MUNICH — In a pooled analysis of data from CMS and four commercial payers, apixaban was associated with lower risk for stroke/systemic embolism and major bleeding compared with dabigatran and rivaroxaban in patients with nonvalvular atrial fibrillation.
All-cause health care costs were similar among patients taking apixaban (Eliquis, Bristol-Myers Squibb/Pfizer) and dabigatran (Pradaxa, Boehringer Ingelheim) and were lower compared with patients taking rivaroxaban (Xarelto, Janssen), according to a poster presented at the European Society of Cardiology Congress.
“We chose to do an analysis that could potentially be more generalizable than a single-source observational study or a network meta-analysis,” Steven Deitelzweig, MD, MMM, SFHM, FACP, FACC, medical director of regional business development, system chairman of hospital medicine and associate professor of medicine at Ochsner Clinical School, told Cardiology Today. “The robustness of this data set may enable us to share our findings widely and change practice.”
For the ARISTOPHANES study, Deitelzweig and colleagues included 321,182 patients aged 18 years or older with nonvalvular AF prescribed apixaban, dabigatran or rivaroxaban for the first time between January 2013 and September 2015. After propensity-score matching, the researchers analyzed 27,096 apixaban-dabigatran pairs (mean age, 72 years; 59% men), 62,619 apixaban-rivaroxaban pairs (mean age, 73 years; 55% men) and 27,538 dabigatran-rivaroxaban pairs (mean age, 71 years; 59% men).
The patients were followed from 1 day past the index therapy initiation date to the earliest of 30 days after discontinuation, switching of therapy, death, end of enrollment in insurance plan or the end of the study period.
The researchers found that patients who initiated apixaban had lower risk for stroke or systemic embolism than patients who initiated dabigatran (HR = 0.69; 95% CI, 0.56-0.84) or patients who initiated rivaroxaban (HR = 0.8; 95% CI, 0.71-0.91), but there was no difference in stroke/systemic embolism risk between the dabigatran and rivaroxaban groups (HR = 1.15; 95% CI, 0.96-1.37).
Patients initiating apixaban also had lower risk for major bleeding than those initiating dabigatran (HR = 0.77; 95% CI, 0.68-0.87) or rivaroxaban (HR = 0.55; 95% CI, 0.51-0.59), according to the researchers. Patients initiating dabigatran had lower major bleeding risk than the rivaroxaban group (HR = 0.7; 95% CI, 0.63-0.77).
All-cause per-patient per-month health care costs were similar in the apixaban and dabigatran groups (P = .993), lower in the apixaban group vs. the rivaroxaban group (P < .001) and lower in the dabigatran group vs. the rivaroxaban group (P < .001), Deitelzweig and colleagues reported.
“The all-cause health care cost difference between apixaban/dabigatran and rivaroxaban was about $350 per patient per month, which adds up a lot,” Deitelzweig said. “We have to think about the value of these drugs going forward.”
Real-world analyses such as this one include older patients who made up a small portion of the study populations in pivotal trials of the drugs, “so we can get better data about the correct dosing regimens,” he said. “We’re finding that it’s often up to 25% of patients being treated with an adjusted dose.” – by Erik Swain
Deitelzweig S, et al. Abstract P2567. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.
Disclosure: The study was funded by Bristol-Myers Squibb and Pfizer. Deitelzweig reports he is a consultant for Bristol-Myers Squibb, Pfizer and Portola Pharmaceuticals.