U.S. Physician and Payer Forum

March 2009

Novel Anticoagulants for Venous Thromboembolism and Stroke Prevention in Atrial Fibrillation: Will Prescribers’ and Payers’ Attitudes Promote or Prevent a Shift Away from Warfarin and Heparins?

Report Authors
Nikhil Mehta, M.Eng.

Introduction:

Despite the proven effectiveness and widespread use of vitamin K antagonists (such as warfarin) for stroke prevention in atrial fibrillation (AF) and of heparins for venous thromboembolism (VTE) prevention, both drug classes have major drawbacks that compromise optimal anticoagulation. A multitude of new anticoagulants are now in late-stage development seeking to overcome these problems and capitalize on the commercial potential offered by the huge at-risk AF and nonsurgical inpatient populations. However, existing anticoagulants are well established and the older versions are inexpensive, which begs the question: Will prescribers and payers support the uptake of new agents?

Decision Resources’ Physician&Payer Forum report "Novel Anticoagulants for Venous Thromboembolism and Stroke Prevention in Atrial Fibrillation: Will Prescribers’ and Payers’ Attitudes Promote or Prevent a Shift Away from Warfarin and Heparins?" explores clinician prescribing of novel anticoagulants and payer attitudes to formulary coverage of emerging brands.

We surveyed 72 PCPs, 50 cardiologists, 31 internists who sit on their hospital pharmacy and therapeutics (P&T) committee, and 20 managed care organization (MCO) pharmacy directors (PDs), and compared their responses to assess similarities and differences. This survey enabled Decision Resources to accomplish the following:

-- Compare the impact of six emerging anticoagulants in their most lucrative markets, stroke prevention in AF and VTE primary prophylaxis in nonsurgical (medically ill) inpatients; Bayer/J&J’s Xarelto, Boehringer Ingelheim’s Pradaxa, Bristol-Myers Squibb/Pfizer’s apixaban, Sanofi-Aventis’s idrabiotaparinux and octaparine, and ARYx’s ATI-5923 (tecarfarin).

-- Determine the nature of antithrombotic therapy among AF patients at low, moderate, and high stroke risk treated by PCPs and cardiologists. What factors influence clinicians’ decisions to prescribe or withhold antithrombotic therapy for stroke prevention? What factors most frequently preclude warfarin treatment?

-- Understand what percentage of nonsurgical inpatients receives VTE prophylaxis, based on clinician specialty and patients’ primary condition. For which conditions is VTE primary prophylaxis underused?

-- Understand how PCPs, hospital P&T committee internists, and cardiologists rank various potential achievements of emerging anticoagulants—do they value improvements in efficacy above improvements in bleeding risk, or vice versa? Do MCO PDs and P&T committee internists concur?

-- Understand whether MCO PDs will pay for novel anticoagulants for stroke prevention, whether hospitals will restrict access to new agents for VTE prophylaxis, and if so, how they will do so.

-- Assess the impact that novel anticoagulants will have on postdischarge prescribing of VTE prophylaxis in nonsurgical inpatients.

-- Analyze the current formulary tier assignments of available branded anticoagulants based on plan type (including Medicare PDPs, Medicare Advantage, and private plans), and review the cost controls imposed by agent and plan type.

-- Understand likely tier placement of novel anticoagulants, based on several efficacy and safety achievement scenarios, as well as drug pricing scenarios.


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