Cardiologists Rapidly Increase Dabigatran Prescriptions

Clinicians in the U.S. have increasingly prescribed the use of the oral anticoagulant dabigatran, a direct thrombin inhibitor, since its 2010 approval by the Food and Drug Administration. According to data published in the forthcoming issue of Circulation Cardiovascular Quality Outcomes, dabigatran's market share increased from 3 percent in the fourth quarter of 2010 (2010Q4) to 19 percent in 2011Q4, replacing warfarin in many patients.

Using the IMS Health National Disease and Therapeutic Index, a nationwide audit of office-based physicians, investigators examined trends in the use of warfarin and dabigatran between 2007 and 2011. During this time, treatment visits for warfarin declined from 2.1 million to 1.6 million quarterly visits. On the other hand, dabigatran treatment visits increased dramatically, from 62,000 in 2010Q4 to 363,000 in 2011Q4. Direct expenditures for warfarin decreased from $169 million per quarter in 2007 to $144 million in 2011Q4, while dabigatran expenditures increased from $16 million in 2010Q4 to $166 million in 2011Q4, also reflecting the drug's higher cost.

The study also analyzed anticoagulant prescriptions according to medical specialty and indication. Prior to the approval of dabigatran, warfarin was most commonly prescribed by physicians in cardiology (34 percent), internal medicine (30 percent), family practice (19 percent) and other specialties (16 percent). In 2011Q4, cardiologists reported the majority of dabigatran visits (53 percent), followed by internists (28 percent), family practitioners (10 percent) and others (9 percent), indicating that cardiologists are responsible for much of the drug's increased use.

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Dabigatran is indicated for the prevention of stroke in patients with nonvalvular atrial fibrillation, and the majority of visits were for this indication. However, off-label use is increasing. In 2010Q4, 92 percent of visits were for atrial fibrillation, but the proportion of on-label visits decreased to 63 percent in 2011Q4. Coronary artery disease, hypertensive heart disease and venous thromboembolism were the most frequent off-label uses of dabigatran.

The introduction of dabigatran has not increased the proportion of patients with atrial fibrillation receiving anticoagulant therapy, according to investigators. Approximately 40 percent of patients still do not receive treatment. The ACC is currently in the early phases of developing a program aimed at reversing this trend and educating patients and providers about the guideline-recommended use of oral anticoagulants.

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