DOACs overtaking warfarin as go-to anticoagulant for Medicaid patients

Direct oral anticoagulants (DOACs) are on their way to surpassing warfarin as the anticoagulant of choice among Medicaid beneficiaries, despite their higher cost, according to new research published in the Journal of the American College of Cardiology.

DOACs such as dabigatran, rivaroxaban, apixaban and edoxaban are safer and easier to use than warfarin, noted lead author Clara Ting, PharmD, and colleagues—but their out-of-pocket costs ranging from $387 to $525 for a one-month supply may be difficult to cover for patients with limited resources, including many of those on Medicaid.

However, Ting et al.’s analysis of anticoagulant usage patterns among 74 million Medicaid beneficiaries from 2010 through 2017 suggests the higher cost didn’t restrict the growth in DOAC prescriptions. DOACs accounted for just 0.2 percent of all oral anticoagulant prescriptions in the fourth quarter of 2010 and exploded to 46.5 percent of oral anticoagulant prescriptions in the fourth quarter of 2017.

Anticoagulant use in general also grew during that seven-year period, increasing from 0.19 percent of total Medicaid prescriptions to 0.41 percent of all prescriptions.

“Despite their greater cost, DOACs may soon overtake warfarin as the predominant oral anticoagulant prescribed to Medicaid beneficiaries,” wrote Ting and co-authors, all with Brigham and Women’s Hospital in Boston. “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.”

DOACs—also called non-vitamin K oral anticoagulants, or NOACs—are gaining momentum in replacing warfarin for multiple clinical scenarios. On Jan. 28, the American College of Cardiology, American Heart Association and Heart Rhythm Society published a focused update to their joint guidelines for managing patients with atrial fibrillation, concluding DOACs are now the preferred treatment option over warfarin for reducing stroke risk in that population.

In making this recommendation, the authors cited the lower bleeding risk of DOACs as well as their equal of better efficacy at reducing stroke or systemic embolism in four recent randomized trials.

Among Medicaid beneficiaries, Ting et al. found dabigatran prescriptions increased rapidly after the medication was approved in October 2010 but then steadily declined from 2012 to 2017. Edoxaban use was low following its 2015 approval, but rivaroxaban and apixaban use increased throughout the study period.

“We speculate that rivaroxaban’s once-daily administration and apixaban’s favorable safety profile drive clinician preferences for these DOACs,” the researchers wrote. “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.”

The authors pointed out their research lacked specific patient-level and cost data, but nevertheless highlighted the increasing use of DOACs among Medicaid beneficiaries over time.