Abstract
Discontinuation of oral anticoagulants may expose non-valvular atrial fibrillation (NVAF) patients to an increased risk of stroke. This study describes the real-world discontinuation rates and compared the risk of drug discontinuation among NVAF patients initiating apixaban, warfarin, dabigatran, or rivaroxaban. This retrospective cohort study evaluated newly-anticoagulated NVAF patients in the MarketScan® data population from 01/01/2012 through 12/31/2014. Discontinuation was defined as a lack of subsequent prescription of the index drug within 30 days after the last supply day of the last prescription. A Cox model was used to estimate the hazard ratio (HR) of discontinuation, adjusted for age, sex, and comorbidities. Among 45,361 eligible NVAF patients, 15,461 (34.1%) initiated warfarin; 7,438 (16.4%) apixaban; 4,661 (10.3%) dabigatran; and 17,801 (39.2%) initiated rivaroxaban treatment. Compared to warfarin, patients who initiated dabigatran (adjusted HR [aHR]: 0.84, 95% confidence interval [CI]: 0.80–0.87, P<0.001), rivaroxaban (aHR: 0.70, 95% CI: 0.68–0.73, P<0.001), or apixaban (aHR: 0.57, 95% CI: 0.55–0.60, P<0.001) were 16%, 30%, and 43% less likely to discontinue treatment, respectively. When compared to apixaban, patients who initiated dabigatran (aHR: 1.46, 95% CI: 1.38–1.54, P<0.001) or rivaroxaban (aHR: 1.23, 95% CI: 1.17–1.28, P<0.001) were more likely to discontinue treatment. Among newly-anticoagulated NVAF patients in the real-world setting, initiation on rivaroxaban, dabigatran, or apixaban was associated with a significantly lower risk of discontinuation compared to warfarin. When compared to apixaban, patients who initiated treatment with warfarin, dabigatran, or rivaroxaban were more likely to discontinue treatment.
Highlights
While warfarin is highly effective for preventing stroke in patients with atrial fibrillation (AF), there is significant inter- and intra-patient variability in dose requirements, necessitating regular anticoagulation monitoring
Among all non-Vitamin K antagonist oral anticoagulants (NOACs) approved for non-valvular AF (NVAF), apixaban is the only drug that has shown, in its respective clinical trial(s), to have a significantly lower discontinuation rate than warfarin possibly due to its significantly better safety and tolerability profile [6,8,9]
Patients who initiated dabigatran, rivaroxaban, or apixaban were 16%, 30%, and 43% less likely to discontinue treatment, respectively
Summary
While warfarin is highly effective for preventing stroke in patients with atrial fibrillation (AF), there is significant inter- and intra-patient variability in dose requirements, necessitating regular anticoagulation monitoring. Warfarin is associated with many diet and drug interactions and can be associated with a significant rate of major bleeding, intracranial hemorrhage [1,2] Given these difficulties, many at-risk AF patients do not receive warfarin or receive an inadequate dose, and often discontinue therapy [1,2]. Among all NOACs approved for non-valvular AF (NVAF), apixaban is the only drug that has shown, in its respective clinical trial(s), to have a significantly lower discontinuation rate than warfarin (or aspirin) possibly due to its significantly better safety and tolerability profile [6,8,9]. Due to the moderate half-life of NOACs, it is important for patients to continue to take medications daily, as indicated For both warfarin and NOACs, drug discontinuation and missing doses (ie, lower adherence) may expose AF patients to an increased risk of stroke. For the purposes of this analysis, there were insufficient real-world data available for edoxaban in the United States
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