What are the prescribing patterns, temporal trends, and reasons for treatment modification of oral anticoagulants in adults with VTE in the US?
DOACs have largely replaced warfarin for VTE treatment in the US, accounting for over 85% of initiations by 2019-2020, with most patients persisting on therapy for about 6 months.
Importance The 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. Objectives To evaluate prescribing patterns of OACs for patients with VTE and identify clinical events that precede treatment changes. Design, Setting, and Participants This 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. Exposures Warfarin and the DOACs rivaroxaban, apixaban, dabigatran, and edoxaban. Main Outcomes and Measures Characteristics 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. Results A 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 Relevance This 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.
Iyer et al. (Wed,) studied this question.