2010-2017 年心房颤动患者口服抗凝药物选择的趋势和变化。
Trends and Variation in Oral Anticoagulant Choice in Patients with Atrial Fibrillation, 2010-2017.
机构信息
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
OptumLabs, Cambridge, Massachusetts.
出版信息
Pharmacotherapy. 2018 Sep;38(9):907-920. doi: 10.1002/phar.2158. Epub 2018 Jul 26.
OBJECTIVE
Since 2010, several non-vitamin K antagonist oral anticoagulants (NOACs) have been brought to the U.S. market, yet little is known regarding their evolving adoption for prophylaxis of atrial fibrillation (AF)-related stroke. We examined temporal trends in choice of oral anticoagulants (OACs) among incident OAC users with AF and its association with patient demographic and clinical characteristics.
METHODS
We conducted a serial cross-sectional analysis of medical and pharmacy claims for commercial and Medicare Advantage enrollees in a large, private, U.S. health plan. We identified 112,187 adults with nonvalvular AF starting OACs between October 2010 and March 2017. Multivariable logistic regression was used to examine the associations of patient characteristics with prescription of NOACs versus warfarin. Multinomial logistic regression was used to test the associations of patient characteristics with choice among NOACs.
RESULTS
The prescription of NOACs has increased dramatically since their introduction in October 2010. In the first quarter of 2017 (2017Q1), 7502 patients started OACs, of whom 78.9% used NOACs and 21.1% warfarin. For NOACs, 3.8% used dabigatran, 25.0% rivaroxaban, and 50.1% apixaban. In multivariable analyses, factors associated with choice of NOACs versus warfarin included younger age, lower stroke or bleeding risk, fewer comorbidities, higher education level or household net worth, and prescription by cardiologists (all p<0.001). There was no sex difference in likelihood of filling NOACs versus warfarin in 2010Q4-2012, but women had higher odds of starting NOACs (odds ratio = 1.19; 95% confidence interval = 1.14-1.25) in 2015-2017Q1. Among NOAC users, the odds of apixaban prescription increased with age, female sex, stroke or bleeding risk, and comorbidities (all p<0.05).
CONCLUSION
NOAC prescriptions have increased substantially among incident OAC users with nonvalvular AF, predominantly driven by increased prescription of apixaban. Warfarin and apixaban were generally preferred for elderly patients, patients with higher stroke or bleeding risk, and patients with more comorbidities.
目的
自 2010 年以来，已有数种非维生素 K 拮抗剂口服抗凝剂（NOAC）在美国上市，但对于这些药物在预防心房颤动（AF）相关卒中方面的应用演变，人们知之甚少。我们研究了初诊 AF 并使用口服抗凝剂（OAC）患者中 OAC 选择的时间趋势及其与患者人口统计学和临床特征的关系。
方法
我们对一家大型私人美国健康计划中商业保险和医疗保险优势计划的参保者的医疗和药房理赔数据进行了一系列连续的横断面分析。我们确定了 112187 名在 2010 年 10 月至 2017 年 3 月期间开始使用 OAC 的非瓣膜性 AF 成年患者。多变量逻辑回归用于检查患者特征与 NOAC 与华法林处方之间的关联。多项逻辑回归用于检验患者特征与 NOAC 选择之间的关联。
结果
自 2010 年 10 月上市以来，NOAC 的处方量大幅增加。在 2017 年第一季度（2017Q1），有 7502 名患者开始使用 OAC，其中 78.9%使用 NOAC，21.1%使用华法林。在 NOAC 中，3.8%使用达比加群，25.0%使用利伐沙班，50.1%使用阿哌沙班。在多变量分析中，与选择 NOAC 而非华法林相关的因素包括年龄较小、卒中或出血风险较低、合并症较少、教育程度或家庭净资产较高以及由心脏病专家开具处方（均 P<0.001）。在 2010Q4-2012 年，性别对 NOAC 与华法林的使用无差异，但在 2015-2017Q1 年，女性开始使用 NOAC 的可能性更高（优势比=1.19；95%置信区间=1.14-1.25）。在 NOAC 使用者中，阿哌沙班的处方几率随年龄、女性、卒中或出血风险以及合并症的增加而增加（均 P<0.05）。
结论
非瓣膜性 AF 初诊 OAC 患者中，NOAC 的处方量大幅增加，主要是由于阿哌沙班的处方量增加。华法林和阿哌沙班通常用于老年患者、卒中或出血风险较高的患者以及合并症较多的患者。
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