Help Navigating Alternatives For Eliquis Due To Cost
In our latest question and answer, our pharmacist discusses some alternatives to Eliquis for AFib due to the high cost of the drug.
My mom has heart failure and AFib. However, after taking Entresto for about a week, her heart function improved and was back to normal (50% or more), so I wonder if it was really true heart failure. Entresto is an expensive medication, and even with insurance, it was unaffordable for my retired, elderly mother on social security. She was switched to Losartan and Diltiazem, but she is still taking Eliquis to prevent clotting, which is also very costly despite having insurance. Although my mother prefers natural remedies like aspirin, garlic, and krill oil or flaxseed, most physicians advise against them as they are not strong enough. Prior to developing heart issues, her blood was already thin, and one physician suggested that her anti-cholinergic medication might have been the cause. I'm wondering if natural blood thinners could be used instead of Eliquis, given that her blood was already thin. Additionally, is there a way to measure blood thickness? My mother doesn't want to take warfarin as it is similar to rat poison. This is causing us a lot of stress as we try to figure everything out. Thank you for your thoughts.
Answered by Dr. Brian Staiger, PharmD
Medical Content Reviewed By HelloPharmacist Staff
Last updated Mar 17, 2023
- Natural remedies like flaxseed, garlic, and krill oil are not substitutes for prescription medications when it comes to treating conditions such as AFib and preventing blood clots.
- Aspirin alone is not a good alternative to anticoagulant medications like Eliquis for AFib, but a combination of aspirin and clopidogrel may be considered in some cases.
- While DOACs (direct oral anticoagulants) like Eliquis are often preferred over warfarin due to their ease of use and lower risk of bleeding complications, warfarin is still considered an effective treatment for preventing blood clots in some patients with AFib and can be considered an alternative if DOACs are not an option.
- Pradaxa, a DOAC similar to Eliquis, is available generically and may be less expensive than Eliquis. It does have a higher risk of bleeding though.
Thanks for reaching out to us!
While I understand the desire to explore natural remedies (and you would be hard-pressed to find a bigger proponent of their use to help support numerous conditions than me), things like flaxseed, garlic, and krill oil are not appropriate substitutes for prescription medications when it comes to treating conditions such as AFib and preventing blood clots.
While some natural products certainly have at least mild blood-thinning properties, they have not been shown to be effective like certain drugs (e.g., Eliquis) in reducing the risk of stroke or other complications in those with AFib.
Heart failure and atrial fibrillation (AFib) are both serious medical conditions that require appropriate medical management.
So, let's talk about some options regarding the concerns you brought up in your question, namely that Eliquis is too expensive, and you are looking for an alternative for that.
Eliquis Alternatives For AFib?
I want to talk about some potential alternatives for your mother as I know first-hand how the high cost of prescription medication can be a burden, especially for elderly patients living on a fixed income.
I do want to reiterate though that natural remedies are not a reasonable substitute for medications like Eliquis, which have been shown to be effective in preventing blood clots in patients with AFib.
Studies evaluating natural remedies in this population (those with AFib) are rare and often lack concrete outcomes data to demonstrate their effectiveness in improving outcomes, such as mortality and stroke, when compared to the high-quality studies and clinical trials drugs like Eliquis have gone through.
What Is Eliquis?
Eliquis (apixaban) is one of several medications known as direct oral anticoagulants (DOACs), which are used to prevent blood clots in those with AFib or other conditions that increase the risk of clotting.
DOACs are often preferred over older anticoagulants like warfarin due to their ease of use and lower risk of bleeding complications.
However, DOACs like Eliquis can be expensive, especially for patients who do not have adequate insurance coverage. This seems to be the case with your mother. There are other options out there.
Is Aspirin An Alternative?
You mentioned aspirin.
Aspirin is often thought of as an alternative to anticoagulant medications like Eliquis in patients with AFib, but numerous studies have shown is not as effective at preventing strokes and may be associated with an increased risk of bleeding. Therefore aspirin alone is not a good alternative to other medications, such as DOACs, for AFib.
Some studies have evaluated 'dual antiplatelet therapy' with aspirin plus clopidogrel (generic for Plavix), and this combination reduces the risk of thromboembolism compared to aspirin alone but provides less protection against thromboembolism than DOACs.
The combination of aspirin and clopidogrel could potentially be an option for your mother, as I imagine clopidogrel, being generic, would be less expensive than Eliquis, but again, studies don't support this combination as having the same benefits as Eliquis.
What About Warfarin?
While warfarin has been associated with a number of side effects, naming bleeding, and requires frequent monitoring, it is still considered an effective treatment for preventing blood clots in patients with AFib.
In fact, some individuals may be better suited to warfarin than DOACs depending on their individual circumstances.
You mentioned concerns about it being a 'poison', and while I understand the sentiment, I don't agree with this characterization to preclude its use.
In rats, warfarin, a vitamin K antagonist, causes uncontrollable bleeding by interfering with its ability to produce vitamin K-dependent clotting factors. Rats are particularly vulnerable to warfarin because they have a faster metabolism than humans, and therefore, they require a higher intake of vitamin K to maintain healthy blood clotting.
In humans, the dose of warfarin is carefully controlled to avoid excessive bleeding, but it does certainly require monitoring and dosage adjustments. It also, overall, has a higher risk of bleeding when compared to DOACs.
There are a number of medications that are derived from substances that may be considered "poisons" in high doses but can nonetheless be used safely and effectively to treat a variety of medical conditions.
For example, Botox (botulinum toxin) is a potent neurotoxin that is used in small doses to treat conditions like chronic migraine, spasticity, and facial wrinkles. Similarly, digitalis, a drug derived from the foxglove plant, is used to treat heart failure.
In regard to whether or not warfarin is a viable alternative to Eliquis for treating Afib for your mother, it is true that for most patients with AFib with an indication for anticoagulation, direct oral anticoagulants (DOAC), rather than vitamin K antagonists (e.g., warfarin), are recommended.
In fact, multiple trials (including RE-LY, ARISTOTLE, ROCKET AF, and ENGAGE AF-TIMI) all show that DOACs like Eliquis are generally better in regard to a reduction in negative outcomes (such as stroke), with fewer side effects, than warfarin in most individuals.
However, warfarin is an alternative and shouldn't be immediately discounted.
Studies show that it does reduce the risk of negative outcomes (e.g., stroke) and is recommended in guidelines for specific patients, including:
- For individuals who are not likely to be adherent to the multiple daily dosing of Pradaxa (dabigatran) or Eliquis (apixaban) and who cannot take once-a-day Xarelto (rivaroxaban) or Savaysa (edoxaban) due to other reasons.
- For individuals who cannot afford a DOAC.
- For individuals with chronic severe kidney disease.
Drugs Similar To Eliquis As Alternatives
As mentioned, Eliquis belongs to a class of drugs known as Direct Oral Anticoagulants (DOACs).
DOACs include the direct thrombin inhibitor Pradaxa (dabigatran) and direct factor Xa inhibitors (e.g., Eliquis [apixaban], Savaysa [edoxaban], and Xarelto [rivaroxaban]).
Only one of these, as of this writing, is available generically, and that is Pradaxa (dabigatran).
Now, even though Pradaxa is available generically, Eliquis is more commonly prescribed than Pradaxa.
One major factor in this is that Eliquis has a lower risk of bleeding complications compared to Pradaxa, likely due to the fact that Pradaxa is an oral direct thrombin inhibitor Pradaxa (dabigatran) and Eliquis is a little more targeted, being a direct factor Xa inhibitor.
Studies show that Eliquis has a significant reduction in major bleeding events compared to warfarin and Pradaxa. This has made Eliquis an attractive choice for physicians, as reducing bleeding risk is a key consideration when choosing a medication for atrial fibrillation.
Regardless, Pradaxa is a likely option for your mother and may be less expensive. It has similar outcomes data to Eliquis too.
Tests That Measure 'Blood Thickness'
There are several tests that can be used to measure blood thickness or clotting potential, including the prothrombin time (PT) and international normalized ratio (INR) tests, which are used to monitor patients on warfarin therapy.
However, these tests are not typically used to monitor patients on DOAC therapy like Eliquis.
You mentioned wondering if your mother even needed to be an anticoagulant due to her blood already seeming to have clotting issues.
When deciding if an individual with AFib should take medicine to thin their blood for a long time, doctors will look at their risk of having a blood clot and the risk of bleeding from the medicine.
Taking the medicine for a long time can lower the risk of blood clots, but it can also increase the risk of bleeding. Doctors need to take into consideration a lot of factors, including what the patient prefers.
One tool that healthcare providers often use is called the CHA2DS2-VASc score, which helps determine which individuals with atrial fibrillation should receive long-term oral anticoagulation.
The CHA2DS2-VASc score is a tool that takes into account several risk factors for stroke in patients with AFib, including age, gender, history of heart failure, hypertension, diabetes, and previous stroke or transient ischemic attack (TIA).
The score assigns points to each risk factor, and the total number of points is used to determine the patient's risk of stroke.
There are other factors that must be taken into consideration and it's absolutely something you should discuss with the doctor. There is not a one size fits all approach and therapy, including whether or not anticoagulant therapy is needed, is highly individualized.
I provided a lot of information here.
Below is a quick summary of what I discussed:
- Natural remedies like krill oil and flaxseed aren't appropriate alternatives to anticoagulants like Eliquis.
- Aspirin alone isn't considered an appropriate alternative to anticoagulants like Eliquis to prevent stroke in those with AFib. A combination of it and clopidogrel (generic Plavix), is, however, an option for some.
- Warfarin (generic for Coumadin), while not as effective as anticoagulants like Eliquis for AFib, is an alternative option, although requires more monitoring.
- Pradaxa (dabigatran) is similar to Eliquis and is available generically. It may be less expensive on your insurance plan. However, it carries a higher bleeding risk than Eliquis (but is generally considered less of a risk compared to warfarin).
You mentioned that your mother was also taking Entresto, but that was switched to some alternative drugs and you didn't write about any issues with those, so I focused this answer on Eliquis alternatives.
If anything else comes up for you, please feel free to write back!
- Rivaroxaban versus warfarin in nonvalvular atrial fibrillation, PubMed
- Edoxaban versus warfarin in patients with atrial fibrillation, PubMed
- Dabigatran versus warfarin in patients with atrial fibrillation, PubMed
- Apixaban versus warfarin in patients with atrial fibrillation, PubMed
- Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial, PubMed
- Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials, PubMed
- Dr. Brian Staiger, PharmD
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