The price of drugs for atrial fibrillation begins to climb

Dear Dr. Roach: My husband takes Eliquis for atrial fibrillation (AFib). The cost increases and there is no generic brand for Eliquis. Looking at drug websites, I found other drugs that are blood thinners: Xarelto, Heparin, and Warfarin are a few. Is there a generic brand you would recommend that we can ask his doctor to see if he will let him take it instead?

— CA

Dear CA: Most people with atrial fibrillation benefit from blood thinners to reduce the risk of stroke. The vast majority of people with atrial fibrillation without valve disease will take either a direct-acting oral anticoagulant (DOA) such as apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), rivaroxaban (Xarelto) or warfarin (Coumadin). Most experts choose one of the DOACs over warfarin because they have been shown to have a lower risk of stroke and major bleeding, compared to warfarin. Also, warfarin should be carefully monitored with clotting time blood tests. People with certain types of heart valve disease (rheumatic mitral stenosis or mechanical heart valve in particular) need treatment with warfarin.

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Generic forms of DOAC have been approved by the FDA, but are not available in pharmacies at the time of this writing.

Among the various DOAs, there is usually no valid reason to favor one over the other beyond cost. The cost, however, varies widely between different agents depending on insurance coverage, and you can ask your husband’s doctor if he can take a different medication from Eliquis. I looked on goodrx.com, and the costs range wildly from $200/month to over $500/month (without insurance). Some people take additional medications, which may interact with one or more of the DOACs, so this should be taken into consideration.

Warfarin is very inexpensive, less than $5/month, but has the disadvantages of requiring frequent blood draws and a higher risk of bleeding and stroke. Heparin (including low molecular weight heparin) is almost never used for long-term treatment of AFib, except during pregnancy.

Dear Dr. Roach: My eldest daughter would like your advice regarding COVID-19 booster shots. She was looking for advice, but so far she hasn’t found anything that relates to someone in her situation. She received the Johnson & Johnson vaccine in March 2021 and a Moderna booster in October 2021. She is in her 30s, works as a flight attendant and has a young child. In addition, her husband suffers from rheumatoid arthritis. Should she get a bivalent booster to better cover Omicron? And if so, which would be better: Pfizer or Moderna?

— BH

Dear BH: I would highly recommend Pfizer or Moderna bivalent boosters for her. Most of the data is about keeping the same booster (Moderna for her), though there are theoretical reasons why mixing and matching could be advantageous.

It is particularly important for her to receive a booster shot, as she is at increased risk of exposure due to her profession. It’s also important for her not to pass the disease on to her husband, who may be at greater risk, since many people with rheumatoid arthritis take medications that predispose them to more severe COVID infections.

The CDC has a tool to help people choose when and what type of booster to get at tinyurl.com/CDCboostercovid.

Readers can email questions to [email protected]

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