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Chan YH, Chen SW, Chan CY, Chao TF. Comparative safety and effectiveness of non-vitamin K oral anticoagulants versus warfarin in patients with non-valvular atrial fibrillation: A network meta-analysis. J Formos Med Assoc 2024; 123:578-586. [PMID: 37996330 DOI: 10.1016/j.jfma.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/21/2023] [Accepted: 10/13/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The introduction of non-vitamin K antagonist oral anticoagulants (NOACs), with a non-inferior or superior clinical efficacy profile compared to vitamin K antagonists (VKAs), has significantly improved the safety profile and treatment adherence of patients with non-valvular atrial fibrillation (AF). However, few studies have compared the effectiveness and safety of NOACs. Therefore, we conducted this systematic review and network meta-analysis to compare the safety and clinical effectiveness of NOACs and VKAs in patients with non-valvular AF. METHODS An online bibliographic search was conducted to retrieve real-world evidence studies published between January 2019 and June 2022. RESULTS Dabigatran was associated with lower risks of major bleeding, ischemic stroke, and intracranial hemorrhage than warfarin. Among the NOACs, only dabigatran had a lower risk of all-cause mortality than warfarin. Dabigatran was also associated with lower risks of major bleeding and intracranial hemorrhage than rivaroxaban. CONCLUSION Our meta-analysis confirms that dabigatran's real-world safety and clinical effectiveness align with the results of pivotal clinical trials.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Chih-Yu Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Wong ES, Done N, Zhao M, Woolley AB, Prentice JC, Mull HJ. Comparing total medical expenditure between patients receiving direct oral anticoagulants vs warfarin for the treatment of atrial fibrillation: evidence from VA-Medicare dual enrollees. J Manag Care Spec Pharm 2021; 27:1056-1066. [PMID: 34337995 PMCID: PMC10391145 DOI: 10.18553/jmcp.2021.27.8.1056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Direct oral anticoagulants (DOACs) are an alternative to warfarin for treatment of atrial fibrillation (AF). Evidence demonstrating the efficacy and safety of DOACs has primarily been from clinical trial settings. The real-world effectiveness of DOACs in specific nontrial populations that differ in age, comorbidity burden, and socioeconomic status is unclear. OBJECTIVE: To compare total downstream medical expenditure between AF patients treated with warfarin and DOACs dually enrolled in the Veterans Affairs (VA) Healthcare System and fee-for-service Medicare. METHODS: This was an exploratory treatment effectiveness study that analyzed VA administrative data and Medicare claims. We examined patients with an incident diagnosis for AF and initiated warfarin or DOAC treatment between 2012 and 2015. The primary outcome was total medical expenditure over 3 years following treatment initiation. To address potential informative censoring, we applied a multipart estimator that extends traditional 2-part models to separate differences between groups due to survival and cost accumulation effects. Inverse probability weighting was applied to address potential treatment selection bias. RESULTS: We identified 31,276 and 17,021 patients receiving warfarin and DOACs, respectively. Mean unadjusted (SD) expenditure was higher for warfarin ($56,265 [$96,666]) compared with DOAC patients ($32,736 [$52,470]). Compared with patients receiving DOACs, adjusted 3-year expenditure was $25,688 (P < 0.001) higher for patients receiving warfarin. CONCLUSIONS: VA patients with AF initiating warfarin incurred markedly higher downstream expenditure compared with similar patients receiving DOACs. The benefits of DOACs found in previous clinical trials were present in this population, suggesting that these DOACs may be the preferred option for treatment of AF in older VA patients. DISCLOSURES: This study was funded by a VA Health Services Research and Development Investigator Initiated Research Award (IIR 15-139). Support for VA/CMS data was provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the University of Washington, Northeastern University, and Boston University. The authors declare no conflicts of interest. This research includes data obtained from the VHA Office of Performance Measurement (17API2), which resides within the Office of Analytics and Performance Integration (API), under the Office of Quality and Patient Safety (QPS; formerly known as RAPID). An oral presentation documenting a subset of the findings from this study was presented at the 2020 AcademyHealth Annual Research Meeting, delivered virtually on July 29, 2020.
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Affiliation(s)
- Edwin S Wong
- VA Puget Sound Health Care System, Seattle, WA, and Department of Health Services, University of Washington, Seattle
| | - Nicolae Done
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
| | - Molly Zhao
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
| | | | - Julia C Prentice
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, and Department of Psychiatry, Boston University, Boston, MA
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, and Department of Surgery, Boston University, Boston, MA
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Kumana CR, Cheung BMY, Siu DCW, Tse HF, Lauder IJ. Non-vitamin K Oral Anticoagulants Versus Warfarin for Patients with Atrial Fibrillation: Absolute Benefit and Harm Assessments Yield Novel Insights. Cardiovasc Ther 2017; 34:100-6. [PMID: 26727005 DOI: 10.1111/1755-5922.12173] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Benefits and/or harms (including costs) of non-vitamin K oral anticoagulants (NOACs) versus warfarin therapy need appreciation in relative and absolute terms. METHODS Accordingly, we derived clinically relevant relative and absolute benefit/harm parameters for NOACs (apixaban, dabigatran, rivaroxaban, edoxaban) compared to warfarin from four clinical trials involving atrial fibrillation (AF) patients. For each trial, we tabulated patient numbers enduring four important outcomes and calculated unadjusted relative risk reduction (RRR) and number needed to treat (NNT)/year values (and 95% confidence intervals) for the NAOC compared to warfarin. These outcomes were as follows: stroke/systemic embolism (primary endpoint), hemorrhagic stroke, major bleeds, and death. We also addressed drug acquisition costs. RESULTS Each NOAC was noninferior to warfarin for primary-outcome prevention; RRRs were 12-33% and NNT/year values were 182-481, and all but one indicated statistically significant superiority. All the NOACs yielded statistically significant reductions in hemorrhagic stroke risk; RRRs were 42-74% and NNT/year values were 364-528. Major bleeding risk was comparable in both groups. Apixaban yielded a lower NNT/year for preventing death than for primary-outcome prevention. Compared to warfarin, NOAC acquisition costs were 70- to 140-fold greater. CONCLUSIONS For the primary outcome, the absolute benefits of NOACs were modest (NNT/year values being large). Reduced hemorrhagic stroke rates with NOACs could be due to superior embolic infarct prevention and fewer consequential hemorrhagic transformations. Among apixaban recipients, the absolute mortality benefit exceeded that for the primary outcome, indicating prevention of additional unrelated deaths. The substantially greater NOAC acquisition costs need viewing against probable greater safety and the avoidance of monitoring bleeding risks.
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Affiliation(s)
- Cyrus R Kumana
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Bernard M Y Cheung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - David C W Siu
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Hung-Fat Tse
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Ian J Lauder
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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Álvarez-Otero J, de la Fuente-Aguado J, Arias-Castaño J, González-González L, Puerta-Louro R, Araújo-Fernández S. Dabigatrán: experiencia en la práctica clínica habitual. Rev Clin Esp 2015; 215:385-90. [DOI: 10.1016/j.rce.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/05/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
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Dabigatran: Experience in standard clinical practice. Rev Clin Esp 2015. [DOI: 10.1016/j.rceng.2015.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Tsivgoulis G, Krogias C, Sands KA, Sharma VK, Katsanos AH, Vadikolias K, Papageorgiou SG, Heliopoulos I, Shiue H, Mitsoglou A, Liantinioti C, Athanasiadis D, Giannopoulos S, Piperidou C, Voumvourakis K, Alexandrov AV. Dabigatran etexilate for secondary stroke prevention: the first year experience from a multicenter short-term registry. Ther Adv Neurol Disord 2014; 7:155-61. [PMID: 24790645 DOI: 10.1177/1756285614528064] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There are growing concerns for the side effects of dabigatran etexilate (dabigatran), including higher incidence of dyspepsia and gastrointestinal bleeding. We conducted a multicenter early implementation study to prospectively evaluate the safety, efficacy and adherence to dabigatran for secondary stroke prevention. METHODS Consecutive atrial fibrillation (AF) patients with ischemic stroke (IS) or transient ischemic attack (TIA) received dabigatran for secondary stroke prevention during their hospital stay according to American Heart Association recommendations at five tertiary care stroke centers. The study population was prospectively followed and outcomes were documented. The primary and secondary safety outcomes were major hemorrhage and all other bleeding events respectively defined according to RE-LY trial methodology. RESULTS A total of 78 AF patients (mean age 71 ± 9years; 54% men; 81% IS, 19% TIA; median CHADS2 (Congestive heart failure, Hypertension, diabetes mellitus, age >75 years, prior stroke or TIA); range 2-5) score 4 were treated with dabigatran [(110mg bid (74%); 150mg bid (26%)]. During a mean follow-up period of 7 ± 5 months (range 1-18) we documented no cases of IS, TIA, intracranial hemorrhage, systemic embolism or myocardial infarction in AF patients treated with dabigatran. There were two (2.6%) major bleeding events (lower gastrointestinal bleeding) and two (2.6%) minor bleedings [hematuria (n = 1) and rectal bleeding (n = 1)]. Dabigatran was discontinued in 26% of the study population with high cost being the most common reason for discontinuation (50%). DISCUSSION Our pilot data indicate that dabigatran appears to be safe for secondary stroke prevention during the first year of implementation of this therapy. However, high cost may limit the long-term treatment of AF patients with dabigatran, leading to early discontinuation.
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Affiliation(s)
- Georgios Tsivgoulis
- University of Athens, School of Medicine, Iras 39, Gerakas Attikis, Athens, 15344, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Kara A Sands
- Comprehensive Stroke Center, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, and YLL School of Medicine, National University of Singapore, Singapore
| | - Aristeidis H Katsanos
- Department of Neurology, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | | | - Ioannis Heliopoulos
- Department of Neurology, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Harn Shiue
- Comprehensive Stroke Center, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Athina Mitsoglou
- Department of Neurology, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Chrissoula Liantinioti
- Second Department of Neurology, University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Athanasiadis
- Vascular Unit, Third Department of Surgery, School of Medicine, University of Athens, School of Medicine, Athens, Greece
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Charitomeni Piperidou
- Department of Neurology, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | | | - Andrei V Alexandrov
- Department of Neurology, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
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Abstract
For years, the pharmaceutical industry has been trying to find a safe and effective drug to replace warfarin. Although warfarin is an effective anticoagulant, its pharmacology, adverse effects, and risk profiles dictate that patients taking this medication must be monitored judiciously. The US Food and Drug Administration has approved two drugs for commercial use, dabigatran and rivaroxaban, that will compete directly with warfarin for use in specific indications. Because of direct marketing to patients, physicians are being asked to comment on these new medications. This brief review illustrates the data available for the two new drugs when compared to warfarin for the specified indications. For some patients, these drugs may be highly beneficial and offer an excellent alternative to warfarin. For others, warfarin may still be the preferred drug.
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