Patterns in anticoagulant utilization in the Czech Republic during 2007–2017

Reimbursement and use of oral anticoagulants during 2014-2022 - A register-based study

Background

Vitamin K antagonists, warfarin in particular, have been the mainstay of anticoagulation therapy, but their use has declined in many countries since direct oral anticoagulants (DOACs) have entered the market.

Objective

To examine utilization trends of oral anticoagulants (OACs) in Finland considering the reimbursement of DOACs and changes to national treatment guidelines for the treatment of atrial fibrillation (AF).

Methods

Both public, aggregated data on reimbursed OAC dispensations and individual-level data on electronic dispensations during 2014-2022 were applied. Data on electronic dispensations during 2015-2016 were used to study OAC initiations. Data on entitlements to reimbursement for DOACs came from public data.

Results

In 2014, there were almost 20,000 DOAC users, rising to 214,000 in 2022. The number of warfarin users declined since 2015 from over 181,000 to around 59,000 users in 2022, DOACs exceeding warfarin in the number of users in 2019. The total DOAC costs were higher than warfarin costs each year. Rivaroxaban was the most widely used DOAC during 2014-2018, and apixaban during 2019-2022. In 2015, there were more warfarin (56.7%) than DOAC (43.3%) initiators, but the result was opposite for 2016 (warfarin 39.4%, DOACs 60.6%). The number of individuals entitled to reimbursement for DOACs has increased steadily, and in 2022, there were over 196,000 individuals entitled to this reimbursement due to AF.

Conclusions

The uptake of DOACs in Finland appears to have been gradual and slower than in many other countries. During the 2010s, the treatment guidelines for AF were more cautious in recommending DOACs than the European guidelines. The use of DOACs increased as their reimbursement became less restrictive.

A drug utilization study of oral anticoagulants in five representative cities of China between 2015 and 2019

WHAT IS KNOWN AND OBJECTIVE

Oral anticoagulants (OACs), including warfarin and newer direct-acting OACs (DOACs), have been used for decades to prevent thromboembolic diseases. A drug utilization study was performed to determine the prescribing patterns of OACs.

METHODS

Data were extracted from the Cooperation Project of Hospital Prescription Analysis in China. A total of 455,490 prescription records from 43 tertiary hospitals in five cities of China (Beijing, Shanghai, Guangzhou, Hangzhou and Chengdu) were selected for inclusion. Quarterly trends of defined daily doses (DDDs) and defined daily dose cost (DDDC) from 1 January 2015 to 31 December 2019 were calculated.

RESULTS AND DISCUSSION

Warfarin was the most widely used OAC with DDDs between 189,982 and 176,323 from the first quarter (Q1) of 2015 to the fourth quarter (Q4) of 2019, whereas the use of DOACs increased rapidly during this period. DDDs of rivaroxaban increased from 5409 in Q1 of 2015 to 125,800 in Q4 of 2019, whereas the DDDC declined from 160.5 to 45.7. From Q1 of 2018, rivaroxaban became the most prescribed OAC, surpassing warfarin, in patients diagnosed with deep vein thrombosis. In addition, the DDDs of rivaroxaban exceeded those of warfarin in patients diagnosed with non-valvular atrial fibrillation since the second quarter (Q2) of 2019. DDDs in outpatients and inpatients increased by 80.6% and 71.4%, respectively, and the DDDC for outpatients in Q4 of 2019 was 6.7-fold higher than that in Q1 of 2015. Among patients of all ages, the DDDs in elderly patients increased from 36.8% in Q1 of 2015 to 59.4% in Q4 of 2019. Moreover, the departments of cardiology and cardiothoracic surgery prescribed the majority of the OACs.

WHAT IS NEW AND CONCLUSION

In this study, we describe OAC prescription patterns in China. DOACs, especially rivaroxaban, contribute to the continuous increase in the use of OACs. In the investigated population of China, outpatients and elderly patients were observed to be administered the highest proportion of DOACs.

Update on drug interactions with non-vitamin-K-antagonist oral anticoagulants for stroke prevention in elderly patients

Introduction: We update the knowledge, since the last review in 2017, about drug-drug interactions (DDI) of non-vitamin-K-antagonist oral anticoagulants (NOAC) in patients ≥75 years.Areas covered: The literature was searched for: 'dabigatran,' 'rivaroxaban,' 'edoxaban,' or 'apixaban' and drugs, affecting platelet function, CYP3A4-, CYP2C9-, or P-Gp-activity. Pharmacodynamic DDI of NOAC with drugs affecting platelet function like nonsteroidal anti-inflammatory drugs and antiplatelet agents occur most frequently. Pharmacokinetic DDI with NOAC were found for 37 of 117 drugs. Reports about DDI with NOAC were found for 51% of P-gp-affecting, 38% for CYP2C9-affecting and 27% for CYP3A4-affecting drugs. Reports about DDI of cardiovascular drugs with NOAC were the most prevalent, followed by anti-infective and nervous system drugs. NOAC plasma levels were measured in retrospective and cohort studies and were associated with concomitant medication. Reports about DDI of NOAC were found in 71 patients ≥75 years.Expert opinion: The knowledge about DDI of NOAC in elderly patients is very limited. Studies should be carried out to investigate the role of drugs potentially interacting with NOAC, which until now have not been investigated. When studying DDI of NOAC, care should be taken to include elderly patients with impaired renal function and patients on polymedication.

Spontaneous reports of adverse drug reactions related to oral anticoagulants in the Czech Republic

Background Oral anticoagulants are established drugs of choice for the prevention and treatment of thromboembolic events. However, monitoring their safety remains warranted. Objective The aim was to analyze spontaneous reports of adverse drug reactions related to oral anticoagulants in the Czech Republic. Setting Retrospective observational pharmacovigilance study. Methods Adverse drug reaction reports were obtained from the State Institute for Drug Control between January 2005 and November 2017. Reports related to warfarin, dabigatran, apixaban, and rivaroxaban received from healthcare professionals and patients were analyzed. Main outcome measure Frequency and nature of adverse drug reactions reported to oral anticoagulants. Results In total, 297 reports containing 672 adverse drug reactions were received; 269 reports were sent by healthcare professionals (85% by physicians). In 65% of all reports, reactions were due to direct oral anticoagulants. A higher total number of adverse drug reactions was associated with direct oral anticoagulants than with warfarin [reporting odds ratio (ROR): 10.76; confidence interval (CI): 8.70-13.32; p < 0.001]. Along with the increasing utilization of direct oral anticoagulants, the reporting rate gradually declined over time, especially for rivaroxaban and apixaban. Fatal outcomes were reported in 7%, mostly for dabigatran. Hemorrhagic reactions were the most frequently reported adverse drug reactions (37% associated with dabigatran, 28% with apixaban, 24% with warfarin, and 23% with rivaroxaban), and compared to warfarin, they were significantly more often associated with direct oral anticoagulants (ROR: 14.36; CI: 9.57-21.54; p < 0.001). Conclusion The number of adverse drug reaction reports related to oral anticoagulants in the Czech Republic was relatively low, compared to other studies, but 96% of the cases were serious. Data from spontaneous adverse drug reactions reporting should be further analyzed in order to obtain additional information on the safety profile of oral anticoagulants.

Direct-acting oral anti-coagulants in dental practice: A Retrospective Observational Study (Part 1)

OBJECTIVES

The objective of this retrospective observational study was to determine the incidence of direct-acting oral anti-coagulant (DOA) use in patients receiving invasive dental procedures. The secondary objective was to investigate the precautionary measures implemented and the post/intraoperative complications associated with DOA use.

METHODS

Electronic record database, Axium, was retrospectively reviewed, and patients using NGOA and treated between 2010 and 2017 were identified. Charts of patients who underwent invasive dental procedures were further reviewed to investigate the preoperative/intraoperative precautionary measures taken and identify any intraoperative/postoperative complications.

RESULTS

A total of 130 patients were identified, with their annual number steadily rising from 12 in 2011 to 52 in 2016. Among those, 64 patients (49.23%) underwent invasive dental procedures. Pretreatment medical consults were obtained in all patients undergoing invasive procedures; however, only 7 (10.94%) were instructed to discontinue their DOA. Preoperative laboratory testing was obtained for two patients. Intraoperatively, 34 (53.13%) cases of excessive bleeding were reported, all were locally controlled with hemostatic agents. Only 4 instances of postoperative complications were documented.

CONCLUSIONS

Despite the rise in the use of DOA, there is no consistent pattern for preoperative laboratory testing and DOA discontinuations. Expert consensus may be of great importance to develop practice guidelines.

The blood compatibility challenge. Part 1: Blood-contacting medical devices: The scope of the problem

Blood-contacting medical devices are an integral part of modern medicine. Such devices may be used for only a few hours or may be implanted for life. Despite advances in biomaterial science, clotting on medical devices remains a common problem. Systemic administration of antiplatelet drugs or anticoagulants is often needed to reduce the risk of clotting. Although effective, such therapy increases the risk of bleeding, which can be fatal. This chapter (a) describes some of the commonly used blood-contacting devices and their potential complications, (b) provides an overview of the mechanisms that drive device-associated clotting, and (c) reviews the strategies employed to attenuate clotting on blood-contacting medical devices. STATEMENT OF SIGNIFICANCE: This paper is part 1 of a series of 4 reviews discussing the problem of biomaterial associated thrombogenicity. The objective was to highlight features of broad agreement and provide commentary on those aspects of the problem that were subject to dispute. We hope that future investigators will update these reviews as new scholarship resolves the uncertainties of today.