent on anticoagulants from 2010 to 2013.
Over the first 6 months, the average combined patient and insurer cost associated with starting a NOAC was $900 greater than the cost of starting warfarin.
“Average patient out-of-pocket and insurance spending was more than 5-fold and 15-fold higher, respectively, for novel anticoagulants as compared with warfarin,” Dr Choudhry said. “A 6-month difference in total costs of $900 in our cohort translates into billions of dollars at a national level.”
Taking their findings together, the researchers said this study suggests more information may be needed to fully understand the implications of rising NOAC prescriptions.
“These findings point to the need to conduct ongoing surveillance of the adoption of new agents into clinical practice,” Dr Choudhry said, “as well as the need for robust, real-world comparative-effectiveness analyses of these medications, to enable patients and providers to make informed decisions about their relative benefit, safety, and cost-effectiveness.”
