Kirley Kate, Qato Dima M, Kornfield Rachel, Stafford Randall S, Alexander G Caleb
Department of Family Medicine, University of Chicago, Chicago, IL, USA.
Circ Cardiovasc Qual Outcomes. 2012 Sep 1;5(5):615-21. doi: 10.1161/CIRCOUTCOMES.112.967299. Epub 2012 Sep 4.
Little is known regarding the adoption of direct thrombin inhibitors in clinical practice. We examine trends in oral anticoagulation for the prevention of thromboembolism in the United States.
We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based providers, to quantify patterns of oral anticoagulant use among all subjects and stratified by clinical indication. We quantified oral anticoagulant expenditures using the IMS Health National Prescription Audit. Between 2007 and 2011, warfarin treatment visits declined from ≈2.1 million (M) quarterly visits to ≈1.6M visits. Dabigatran use increased from 0.062M quarterly visits (2010Q4) to 0.363M visits (2011Q4), reflecting its increasing share of oral anticoagulant visits from 3.1% to 18.9%. In contrast to warfarin, the majority of dabigatran visits have been for atrial fibrillation, though this proportion decreased from 92% (2010Q4) to 63% (2011Q4), with concomitant increases in dabigatran's off-label use. Among atrial fibrillation visits, warfarin use decreased from 55.8% visits (2010Q4) to 44.4% (2011Q4), whereas dabigatran use increased from 4.0% to 16.9%. Of atrial fibrillation visits, the fraction not treated with any oral anticoagulants has remained unchanged at ≈40%. Expenditures related to dabigatran increased rapidly from $16M in 2010Q4 to $166M in 2011Q4, exceeding expenditures on warfarin ($144M) in 2011Q4.
Dabigatran has been rapidly adopted into ambulatory practice in the United States, primarily for treatment of atrial fibrillation, but increasingly for off-label indications. We did not find evidence that it has increased overall atrial fibrillation treatment rates.
关于直接凝血酶抑制剂在临床实践中的应用情况，人们了解甚少。我们研究了美国预防血栓栓塞的口服抗凝治疗趋势。
我们使用艾美仕市场研究公司的全国疾病和治疗指数（这是一项对门诊医疗服务提供者具有全国代表性的审计），对所有受试者以及按临床指征分层后的口服抗凝药使用模式进行量化。我们使用艾美仕市场研究公司的全国处方审计来量化口服抗凝药的支出。在2007年至2011年期间，华法林治疗就诊次数从约每季度210万次降至约160万次。达比加群的使用从2010年第四季度的每季度6.2万次增加至2011年第四季度的36.3万次，这反映出其在口服抗凝药就诊中所占份额从3.1%增至18.9%。与华法林不同，达比加群就诊的大多数是用于心房颤动，不过这一比例从2010年第四季度的92%降至2011年第四季度的63%，同时达比加群的超说明书用药有所增加。在心房颤动就诊中，华法林的使用从2010年第四季度的55.8%降至2011年第四季度的44.4%，而达比加群的使用从4.0%增至16.9%。在心房颤动就诊中，未接受任何口服抗凝药治疗的比例保持不变，约为40%。与达比加群相关的支出从2010年第四季度的1600万美元迅速增至2011年第四季度的1.66亿美元，超过了2011年第四季度华法林的支出（1.44亿美元）。
在美国，达比加群已迅速被应用于门诊治疗，主要用于治疗心房颤动，但用于超说明书指征的情况日益增多。我们没有发现证据表明它提高了总体心房颤动治疗率。
