Time Trends and Treatment Pathways in Prescribing Individual Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation: An Observational Study of More than Three Million Patients from Europe and the United States.

Pareen Vora,Gunnar Brobert,Beth Russell,Henry Morgan Stewart,Alex Asiimwe,Pietro Scicchitano

doi:10.1155/2022/6707985

Pareen Vora, Gunnar Brobert + Show 4 more

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https://doi.org/10.1155/2022/6707985

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Abstract

Background Data directly comparing trends in the use of different oral anticoagulants (OACs) among patients with atrial fibrillation (AF) from different countries are limited. We addressed this using a large-scale network cohort study in the United States (US), Belgium, France, Germany, and the United Kingdom (UK). Methods We used nine databases (claims or electronic health records) that had been converted into the Observational Medical Outcomes Partnership Common Data Model with analysis performed using open-source analytical tools. We identified adults with AF and a first OAC prescription, either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC), from 2010 to 2017. We described time trends in use, continuation, and switching. Results In 2010, 87.5%–99.8% of patients started on a VKA. By 2017, the majority started on a DOAC: 87.0% (US), 88.3% (Belgium), 93.1% (France), 88.4% (Germany), and 86.1%–86.7% (UK). In the UK, DOACs became the most common starting OAC in 2015, 2-3 years later than elsewhere. Apixaban was the most common starting OAC by 2017, 50.2%–57.8% (US), 31.4% (Belgium), 45.9% (France), 39.5% (Germany), and 49.8%–50.5% (UK), followed by rivaroxaban, 24.8%–32.5% (US), 25.7% (Belgium), 38.4% (France), 24.9% (Germany), and 30.2%–31.2% (UK). Long-term treatment was less common in the US than in Europe, especially the UK. A minority of patients switched from their index OAC in the short and long term. Conclusions From 2010 to 2017, VKA use had significantly declined and DOAC use had significantly increased in the US and Europe. Apixaban was the most prescribed OAC in 2017, followed by rivaroxaban.

Highlights

Patients with atrial fibrillation (AF) at increased risk of stroke require long-term treatment with oral anticoagulants (OACs) to reduce their stroke risk. e introduction of direct oral anticoagulants (DOACs) as an alternative to vitamin K antagonists (VKAs) for stroke prevention in patients with AF over the last decade has resulted in a clear shift towards greater use of these drugs in this patient population. is newer class of drugs has demonstrated at least equivalent efficacy and safety to warfarin with a lower risk of intracranial bleeding in randomized controlled trials
Data were available from 2010 to 2017, for all sources except for the Longitudinal Prescription Diagnosis Database in the United States (US), which at the time of the study held information from 2011 to 2017, and the French Disease Analyzer database, which held data from 2012 to 2017. ese databases had been converted to a standardised format using Observational Medical Outcomes Partnership (OMOP) common data model, [18] which was developed through public-private partnership in the US. e common data model is updated by the Observational Health Data Sciences and Informatics (OHDSI) community—an interdisciplinary collaboration based on the principle of open-source data analytics [19]
Mean age at first OAC prescription ranged from 56.2 years (SD 7.1; US CCAE database) to 78.0 years (SD 7.3; US MDCR database), and females accounted for between 31% (UK CCAE database) and 47% (US MDCR and Germany Disease Analyzer (DA) database)

Summary

Introduction

Patients with atrial fibrillation (AF) at increased risk of stroke require long-term treatment with oral anticoagulants (OACs) to reduce their stroke risk. e introduction of direct oral anticoagulants (DOACs) as an alternative to vitamin K antagonists (VKAs) for stroke prevention in patients with AF over the last decade has resulted in a clear shift towards greater use of these drugs in this patient population. is newer class of drugs has demonstrated at least equivalent efficacy and safety to warfarin with a lower risk of intracranial bleeding in randomized controlled trials.[1,2,3,4] Currently, four DOACs are available on the market, approved at different times for stroke prevention in AF in the last decade—dabigatran (a thrombin inhibitor) was introduced in 2010, followed by the factor Xa inhibitors rivaroxaban, apixaban and, more recently, edoxaban.e change in the clinical landscape of OAC use away from VKAs towards DOACs and between individual DOACs, which have slightly different clinical profiles and dosing frequency, is evident from studies across several countries [5,6,7,8,9,10,11,12]. Using a large-scale network study approach, we aimed to characterize and compare time trends in the prescribing VKA and individual DOACs and OAC treatment pathways (including switching), among patients with AF in routine clinical practice in Belgium, France, Germany, the United States (US), and the United Kingdom (UK). Data directly comparing trends in the use of different oral anticoagulants (OACs) among patients with atrial fibrillation (AF) from different countries are limited. We addressed this using a large-scale network cohort study in the United States (US), Belgium, France, Germany, and the United Kingdom (UK). Apixaban was the most prescribed OAC in 2017, followed by rivaroxaban

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