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

Abstract

Direct-acting oral anticoagulants (DOACs) are replacing conventional VKA (vitamin K antagonist, i.e., warfarin) for various indications where a therapeutic anticoagulant effect is desired. We evaluated the prescribing patterns of the DOACs and warfarin, cost implications of the increasing DOACs prescribing, and deduce the reporting of serious and fatal events, during 2009-2019 in primary care England. Prescriptions and fatal or serious adverse events reporting data, between 2009 and 2019 were analysed, using linear regression to examine the trends in prescriptions, costs, and serious and fatal events reporting. We also compared the prescribing trends of four direct-acting oral anticoagulants and warfarin, normalised to per 1000 clinical commissioning group (CCG) patient population for the year 2019 to better understand the regional differences in DOACs prescribing. The overall use of any DOACs (as a proportion of total anticoagulants) increased from 16% in 2015 to 62% in 2019 with an average increase of 87% (95% CI 83.1, 90.5) per year. The reporting of serious and fatal events associated with DOACs decreased by 6% (95% CI 12.5, - 0.1) per year. Apixaban is by far the most prescribed with an average drug cost increasing to 156% (95% CI 140, 172) per year. In England, the lowest anticoagulant prescribing region was Greater London whereas the highest prescribing regions were Yorkshire and Humber for DOACs and the East Midlands for warfarin. Interestingly, Lancashire, Merseyside, and Cheshire showed a higher usage for warfarin over DOACs. The differing prescription patterns could be a result of changes in national guidelines and increasing population. Nevertheless, DOACs appear to make an increasing contribution to total anticoagulant prescription items and costs.

Keywords: Atrial fibrillation; Direct-acting oral anticoagulants (DOACs); INR; Prescriptions trends; Warfarin.

Fig. 1

Trends of DOACs and Warfarin use (in millions) in the UK over 11 years (2009–2019)

Fig. 2

Total prescription items for warfarin and DOACS, normalised to per 1000 CCG population for the year 2019 (Red = warfarin; Blue = DOACs)

Fig. 3

Serious/fatal adverse drug reactions (ADRs) for various anticoagulant drugs normalised to the number of anticoagulant items prescribed during the last 11 years