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MERCURY PE: Rivaroxaban confers lower costs, shorter hospital stay in low-risk PE
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Among patients with low-risk pulmonary embolism, compared with standard of care, discharge on rivaroxaban was associated with lower costs and shorter length of stay without a difference in clinical outcomes, researchers reported.
For the MERCURY PE study, W. Frank Peacock IV, MD, FACEP, FACC, associate chief of emergency medicine research and professor of emergency medicine at Baylor College of Medicine, and colleagues randomly assigned 114 patients with low-risk PE to early discharge from the ED on rivaroxaban (Xarelto, Janssen) or standard of care.
“This was prefaced by about 5 years of work looking at PE and how we manage it in the United States,” Peacock told Cardiology Today’s Intervention. “The most important paper that came out of that (Wang L, et al. PLoS ONE. 2017;doi:10.1371/journal.pone.0185022) found that patients with PE admitted to the hospital who don’t need to be admitted to the hospital have a more than 800% increase in hospital-acquired conditions. In the old days, we had to keep everyone in the hospital. The patients had to be anticoagulated and warfarin took 5 days to work, so we had to bridge with an IV agent. Once the [direct oral anticoagulants] came out, we didn’t have to keep everyone in the hospital anymore. Why would you go into the hospital just to have a pill? We found that compared with people who went home, people who could have gone home but didn’t had frightening rates of hospital-acquired conditions: 13.3% vs. 1.5%. Yet, keeping these people in the hospital is what we did. Everybody thought it was wrong and unethical to send somebody home with a PE.”
Peacock and colleagues obtained funding from Janssen to determine if early discharge on rivaroxaban would improve outcomes in low-risk PE; he said the other direct oral anticoagulants have not yet been studied for this purpose. “We clearly demonstrated that it’s bad to stay in the hospital,” he said. “All we had to do now was demonstrate that it’s not bad to go home.”
Shorter stays
The primary efficacy outcome was total number of hospital hours, expressed as the initial hospital visit plus subsequent hours in the hospital for venous thromboembolism or bleeding, at 30 days after randomization. The primary safety outcome was major bleeding, clinically relevant nonmajor bleeding or mortality at 90 days.
The mean initial hospital visit was 4.8 hours in the rivaroxaban group vs. 33.6 hours in the standard of care group (mean difference, –28.8 hours; 95% CI, –42.55 to –15.12).
At 90 days, mean hospital hours were 19.2 the rivaroxaban group and 43.2 in the control group (mean difference, –26.4 hours; 95% CI, –46.97 to –3.34), according to the researchers.
There were no bleeding, recurrent VTE or mortality events at 90 days. The primary safety outcome was similar between the groups (difference in proportions, 0.005; 95% CI, –0.18 to 0.19), Peacock and colleagues wrote.
Total costs at 30 days were lower in the rivaroxaban group ($1,496 vs. $4,234; median difference, –$2,496; 95% CI, –2,999 to –2,151), according to the researchers.
Safety, cost benefits
“While some will say that this trial is too small to change clinical practice, we have about 14,000 patients from the ROCKET trial and about 7,000 patients from the EINSTEIN trial who demonstrated the safety and efficacy of rivaroxaban,” Peacock said in an interview. “There was no need to repeat EINSTEIN for great costs and no benefit. We know the drug is safe and effective, and now we know that PE patients can go home on this drug, and it saves a lot of money and hospital-acquired condition exposure.”
Future studies should include larger populations and patients who did not meet the inclusion criteria for the present study, including those with cancer, he said.
“You don’t need to be in the hospital for a pill,” he said. “The idea that some magic happens in the hospital is completely fallacious.” – by Erik Swain
For more information:
W. Frank Peacock IV, MD, FACEP, FACC, can be reached at frankpeacock@gmail.com; Twitter: @WFPeacock
Disclosures: The study was funded by Janssen. Peacock reports he has received consultant fees from Bayer and Janssen and institutional grant support from Janssen. Please see the study for all other authors’ relevant financial disclosures.
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