In a previous post we talked about the fact that NOACs make a lot of people uneasy, even though the data suggests that they’re often the better choice for afib patients.
And making the right choice can be difficult, since nobody’s really taken the time to sit down and line it all up: how each drug compares to all of the other drugs. In fact, sometimes even doctors aren’t sure which one to prescribe.
After all, there are now five different anticoagulants atrial fibrillation patients have to choose from to help prevent stroke. The old standby has always been warfarin (brand name Coumadin) having been around since 1954. There are now four newer anticoagulants to choose from called novel oral anticoagulants, or NOACs for short. They are:
Brand name listed first followed by the generic, or drug name, in parenthesis.
- Xarelto (rivaroxaban)
- Eliquis (apixaban)
- Pradaxa (dabigatran)
- Savaysa (edoxaban)
What factors should you consider when choosing a blood thinner?
We all have budgets so cost is the first thing you’re going to have to look at when you’re sitting down with your doctor to determine which of these anticoagulants is right for you.
Here is the break down of the average costs of these drugs in the U.S. for a 30-day supply:
- $17 for generic Warfarin (5mg once daily)
- $340 for Savaysa (60mg once daily)
- $348 for Pradaxa (150mg twice daily)
- $418 for Xarelto (20mg once daily)
- $418 for Eliquis (5mg twice daily)
Fortunately, most patients aren’t actually paying these prices. In many cases health insurance covers a portion of these costs. You’ll want to check with your insurance provider to find out which of these drugs they’ll cover and how much they’ll pay for each drug so you’ll know what your true out-of-pocket costs are going to be.
Once you’re armed with that information you can communicate with your doctor which drugs you can afford. You don’t want your doctor to prescribe a blood thinner that you simply can’t afford.
But what if your doctor recommends one of these drugs that isn’t covered by your insurance, or the coverage you have is minimal? You have a couple options.
First, most of the pharmaceutical companies behind these drugs offer patient assistance programs to help significantly lower your out-of-pocket costs. These programs are for low income or uninsured and under-insured patients who meet specific guidelines, which vary from program to program.
These programs are usually temporary, however, meaning you can only participate in them for a certain period of time (usually 2-3 years). Here are links to the assistance programs for these blood thinners:
- Xarelto – Johnson & Johnson Patient Assistance Foundation
- Eliquis – Bristol-Myers Squibb Patient Assistance Foundation
- Pradaxa – Boehringer Ingelheim Cares Foundation
- Savaysa – Daiichi Sankyo Open Care Program
If you don’t qualify for the assistance program for the drug you want or your doctor recommends, there is a second option – buy your drugs from Canada. I’ve done some research and the best prices I can find from Canadian pharmacies were from YouDrugStore.com.
I buy my prescription drugs from them because I can buy them cheaper through them than I can even with my prescription insurance coverage here in the U.S.!
Here are the prices you’ll pay for a 30-day supply of these drugs at YouDrugStore.com:
- $158 for Pradaxa (150mg twice daily)
- $100 for Xarelto (20mg once daily)
- $130 for Eliquis (5mg twice daily)
Prices as of 3/16/17. Savaysa not available.
After cost considerations, the effectiveness of each of these drugs is an important consideration.
There are studies which compare individual NOACs to warfarin. The statistics say that the outcome is usually better for NOAC patients than for warfarin patients.
There is no real data, however, to compare the efficacy of one NOAC to another.
Some patients have other illnesses which prevent them from being able to take a NOAC so doctors are left with only one choice – warfarin.
And still some doctors are reluctant to prescribe the NOACs because they haven’t been on the market very long so they tend to favor warfarin.
One factor in the effectiveness of these drug is you. Doctors look at how likely you are to remember to take your medication. Eliquis is a twice-daily medication where Xarelto is a once-daily medication.
In fact, if you tend to be absent-minded doctors do, again, like going back to warfarin…if only because they know that this will put you under their watchful eye. Warfarin requires regular monitoring.
Any kidney dysfunction in your body could have a serious impact on which drugs are right for you. NOACs are cleared by the kidneys. That means your bleeding risk goes up as your kidney function grows less effective.
People with kidney problems can tolerate Xarelto in low doses, as long as they take it with the evening meal. “Low doses” just means that you’re taking it down from 20 mg daily to 15 mg daily.
You can do the same with Pradaxa, but you have to lower the 150 mg dose down to 75 mg.
But when it comes to kidney patients, Eliquis might be the clear winner. You don’t even have to reduce the dose for Eliquis unless the patient has end-stage renal disease, and are on dialysis, and weigh less than 132 pounds, or are older than 80.
Risk of Bleeding
Blood thinners are designed to make it harder for your blood to clot. Unfortunately, this means opening yourself up to problems when, well, you really need your blood to clot.
Warfarin has an antidote. So if you get into a car accident and need to go into surgery, they can get your blood temporarily back to normal so that you don’t bleed out.
NOACs are working on similar antidotes, but they don’t have them yet. Some doctors do note, however, that specific antidotes are really all that is missing.
“While specific antidotes for each are on the very near horizon, they may be reversed with infusion of prothrombin complex concentrate,” he told MedPage Today. “With the expected rapid approval of direct inhibitors of each drug — which literally work within a matter of minutes — this issue should be resolved once and for all.”
Once reversal agents become commercial available, “then I don’t think there’s going to be that much of a role for warfarin at all” if patients aren’t already on it and doing well, Kirtane said.
Are you on warfarin? Are you doing well? Are you on NOACs? What’s your experience? Which drug did you ultimately choose?
Please share your comments and observations below.