Impact of the COVID-19 Pandemic on Global Anticoagulant Sales: A Cross-Sectional Analysis Across 39 Countries

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has been associated with important changes in the use of anticoagulants, including (1) the recommendation of low-molecular-weight heparin (LMWH) or fondaparinux to prevent thrombotic complications associated with COVID [1–3], and the increased use of direct oral anticoagulants (DOACs) in atrial fibrillation to prevent exposure to healthcare facilities for blood monitoring required with warfarin. We quantified the change in global sales of anticoagulant agents after the COVID-19 pandemic declaration in March 2020. MIDAS® data for August 2014–August 2020 were obtained from IQVIA [4], which contains retail and hospital drug purchase data for 39 countries. We extracted records for anticoagulants, including injectable anticoagulants (heparins and LMWH), vitamin K antagonists, and DOACs. For each month and country, we calculated the number of units sold per 1000 population, and we conducted interrupted time-series analyses to examine changes in the trend of sales after the pandemic declaration in March 2020. Regression models included a continuous variable for month, an indicator variable for the period after March 2020, the interaction between them, and an indicator variable for developing countries. To quantify country-level variation, we calculated the proportion change in the number of units sold in March–August 2020 versus March–August 2019. Due to the instability of estimates for smaller countries, we constrained these analyses of variation in units for March–August 2020 versus March–August 2019 to countries with a population of at least 20 million (n = 17 countries). Before 2020, sales of anticoagulants increased by an annual average of 6%, driven by an annual average increase in sales of DOACs of 26%. Sales of vitamin K antagonists decreased by an annual average of 8%, and sales of injectable anticoagulants remained constant (Fig. 1). After the pandemic declaration in March 2020, there was a significant increase in sales of all anticoagulant products (p-value for level change = 0.006) and DOACs (p-value for level change = 0.019). Global sales of injectable products remained constant, while sales of vitamin K antagonists increased after the pandemic declaration, but the change was not significant (p = 0.133). On average, countries purchased 11% more anticoagulant units in March–August 2020 than in March–August 2019 (Fig. 2). Russia and Mexico had the largest increases in sales of anticoagulant products, with increases of 39% and 40%, respectively. The UK was the only country with a decrease in sales of anticoagulant products (− 2%). Country-level variation in changes in anticoagulant sales was particularly large for injectable products. While global sales of injectable anticoagulants were lower in March–August 2020 than in March–August 2019, five countries increased their demand, most remarkably Australia (55%), Russia (42%), and Mexico (34%). Russia and Mexico also presented the greatest increases in purchases of DOACs (73% and 43%, respectively), while the US had the largest decrease in purchases of injectable anticoagulants (− 22%). Our paper is subject to four main limitations. First, we did not include fondaparinux in analyses because of missing data for some countries. Second, because we did not have access to drug utilization data, it is possible that changes in * Inmaculada Hernandez [email protected]