Exclusive GPs are increasingly prescribing the newer anticoagulant alternatives to warfarin for the prevention of stroke, although their uptake has been slower than expected due to cost concerns, Pulse can reveal.
An analysis of NHS primary care prescribing data for the past three years shows a fourteen-fold increase in the use of the newer anticoagulants dabigatran, rivaroxaban and apixaban in 2012, compared with 2011.
There was also a 9% increase in the use of warfarin from 2011 to 2012, leading experts to conclude that newer anticoagulants are being reserved for patients who are unsuitable for warfarin.
Pulse reported last year that following the NICE approval of dabigatran in March for certain patients with atrial fibrillation, CCGs put restrictions in place to limit use of the drug, with some warning its use as an alternative to warfarin could ramp up primary care drug budgets by as much as 20%.
This looks to have put a lid on demand, alongside concerns about the safety profile of some of the newer alternatives.
The figures from the NHS Information Centre Prescribing and Primary Care Services show that the total number of NHS prescriptions in 2012 for warfarin rose to 10.2 million prescriptions dispensed last year, compared with 9.4 million in 2011.
The total prescribed items for dabigatran – including those prescribed in patients with atrial fibrillation and venous thromboembolism – went up from around 3,200 in 2011, to 48,300 in 2012. Prescriptions for rivaroxaban and apixaban also rose, but their use remains much lower than that of dabigatran.
Professor David Fitzmaurice, GP and professor of primary care at Birmingham University, told Pulse the data reflect increasing awareness of atrial fibrillation, but that uptake of the newer anticoagulants was still relatively slow.
He said: ‘Basically the uptake of dabigatran has been slow, mainly due to cost, but [there is] increased awareness of atrial fibrillation, therefore increased warfarin use. Local policies are variable but generally limit use to poorly controlled warfarin patients, or those who can’t tolerate it for other reasons.’
Dr Terry McCormack, a GP in Whitby and an editor of the British Journal of Cardiology, said: ‘This is all good news. Both warfarin and dabigatran are being used more, which means more people are being protected from having strokes.
‘As a nation we do not provide enough anticoagulation protection for people with atrial fibrillation and whatever drug is suitable for an individual should be used.’
He added: ‘Where warfarin is well tolerated and good INRs can be achieved, it is clearly the first choice. Where warfarin cannot be used the new oral anticoagulants are much more cost effective than putting patients at risk of stroke.’
Dr Peter Weaving, GP in Carlisle and clinical director at North Cumbria University Hospitals Trust, said: ‘I am delighted to see overall anticoagulation rising significantly – historically GPs have been reluctant to use it widely particularly in the elderly where it is often as safe, if not safer, than aspirin and far more effective in preventing strokes in nonvalvular atrial fibrillation.
‘Dabigatran use has increased significantly which is what one would expect with its inclusion as an option in NICE guidance, but its relatively low overall usage may reflect innate caution for a new drug particularly one which is irreversible once given.’
Professor Jonathan Mant, professor of primary care research at the University of Cambridge, said: ‘Certainly it is encouraging that prescription volume of warfarin has increased while dabigatran has started to be used.’
Professor Mant said uptake of dabigatran has been patchy because of the cost. He said: ‘With the current downward pressure on spending in all sectors of government there’s been perhaps less emphasis on cost-effectiveness than on cost. It’s a shame as the whole point of NICE was to promote cost-effectiveness and NICE was very supportive of dabigatran, but in the current climate it has not been sufficient to ensure adoption.’
Summary – total prescription items (thousands)
2010 2011 2012
Warfarin 8,793.02 9,356.86 10,197.66
Dabigatran 0.755 3.2 48.3
Rivaroxaban 1.61 1.45 15.72
Apixaban – 0.001 0.036