Economic evaluation of prescribing conventional and newer oral anticoagulants in older adults

Abstract

Anticoagulants refer to a variety of agents that inhibit one or more steps in the coagulation cascade. Generally, clinical conditions that require the prescribing of an oral anticoagulant increase in frequency with age. However, a major challenge of anticoagulation use among older patients is that this group of patients also experience the highest bleeding risk. To date, economic evaluation of prescribing of anticoagulants that includes the novel or newer oral anticoagulants (NOACs) in older adults has not been conducted and is warranted. Areas covered: A review of articles that evaluated the cost of prescribing conventional (e.g. vitamin K antagonists) and NOACs (e.g. direct thrombin inhibitors and direct factor Xa inhibitors) in older adults. Expert commentary: While the use of NOACs significantly increases the cost of the initial treatment for thromboembolic disorders, they are still considered cost-effective relative to warfarin since they offer reduced risk of intracranial haemorrhagic events. The optimum anticoagulation with warfarin can be achieved by providing specialised care; clinics managed by pharmacists have been shown to be cost-effective relative to usual care. There are suggestions that genotyping the CYP2C9 and VKORC1 genes is useful for determining a more appropriate initial dose and thereby increasing the effectiveness and safety of warfarin.

Prescribing trends of oral anticoagulants in England over the last decade: a focus on new and old drugs and adverse events reporting

“…Despite warfarin being used for almost 70 years [6], DOACs are slowly but surely replacing warfarin [7]. DOACs are favoured over vitamin K antagonists (warfarin) as they require less frequent monitoring, which deems them more convenient and cost-efficient [8,9]. Furthermore, they have pharmacological advantages over warfarin as they have a faster onset of action, predictable pharmacokinetics, and fewer drug and food interactions [9].…”

“…DOACs are favoured over vitamin K antagonists (warfarin) as they require less frequent monitoring, which deems them more convenient and cost-efficient [8,9]. Furthermore, they have pharmacological advantages over warfarin as they have a faster onset of action, predictable pharmacokinetics, and fewer drug and food interactions [9]. The recent findings from the PROSPER study show that older patients with atrial fibrillation and ischemic stroke receiving DOACs were less likely to experience major adverse cardiovascular events and had fewer deaths and readmissions compared with warfarin [8].…”

Potentially inappropriate medication among older patients with diabetic kidney disease

“…In advanced CKD patients (i.e., Stage 4 and particularly stage 5), NOACs were not recommended due to the paucity of RCT data ( Giugliano et al, 2013 ; Stamellou and Floege, 2018 ). Meanwhile, a major challenge of using anticoagulants among older patients was their higher risk of bleeding ( Hasan et al, 2018 ). Importantly, patients receiving NOACs need regular checks of renal function to avoid overdosing.…”