Prescribing Trends of Oral Anticoagulants in US Patients With Cirrhosis and Nonvalvular Atrial Fibrillation

Abstract

Background Many patients with cirrhosis have concurrent nonvalvular atrial fibrillation (NVAF). Data are lacking regarding recent oral anticoagulant (OAC) usage trends among US patients with cirrhosis and NVAF. Methods and Results Using MarketScan claims data (2012-2019), we identified patients with cirrhosis and NVAF eligible for OACs (CHA₂DS₂-VASc score ≥2 [men] or ≥3 [women]). We calculated the yearly proportion of patients prescribed a direct OAC (DOAC), warfarin, or no OAC. We stratified by high-risk features (decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease, or end-stage renal disease). Among 32 487 patients (mean age=71.6 years, 38.5% women, 15.1% with decompensated cirrhosis, mean CHA₂DS₂-VASc=4.2), 44.6% used OACs within 180 days of NVAF diagnosis, including DOACs (20.2%) or warfarin (24.4%). Compared with OAC nonusers, OAC users were less likely to have decompensated cirrhosis (18.6% versus 10.7%), thrombocytopenia (19.5% versus 12.5%), or chronic kidney disease/end-stage renal disease (15.5% versus 14.0%). Between 2012 and 2019, warfarin use decreased by 21.0% (32.0% to 11.0%), whereas DOAC use increased by 30.6% (7.4% to 38.0%), and among all DOACs between 2012 and 2019, apixaban was the most commonly prescribed (46.1%). Warfarin use decreased and DOAC use increased in all subgroups, including in compensated and decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease/end-stage renal disease, and across CHA₂DS₂-VASc categories. Among OAC users (2012-2019), DOAC use increased by 58.9% (18.7% to 77.6%). Among DOAC users, the greatest proportional increase was with apixaban (61.2%; P<0.001). Conclusions Among US patients with cirrhosis and NVAF, DOAC use has increased substantially and surpassed warfarin, including in decompensated cirrhosis. Nevertheless, >55% of patients remain untreated, underscoring the need for clearer treatment guidance.

Keywords: anticoagulation; atrial fibrillation; cirrhosis; usage.

Figure 1. Proportions of warfarin and DOAC prescriptions, among patients with cirrhosis and NVAF in MarketScan, 2012 to 2019.

A, Total population; (B) compensated cirrhosis; (C) decompensated cirrhosis; (D) thrombocytopenia; (E) no thrombocytopenia; (F) coagulopathy; (G) no coagulopathy. DOAC indicates direct oral anticoagulant; and NVAF, nonvalvular atrial fibrillation.

Figure 2. Warfarin and DOAC prescriptions as a proportion of all OAC prescriptions, among patients with cirrhosis and NVAF in MarketScan, 2012 to 2019.

A, Total population; (B) compensated cirrhosis; (C) decompensated cirrhosis; (D) thrombocytopenia; (E) no thrombocytopenia; (F) coagulopathy; (G) no coagulopathy. DOAC indicates direct oral anticoagulant; NVAF, nonvalvular atrial fibrillation; and OAC, oral anticoagulant.