Author + information
- Clara Ting, PharmD@ClaraTingPharmD,
- Christopher Fanikos, BS,
- Nayyra Fatani, PharmD,
- Leo F. Buckley, PharmD∗ (, )@BrighamWomens and
- John Fanikos, RPh, MBA
- ↵∗Division of Cardiovascular Medicine, Brigham and Women’s Hospital, 45 Francis Street, PBB-AB-314, Boston, Massachusetts 02115
The direct oral anticoagulants (DOAC) are safer and easier to use than warfarin. Little is known about DOAC use among socioeconomically disadvantaged populations, for whom DOAC cost (out-of-pocket cost of $387 to $525 for a 1-month supply) (1) may be prohibitive. We characterized DOAC use patterns among 74 million Medicaid beneficiaries in the United States between 2010 and 2017.
We used current and deprecated National Drug Codes to query the State Drug Utilization Database between October 2010 and December 2017 for warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban. We calculated the number of prescriptions over time for all oral anticoagulants and for each DOAC. We report absolute numbers of prescriptions and, for each anticoagulant, the number of prescriptions as a proportion of total oral anticoagulant prescriptions.
The total number of oral anticoagulant prescriptions increased from 246,558 (0.19% of total Medicaid prescriptions) in the fourth quarter of 2010 to 626,999 (0.41% of total Medicaid prescriptions) in the fourth quarter of 2017. Over the same period, the number of warfarin prescriptions increased from 246,096 (187 per 100,000 total Medicaid prescriptions) to 335,158 (219 per 100,000 total Medicaid prescriptions), while DOAC prescription rates increased from 462 prescriptions (0.35 per 100,000 total Medicaid prescriptions) to 291,841 prescriptions (190 per 100,000 total Medicaid prescriptions).
DOACs accounted for 0.2% of all oral anticoagulant prescriptions in the fourth quarter of 2010 compared with 46.5% in the fourth quarter of 2017 (Figure 1). Dabigatran use increased rapidly after approval in October 2010 before steadily declining from 2012 to 2017. Rivaroxaban and apixaban use increased consistently over the observed period, with a minor decline in apixaban use between the third and fourth quarters of 2017. Minimal edoxaban use was observed since its 2015 approval.
In summary, we report 2 important and recent trends in oral anticoagulant use among Medicaid beneficiaries. First, the number of warfarin and DOAC prescriptions is increasing over time. Second, DOAC prescriptions account for a growing proportion of total oral anticoagulant prescriptions, primarily due to rivaroxaban and apixaban use. These observations mirror patterns in contemporary DOAC registries (2) and have important public health implications.
The increasing incidence of hypercoagulable conditions (3), increasing anticoagulant use in low-risk patients (4), and Medicaid expansion in 2013 (5) suggest that many clinicians, including noncardiovascular specialists, will encounter a patient on, or will themselves prescribe, an oral anticoagulant. Clinicians should familiarize themselves with these effective yet potentially harmful agents.
Despite their greater cost, DOACs may soon overtake warfarin as the predominant oral anticoagulant prescribed to Medicaid beneficiaries. Due to the structure of the American health care system, the actual out-of-pocket expense to a patient varies widely and represents a fraction of the drug’s wholesale price. Although warfarin copays are likely less expensive than DOAC copays, this difference does not appear to preclude DOAC use. Moreover, we speculate that rivaroxaban’s once-daily administration and apixaban’s favorable safety profile drive clinician preferences for these DOACs. Relative underuse of dabigatran may be attributable to its gastrointestinal intolerance, whereas edoxaban’s underuse may be due to its unusual dosing (contraindicated if creatinine clearance >95 ml/min in atrial fibrillation) and being last to market.
This analysis lacked patient-level and cost data. Thus, we could not differentiate between new and existing users of oral anticoagulants or the characteristics of such persons. Nevertheless, oral anticoagulant use, primarily due to DOAC use, is increasing among Medicaid beneficiaries.
In conclusion, we found that DOACs have begun to displace warfarin as the predominantly used oral anticoagulant among patients with limited financial resources despite the higher overall cost of these agents.
Please note: Dr. Fanikos has served as a consultant for Boehringer Ingelheim. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- ↵GoodRx. Available at: https://www.goodrx.com/. Accessed November 9, 2018.
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