Steve Deitelzweig, MD: An Analysis of the Use of DOACs

Steve Deitelzweig, MD, the assistant chair of hospital medicine at Ochsner Health System, sat with MD Magazine at ACC.18 to discuss the real-world usage of direct-acting anticoagulants (DOACs) in comparison with the conventional warfarin, as well as the benefits they have shown based on a large data analysis Deitelzweig presented on at the conference.

Steve Deitelzweig, MD:

We are seeing pretty notable reductions with apixaban in comparison to dabigatran and rivaroxaban of significance to not just strokes and systemic embolism, but major bleeding and net clinical outcome. Net clinical outcome incorporates both of those other elements. With dabigatran versus rivaroxaban, we didn't see a difference in the analysis with stroke and systemic embolism, but we did see a reduction in the favor of dabigatran to rivaroxaban on major bleeding and net clinical outcome.

You have to incorporate utilization. Utilization could be the length of stay, could be readmission rates, and we are seeing that these agents, pretty routinely now, are having that reduction because even if we just have less major bleeding in comparison to the traditional agent warfarin, that's good. You can avoid hospitalization altogether, let alone even have a length of stay.

[In the same breadth] as the utilization side, we are seeing a reduction in not just the length of stay, but in readmissions as well. Now, these are not enormous datasets, so we're waiting for a little bit more information to come out on that to be definitive, but it's only logical that it will dictate that you're not going to have as many hospitalizations, or when you have bleeding it's not going to be severe bleeding, it should be curtailed.

We're seeing that now in quite a number of different venues. In some of the work that I just presented here at ACC.18, it was looking at 5 databases. It was CMS, Optum, Humana, PharMetrics, and MarketScan, so it was all these huge commercial payers. When it came together, it was over half the United States, and whenever you have that, it becomes very compelling information about how to consider the use of these agents.

The higher-risk patients, those are the ones where there is a little bit of hesitancy in prescribing any anticoagulant, be it warfarin or DOAC, but they have the greatest benefit. They're the people at the highest risk of stroke and systemic embolism, so you have to recognize that. The datasets now are showing that not just septuagenarians, but octogenarians, nonagenarians, and centenarians, they're all showing a benefit.

Probably the most notable [benefit] on the adverse event side is the reduction of intracranial hemorrhage. We're seeing at least half—a 50% reduction of intracranial hemorrhage, which is a disaster if it was to arise with warfarin, even if it's well-managed warfarin (which is harder to do than we used to think) than with the DOACs as a class. Then, within the DOACs, we're seeing subtle differences as well.

Fortunately, we don't have to use these reversal agents—and shouldn't use them—that commonly. It's only in the unique circumstance like with intracranial hemorrhage or things of that nature where they come into play. By and large, it's just holding the agent for minor bleeding or doing things like that.

But if you have an intervention that's required, we're looking at the next compound, which would be andexanet, as a competitive inhibitor for selective Xa. There are other agents that are being exposed to us as a universal reversal agent, but none of these have been approved by the US FDA or the EMA or really any large body.