Trends in the Use of Oral Anticoagulants for Adults With Venous Thromboembolism in the US, 2010-2020

Abstract

ImportanceThe introduction of direct oral anticoagulants (DOACs) has transformed the treatment of venous thromboembolism (VTE). Large health care databases offer valuable insight into how oral anticoagulants (OACs) are used in clinical practice and may aid in understanding reasons for changes in therapy.ObjectivesTo evaluate prescribing patterns of OACs for patients with VTE and identify clinical events that precede treatment changes.Design, Setting, and ParticipantsThis retrospective cohort study used data from a public (Medicare fee-for-service) and a commercial (IBM MarketScan) health insurance database on 298 609 patients initiating OACs within 90 days of index VTE hospitalization from January 1, 2009, to December 31, 2020. Statistical analysis was conducted from April to August 2022.ExposuresWarfarin and the DOACs rivaroxaban, apixaban, dabigatran, and edoxaban.Main Outcomes and MeasuresCharacteristics of patients initiating different OACs, along with trends over time of patients initiating OACs, were compared. Time receiving continuous anticoagulant therapy, patterns of anticoagulant discontinuation (treatment gap of ≥30 days), and treatment switches were assessed. Clinical events in the 30 days preceding treatment modifications were identified.ResultsA total of 203 378 individuals with Medicare (mean [SD] age, 76.9 [7.6] years; 122 554 women [60.3%]) and 95 231 with commercial insurance (mean [SD] age, 57.6 [15.8] years; 47 139 women [49.5%]) were included (N = 298 609). Warfarin was the most frequent OAC prescribed (163 044 [54.6%]), followed by rivaroxaban (66 882 [22.3%]) and apixaban (65 997 [22.1%]). The proportion of patients initiating DOACs increased from 0% in 2010 to 86.8% (22 420 of 25 817) in 2019 for patients with Medicare and 92.1% (4012 of 4357) in 2020 for commercially insured patients. Patients with chronic kidney disease were more likely to initiate warfarin (35 561 [11.9%]) or apixaban (16 294 [5.5%]) than rivaroxaban (10 136 [3.4%]), and those with a history of bleeding were more likely to initiate apixaban (5424 [1.8%]) than rivaroxaban (3007 [1.0%]). Overall, patients received persistent OAC treatment for approximately 6 months (Medicare: median, 175 days [IQR, 76-327 days]; commercial insurance: median, 168 days [IQR, 83-279 days]). A total of 33 011 patients (11.1%) switched anticoagulant therapy within a year. Switching to another anticoagulant was preceded most frequently by codes for a VTE diagnostic procedure (27.2% of all switchers [8983 of 33 011]).Conclusions and RelevanceThis cohort study using data from 2 US health insurance databases suggests that most patients with VTE continued oral anticoagulant treatment for approximately 6 months. Clinical reasons for modifying anticoagulant therapy were identified in one-third of patients. Identifying reasons for treatment modification is crucial for generating valid evidence on drug safety and effectiveness.

Initiation patterns of anticoagulants for atrial fibrillation among older UK adults with and without chronic kidney disease, 2010–2020

“…Our study findings are aligned with the existing literature, showing a decline in warfarin use in favour of DOACs in the general AF population, 28–30 and generally consistent with the limited available literature examining AF patients with CKD. A prior study examining anticoagulant use in newly admitted nursing home residents with AF and CKD (2011–2018) noted a clear preference for warfarin among patients with CKD compared with those without CKD 31 ; whereas, our study found a more modest difference in warfarin use between patients with CKD and non-CKD.…”

Racial and Ethnic Disparities in Initiation of Direct Oral Anticoagulants Among Medicare Beneficiaries

“…Our study findings are generally consistent with the available literature on the general trends in DOAC use in the US and globally . A Medicare study of older data from 2012 to 2014 found that Black patients had 25% lower odds of initiating DOACs compared with White patients, whereas Hispanic patients exhibited similar odds .…”

“…26 Our study findings are generally consistent with the available literature on the general trends in DOAC use in the US and globally. 12,14,[27][28][29][30] A Medicare study of older data from 2012 to 2014 found that Black patients had 25% lower odds of initiating DOACs compared with White patients, whereas Hispanic patients exhibited similar odds. 14 Another investigation of 12 417 patients with AF who were 21 years or older in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II registry from 2013 to 2016 found that Black patients were 40% less likely to use DOACs compared with White patients.…”

Pulmonary Infarction Due to Direct-acting Oral Anticoagulant Malabsorption

“…5 After the US Food and Drug Administration approved DOACs for the secondary prevention of VTE, DOACs quickly overtook warfarin as the most commonly initiated oral anticoagulants for VTE, and the American Society of Hematology currently recommends DOACs as the treatment of choice for VTE. 6,7 While studies comparing VTE patients' mortality and PE risk show DOACs do not provide an advantage over warfarin, DOACs do not require the INR monitoring, dietary restrictions, and dose adjustments required in warfarin use. 7 Overall failure rates of anticoagulation with DOACs are low, with failure being more common in patients with a hypercoagulable condition such as malignancy and antiphospholipid syndrome as well as in patients with mechanical heart valves.…”