11. Xarelto

Xarelto is getting beat to the punch by anticoagulant superstar Eliquis. (Bayer)

: Bayer, Johnson & Johnson
2019 sales: $6.35 billion
Projected 2026 sales: $2.55 billion
Projected CAGR: -12%
Used for: blood clots, coronary artery disease, peripheral artery disease

In a blood thinner field increasingly dominated by Pfizer and Bristol Myers Squibb's Eliquis, Bayer and J&J's Xarelto has seen a tougher road to megablockbuster sales. With patent expiration coming in 2024, Xarelto could be staring at an uncertain future in the coming years. 

Xarelto hit $6.35 billion in sales in 2019, but Evaluate Pharma is predicting a hard decline once the drug goes off patent. In 2026, Evaluate forecasts, Xarelto will post just $2.55 billion in sales at a 12% annual decline.

With nearly 10 years on the market, Xarelto has seen stagnant growth in prescription figures as Eliquis first dominated the warfarin alternative market and then eventually overtook warfarin itself in terms of patient numbers. 

RELATED: ACC: J&J, Bayer's blood thinner Xarelto scores in artery disease post-surgery

Part of Xarelto's problem is a less-than-stellar label, including a black box warning for blood clots and spinal hematomas that its competitors don't have. 

Bayer and J&J have still attempted to expand Xarelto's label to help pull in more physicians, including a possible indication in peripheral artery disease patients who previously underwent surgery. 

In March, the partners released data showing a combination of Xarelto and aspirin reduced the risk of major limb and cardiovascular events by 15% over aspirin alone in those patients. At 28 weeks of treatment, 17.3% of patients treated with a Xarelto-aspirin combo suffered acute limb ischemia, major amputation for vascular cause, heart attack, ischemic stroke or cardiovascular death compared with 19.9% in the solo aspirin arm.

RELATED: AHA: Johnson & Johnson, Bayer still looking for answers in aborted Xarelto study

11. Xarelto