Use of warfarin down, DOACs up in commercially insured patients with cirrhosis, nonvalvular afib
While more than half of eligible patients with cirrhosis and concurrent nonvalvular atrial fibrillation did not receive anticoagulation between 2012 and 2019, use of direct oral anticoagulants (DOACs) increased substantially during that time, a recent study found.
From 2012 to 2019, direct oral anticoagulant (DOAC) use increased substantially among eligible patients with cirrhosis and concurrent nonvalvular atrial fibrillation (NVAF), a recent study found.
Researchers used MarketScan claims data to identify commercially insured U.S. patients with cirrhosis and NVAF who were eligible for oral anticoagulants (CHA2DS2-VASc score ≥2 in men or ≥3 in women). They calculated the yearly proportion of patients prescribed a DOAC, warfarin, or no oral anticoagulant and stratified patients by high-risk features (decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease, or end-stage renal disease). The primary outcome was prescription of an oral anticoagulant (including warfarin and the individual DOACs apixaban, rivaroxaban, and dabigatran) in the six months following the cohort entry date between 2012 and 2019. Results were published online Jan. 10 by the Journal of the American Heart Association.
Among 32,487 patients (mean age, 71.6 years; 38.5% women), 15.1% had decompensated cirrhosis and the mean CHA2DS2-VASc score was 4.2. Overall, 44.6% used oral anticoagulants within 180 days of NVAF diagnosis (DOACs, 20.2%; warfarin, 24.4%). Compared with nonusers of oral anticoagulants, users were less likely to have decompensated cirrhosis (18.6% vs. 10.7%), thrombocytopenia (19.5% vs. 12.5%), or chronic kidney disease/end-stage renal disease (15.5% vs. 14.0%). The proportion of oral anticoagulant users increased during the study period, from 39.4% in 2012 to 49.0% in 2019 (P<0.001). During that time, warfarin use decreased from 32.0% to 11.0%, whereas DOAC use increased from 7.4% to 38.0%; apixaban was the most prescribed DOAC (46.1%). Warfarin use decreased and DOAC use increased in all subgroups and across CHA2DS2-VASc categories. DOACs comprised 77.6% of all oral anticoagulant use in 2019, compared with 18.7% in 2012 (P<0.001).
The study results may not be generalizable to patients who are not commercially insured, among other limitations, the authors noted. They added that they lacked data on race, ethnicity, and income and did not have access to clinical notes, laboratory data, and formulary information.
“Given the changing patterns of OAC [oral anticoagulant] prescribing in patients with cirrhosis and NVAF, further research is needed to evaluate the safety and effectiveness of DOACs compared with warfarin and with one another, including in high-risk patients with advanced, decompensated cirrhosis,” the authors wrote. “Future studies should also investigate clinical outcomes of patients with cirrhosis and NVAF who are not initiated on guideline-based OAC therapy in order to optimize stroke prevention strategies for this vulnerable and understudied population.”