In talking to healthcare leaders about drug utilization, I’ve fielded many questions concerning the application of clinical evidence to specific drugs and drug categories. I address one popular topic below.
DEAR LUMERE: I would like to standardize my hospital formulary to a single novel oral anticoagulant (NOAC). Is there evidence demonstrating the best option for treating and preventing venous thromboembolism (VTE)? – NEEDING NOAC KNOWLEDGE
DEAR NEEDING NOAC KNOWLEDGE: For more than 50 years, warfarin was the only oral anticoagulant approved for use in the US. This changed with the launch of Pradaxa (dabigatran) in 2010, which introduced a novel mechanism for reducing clotting. Of the four NOAC options now on the market, the award for the best VTE treatment and prevention goes to Eliquis (apixaban).
For outpatient treatment of acute VTE, the consistent efficacy and superior safety1 of Eliquis relative to warfarin and other NOACs make it cost effective2. For example, in indirect analyses of the NOACs in patients with VTE, Eliquis appears to be associated with a lower risk of major or clinically relevant non-major bleeding than other NOACs. Eliquis is also recommended for inpatients to achieve higher patient safety for discharge to home.
Enoxaparin and unfractionated heparin are recommended for VTE prophylaxis in medical and surgical patients during hospitalization3. However, for orthopedic surgery patients continuing medication at home, Eliquis provides the best balance of safety, efficacy and cost effectiveness4.
Hospitals looking to streamline their formularies can standardize to Eliquis, relying on therapeutic interchange or home meds for patients who have previously been prescribed a different NOAC.
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1Source: “Indirect Comparison of Dabigatran, Rivaroxaban, Apixaban and Edoxaban for the Treatment of Acute Venous Thromboembolism.” Mantha S, Ansell J, Journal of Thrombosis and Thrombolysis, (2/2015)
2 Clinical event rates from RE-SONATE, EINSTEIN-EXT, and AMPLIFY-EXT trials were used to measure recurrent VTE reduction. When the NOACs were compared to placebo, medical costs were reduced for dabigatran (-$2,794), rivaroxaban (-$2,948), apixaban 2.5mg (-$4,249) and apixaban 5mg (-$4,244). This study was supported by the manufacturer of apixaban, so the results should be interpreted cautiously until further studies exist for comparison. Source: “Evaluation of Medical Costs Avoided When New Oral Anticoagulants Are Used for Extended Treatment of Venous Thromboembolism Based on Clinical Trial Results.” Amin A, Jing Y, Trocio J, Lin J, et al. Journal of Thrombosis and Thrombolysis, (8/2015)
3 Source: “Prevention and Treatment of Venous Thromboembolism–International Consensus Statement.” Nicolaides AN, Fareed J, et al. International Angiology: A Journal of the International Union of Angiology, (4/2013)
4 When NOACs were considered for extended prophylaxis beyond the guideline-recommended 3 months for VTE prophylaxis, apixaban had an incremental cost per QALY gained of $4400 compared to dabigatran, $980 compared to rivaroxaban and $17,150 compared to LMWH with warfarin. Source: Cost-Effectiveness of Apixaban Compared to Other Anticoagulants for Lifetime Treatment and Prevention of Recurrent Venous Thromboembolism.” Lanitis T, Hamilton M, et al. Value in Health: The Journal of the International Society for Pharmacoeconomics and Outcomes Research, (11/2014)