Rivaroxaban at home after DVT, PE offers positive outcomes, reduced costs

Rivaroxaban demonstrated favorable outcomes and cost savings in patients with deep vein thrombosis and pulmonary embolism when used for at-home treatment after discharge from the emergency room, according to the results of companion studies published in Academic Emergency Medicine.

Researchers from the Indiana School of Medicine have performed two novel investigations, enrolling patients with low-risk venous thromboembolism (VTE), including DVT and PE, in both.

At-home treatment

In the first study, Daren M. Beam, MD, MS, of the departments of emergency medicine and cellular and integrative physiology at Indiana University School of Medicine, and colleagues examined 106 patients hospitalized for DVT and PE.

Daren M. Beam

Patients were identified as low risk by a modified version of the Hestia criteria, an 11-item questionnaire used to identify patients with PE who are eligible for treatment in an outpatient setting and immediately discharged from the emergency department; 71 patients had DVT, 30 patients had PE and five patients had both conditions.

Patients were treated with rivaroxaban (Xarelto, Janssen) from March 2013 to April 2014 at home; follow-up was conducted at 2 to 5 weeks and 3 to 6 months. Mean follow-up time was just over 1 year. The researchers defined acceptable outcome rates as a recurrence of VTE of ≤ 2.1% or a rate of bleeding during treatment of ≤ 9.4%.

Patients did not experience a recurrence of either DVT or PE. No major or clinically relevant bleeding events were seen during treatment with rivaroxaban, although three patients (2.8%; 95% CI = 1%-8%) experienced recurrent DVT after treatment ended.

“This preliminary report provides data to support the initial outpatient treatment of low-risk emergency department patients with deep vein thrombosis and pulmonary embolism,” Beam and colleagues conclude. “These patients can be treated at home with an orally available target-specific anticoagulant with a low rate of venous thromboembolism recurrence and low rate of bleeding.”

Costs of Care

The same group of researchers conducted a second study under Zachary P. Kahler, MD, also of the departments at the institution, enrolling 97 patients with DVT and PE to compare the cost of at-home treatment for these conditions in place of hospitalization. Patients in this study were also identified as low risk by the Hestia criteria.

Zachary P. Kahler

The researchers compared total expenditures for case patients (n = 50), treated with an initial dose of rivaroxaban in the emergency department followed by same-day discharge and at-home treatment with rivaroxaban, and controls (n= 47), treated with usual care using low-molecular-weight heparin followed by warfarin. All patients received anticoagulation therapy for 6 months.

Median hospital charges for all VTEs 6 months after diagnosis were $11,128 (interquartile range [IQR] = $8,110-$23,390) for controls compared with $4,787 (IQR = $3,042-$7,596) for cases (Mann-Whitney U-test, P < 0.001). The researchers performed subgroup analyses of costs for the first week of therapy, PE, DVT and inpatient pharmacy, which resulted in retained significance; the cost of rivaroxaban treatment for patients with PE was 57% lower than controls with PE (P < 0.001) and 56% lower for patients with DVT (P = 0.003).

“When comparing the patients treated with low-molecular-weight heparin and warfarin to those patients treated as outpatients with the target-specific anticoagulants, the costs of medical care were significantly lower for the target-specific anticoagulant patients,” Kahler and colleagues conclude. “Costs were approximately 59% to 65% lower for the target-specific anticoagulant patients in the first week after diagnosis and 56% to 57% lower after 6 months.”– by Julia Ernst, MS

References:

Beam DM, et al. Acad Emerg Med. 2015;doi:10.1111/acem.12711.

Kahler ZP, et al. Acad Emerg Med. 2015;doi:10.1111/acem.12713.

Disclosure: Beam and Kahler report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.