A two-speed Europe in oral anticoagulation: Spain versus northern Europe, NHS and Germany

Background

Direct oral anticoagulants have a more favourable benefit-risk profile than vitamin K antagonists for most patients with non-valvular atrial fibrillation and simplify clinical management. Unequal uptake may generate avoidable differences in stroke prevention and health inequities across Europe.

Methods

We conducted a descriptive multinational drug-utilisation study using aggregated population data. Outpatient use of apixaban, rivaroxaban, edoxaban, dabigatran, acenocoumarol and warfarin (ATC B01AF, B01AE and B01AA) was expressed as DHD, defined daily doses per 1,000 inhabitants per day, following WHO ATC/DDD methodology. Data for 2020-2024 came from official administrative sources in Spain, Germany, Norway, Denmark, Italy and NHS England. All data referred to ambulatory care: prescription medicines dispensed in community pharmacies and funded by public or mandatory systems. We analysed trends and compared Spain in 2024.

Results

In 2024, apixaban use in Spain was 5.51 DHD, below Norway (19.14), NHS England (18.90) and Germany (18.82). Denmark showed intermediate values (12.50) and Italy a moderate pattern (6.70). Rivaroxaban followed a similar gradient, with use in Spain (3.48 DHD) around three times lower than in Nordic countries and NHS England. Edoxaban use was more homogeneous, although Spain remained below Germany and Italy. VKA use was almost residual in Norway and NHS England, while Spain maintained relevant use in 2024 (acenocoumarol 3.92 DHD; warfarin 0.41 DHD).

Conclusions

These findings show divergent oral anticoagulation patterns in Europe, with faster transition towards direct oral anticoagulants in Nordic countries, NHS England and Germany, and slower adoption in Spain. This suggests persistent population exposure to vitamin K antagonists and possible inequities in access to safer therapies. Future studies should assess the impact of these differences on stroke, bleeding and costs, to guide equitable anticoagulation policies.

Key messages

• Spain shows slower uptake of direct oral anticoagulants and persistent vitamin K antagonist use compared with northern Europe and NHS England.

• Unequal anticoagulant use may signal avoidable inequities in access to safer stroke prevention therapies across Europe.