For decades, warfarin was the only FDA-approved oral anticoagulant to treat and prevent blood clots, until direct oral anticoagulants (DOACs) came along. Now there are four DOACs available to treat blood clots and prevent strokes in Afib: rivaroxaban (Xarelto®), apixaban (Eliquis®), dabigatran (Pradaxa®), and edoxaban (Savaysa®).

Katelyn Sylvester, PharmD

DOACs are as effective as warfarin and are safer and easier to use – but they still aren’t always the right fit for all patients. “Anticoagulants are not one size fits all. Patients should work with their healthcare teams to figure out which anticoagulant might work best for their particular condition and lifestyle, and there may be more than one best option,” explains Katelyn Sylvester, Pharmacy Manager at the Brigham and Women’s Hospital Anticoagulation Management Service.

Q: What should I consider when taking an anticoagulant?

There are several factors to discuss with your provider, including your medical history, lifestyle, medication preferences, and insurance coverage.

Before starting an anticoagulant, be sure to understand why you need it. Your healthcare provider may prescribe it to treat a blood clot, to prevent another one from forming, or to prevent stroke if you have Afib. Be sure to tell your provider about any personal history of kidney issues, bleeding, cancer, diabetes, high blood pressure, falls, or recent injury.

Your history is a key component in choosing an appropriate anticoagulant. For example, if you have a high risk of bleeding or a history of stomach bleeding, apixaban may be a good choice. (Patients have a higher bleeding risk when they’re older, have high blood pressure that’s not well controlled, have reduced liver or kidney function, or take other medications that increase the risk of bleeding.) If you have a history of ischemic stroke, you may benefit most from dabigatran. Some patients being treated for certain types of pulmonary embolism may be prescribed edoxaban. If you have a mechanical heart valve, DOACs are not recommended.

Your lifestyle and preferences also play a large role when choosing an anticoagulant. To have the best outcomes, you must take your anticoagulants as prescribed, which can be difficult if you’re already taking multiple medications each day. Patients on apixaban, for instance, must take one tablet in the morning and one in the evening. It may be hard to stick to this regimen if you have a busy or inconsistent schedule, so your provider may choose rivaroxaban for you instead (a once-daily dose). Patients who take warfarin instead of a DOAC must be monitored closely to make sure that they’re receiving the appropriate dose of medication. Warfarin also has several food and drug interactions that patients need to be aware of. Be sure to tell your provider about all medications that you take (including nonprescription medications and supplements) before starting an anticoagulant.

The cost of anticoagulation is another important consideration. In general, patients are less likely to start or continue taking a prescribed medication if it’s very expensive. The cost of a DOAC with or without insurance may be as high $600 a month, and in that case, warfarin is likely to be much cheaper.

Q: Why are DOACs so expensive and why do some patients pay more than others?

Your medication costs largely depend on the structure of your insurance plan and the plan’s “preferred” medication list, known as a formulary. Insurance will cover medications listed in the formulary but will typically categorize medications into tiers or buckets. Medications in a preferred tier usually don’t require additional paperwork from the provider, but you may have a small copay. “Non- preferred” medications often have a higher out-of- pocket cost and your provider may need to fill out paperwork stating why this medication is necessary. (These documents are called prior authorizations or formulary exception forms.)

Some insurance plans have low monthly fees but high deductibles, and the insurer will not contribute to the cost of the medication until you hit your required deductible. Other plans may have high monthly costs, but little or no deductible and would only require you to pay a small copay. To complicate things further, if you have a Medicare Part D plan (prescription insurance), you may encounter a coverage gap known as the “donut hole.” The coverage gap begins once you and the insurer have paid a certain amount of money towards prescription drugs over the year. At that point, you’d be responsible for a percentage of the prescription cost until another limit is met; the insurance company will then cover medication costs until the end of the year. Because of the donut hole, the cost of your medication could change multiple times in a calendar year.

Medications are also more expensive when they first become available since only one company is producing them. After a drug has been on the market for a while, other companies can manufacture similar products (generics), which creates market competition and results in lower drug prices. Warfarin has been available in a generic form for years. In December 2019, the FDA approved a generic form of apixaban, but it is not available yet. The other DOACs don’t currently have generics. The good news is that many drug companies have patient assistant programs that can help with medication costs. You can access these resources by calling the patient assistance line found on the drug manufacturer’s website.

For more information, please see our anticoagulation comparison chart here.

*Originally published in The Beat – February 2020. Read the full newsletter here.