Clinical Review

Selecting a Direct Oral Anticoagulant for the Geriatric Patient with Nonvalvular Atrial Fibrillation

Journal of Clinical Outcomes Management. 2015 December;22(12)

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Harrington et al [80] compared the cost-effectiveness of dabigatran, rivaroxaban, and apixaban versus warfarin. This cost-effectiveness study used published clinical trial data to build a decision model, and results indicated that for patients ≥ 70 years of age with an increased risk for stroke, normal renal function, and no previous contraindications to anticoagulant therapy, apixaban 5 mg, dabigatran 150 mg, and rivaroxaban 20 mg were cost-effective substitutes for warfarin for the prevention of stroke in nonvalvular AF [80]. Apixaban was the preferred anticoagulant for their hypothetical cohort of 70-year-old patients with nonvalvular AF, as it was most likely to be the cost-effective treatment option at all willing-to-pay thresholds > $40,000 per quality-adjusted life-year gained [76,81].

Prescription costs may vary depending on payor and level of insurance. If a patient does not have prescription insurance, the annual price of generic warfarin is roughly $200 to $360, depending on dosage. Approximate annual costs for the DOACs are greater than 20 times the cost of warfarin (apixaban $4500, dabigatran $4500, and rivaroxaban $4800) [82]. However, most patients on these medications are over 65 years old and have prescription coverage through Medicare Part D. Of note, patients may have more of a burden if or when they reach the “donut hole” coverage gap. Currently, once patients spend $2960 (for 2015) and $3310 (for 2016) on covered drugs they will fall into the donut hole unless they qualify for additional assistance. At this point Medicare Part D will reimburse 45% of the cost of the newer anticoagulants since generics are currently unavailable. As a result, individual affordability may become an issue. Further complicating the scenario is the inability to apply coupon and rebate cards in the setting of government-funded prescription coverage. Clinicians should discuss these issues with their patients to help select the most valuable therapy.

Conclusions And Recommendations

With life expectancy among the elderly continuing to improve, the number of patients requiring chronic anti-coagulation will continue to rise. Understanding the strengths and limitations of oral anticoagulants and the literature to support their use is essential to select the most appropriate agent in the geriatric patient. When selecting an anticoagulant strategy, clinicians should consider clinical data, patient factors, and patient preferences. Figure 2 provides a suggested anticoagulant selection pathway to complement the clinical decision process [83,84].

Corresponding author: Luigi Brunetti, PharmD, MPH, Rutgers University, 160 Frelinghuysen Rd, Piscataway, NJ 08854, brunetti@pharmacy.rutgers.edu.