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Kocabaş U, Ergin I, Yavuz V, Murat S, Özdemir I, Genç Ö, Altın C, Tüner H, Meriç BK, Çoner A, Yüce Eİ, Boyraz B, Aslan O, Dal A, Şen T, İbişoğlu E, Erdoğan A, Özgeyik M, Demir M, Bilgel ZG, Şengör BG, Urgun ÖD, Doğduş M, Tekin DDN, Çakal S, Çayırlı S, Güler A, Karabulut D, Dalgıç O, Uzman O, Murat B, Şahin Ş, Karabulut U, Kıvrak T, Coşgun MS, Özyurtlu F, Kaplan M, Özçalık E. PrevAleNce and Associated factors of inappropriaTe dosing of direct Oral anticoaguLants In pAtients with Atrial Fibrillation: the ANATOLIA-AF Study. Cardiovasc Drugs Ther 2024; 38:581-599. [PMID: 36527566 DOI: 10.1007/s10557-022-07409-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Inappropriate dosing of direct oral anticoagulants is associated with an increased risk of stroke, systemic embolism, major bleeding, cardiovascular hospitalization, and death in patients with atrial fibrillation. The main goal of the study was to determine the prevalence and associated factors of inappropriate dosing of direct oral anticoagulants in real-life settings. METHODS This study was a multicenter, cross-sectional, observational study that included 2004 patients with atrial fibrillation. The study population was recruited from 41 cardiology outpatient clinics between January and May 2021. The main criteria for inappropriate direct oral anticoagulant dosing were defined according to the recommendations of the European Heart Rhythm Association. RESULTS The median age of the study population was 72 years and 58% were women. Nine-hundred and eighty-seven patients were prescribed rivaroxaban, 658 apixaban, 239 edoxaban, and 120 dabigatran. A total of 498 patients (24.9%) did not receive the appropriate dose of direct oral anticoagulants. In a logistic regression model, advanced age, presence of chronic kidney disease and permanent atrial fibrillation, prescription of reduced doses of direct oral anticoagulants or edoxaban treatment, concomitant use of amiodarone treatment, and non-use of statin treatment were significantly associated with potentially inappropriate dosing of direct oral anticoagulants. CONCLUSION The study demonstrated that the prevalence of inappropriate direct oral anticoagulant dosing according to the European Heart Rhythm Association recommendations was 24.9% in patients with atrial fibrillation. Several demographic and clinical factors were associated with the inappropriate prescription of direct oral anticoagulants.
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Affiliation(s)
- Umut Kocabaş
- Department of Cardiology, Başkent University Izmir Hospital, Izmir, Turkey.
| | - Isil Ergin
- Faculty of Medicine, Department of Public Health, Ege University, Izmir, Turkey
| | - Veysel Yavuz
- Department of Cardiology, Akhisar State Hospital, Manisa, Turkey
| | - Selda Murat
- Faculty of Medicine, Department of Cardiology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Ibrahim Özdemir
- Department of Cardiology, Manisa City Hospital, Manisa, Turkey
| | - Ömer Genç
- Department of Cardiology, Ağrı Training and Research Hospital, Ağrı, Turkey
| | - Cihan Altın
- Faculty of Medicine, Department of Cardiology, Izmir University of Economics, Izmir, Turkey
| | - Haşim Tüner
- Department of Cardiology, Hakkari State Hospital, Hakkari, Turkey
| | | | - Ali Çoner
- Department of Cardiology, Başkent University Alanya Hospital, Antalya, Turkey
| | - Elif İlkay Yüce
- Department of Cardiology, Fethiye State Hospital, Muğla, Turkey
| | | | - Onur Aslan
- Department of Cardiology, Mersin City Hospital, Mersin, Turkey
| | - Ahmet Dal
- Faculty of Medicine, Department of Cardiology, Izmir University of Economics, Izmir, Turkey
| | - Taner Şen
- Faculty of Medicine, Department of Cardiology, Kütahya Health Sciences University, Kütahya, Turkey
| | - Ersin İbişoğlu
- Department of Cardiology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Aslan Erdoğan
- Department of Cardiology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Mehmet Özgeyik
- Department of Cardiology, Eskişehir City Hospital, Eskişehir, Turkey
| | - Mevlüt Demir
- Faculty of Medicine, Department of Cardiology, Kütahya Health Sciences University, Kütahya, Turkey
| | - Ziya Gökalp Bilgel
- Department of Cardiology, Başkent University Adana Hospital, Adana, Turkey
| | | | | | - Mustafa Doğduş
- Department of Cardiology, Uşak University Training and Research Hospital, Uşak, Turkey
| | | | - Sinem Çakal
- Department of Cardiology, Health Sciences University, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Sercan Çayırlı
- Faculty of Medicine, Department of Cardiology, Adnan Menderes University, Aydın, Turkey
| | - Arda Güler
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Dilay Karabulut
- Department of Cardiology, Istanbul Bakirköy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Onur Dalgıç
- Department of Cardiology, Kardiya Medical Center, Izmir, Turkey
| | - Osman Uzman
- Department of Cardiology, Sarıkamış State Hospital, Kars, Turkey
| | - Bektaş Murat
- Department of Cardiology, Eskişehir City Hospital, Eskişehir, Turkey
| | - Şeyda Şahin
- Department of Cardiology, Turhal State Hospital, Tokat, Turkey
| | - Umut Karabulut
- Department of Cardiology, Istanbul Acıbadem International Hospital, Istanbul, Turkey
| | - Tarık Kıvrak
- Faculty of Medicine, Department of Cardiology, Elazığ Fırat University, Elazığ, Turkey
| | - Muharrem Said Coşgun
- Department of Cardiology, Erzincan Binali Yıldırım University, Mengücek Gazi Training and Research Hospital, Erzincan, Turkey
| | - Ferhat Özyurtlu
- Department of Cardiology, Grandmedical Hospital, Manisa, Turkey
| | - Mehmet Kaplan
- Faculty of Medicine, Department of Cardiology, Gaziantep University, Gaziantep, Turkey
| | - Emre Özçalık
- Department of Cardiology, Başkent University Izmir Hospital, Izmir, Turkey
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van der Horst SFB, van Rein N, van Mens TE, Huisman MV, Klok FA. Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: A narrative review. Thromb Res 2023; 231:135-140. [PMID: 37005194 DOI: 10.1016/j.thromres.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Direct oral anticoagulants (DOACs) have become the cornerstone for prevention of thromboembolic events in patients with atrial fibrillation and patients with a history of venous thromboembolism. However, studies show that DOAC prescriptions are commonly inconsistent with guideline recommendations. DOAC dosing in the acutely ill patient could impose an even greater challenge. In this review, we describe the prevalence of inappropriate inpatient prescribing of DOACs and the associated rationales, predictors and clinical consequences. With the aim of promoting appropriate prescriptions of DOACs to hospitalized patients, we further outline DOAC dose reduction criteria justified by various guidelines, illustrating the complexities of appropriate dosing, especially in acutely ill patients. Moreover, we will discuss the impact of anticoagulant stewardship programs and the vital role that pharmacists may play in optimizing inpatient DOAC treatment.
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Affiliation(s)
- S F B van der Horst
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands.
| | - N van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands; Amsterdam UMC, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, University of Amsterdam, Amsterdam, Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
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Prevalence and risk of inappropriate dosing of direct oral anticoagulants in two Swiss atrial fibrillation registries. Vascul Pharmacol 2022; 147:107120. [PMID: 36182083 DOI: 10.1016/j.vph.2022.107120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have a favourable risk-benefit profile compared to vitamin K-antagonists (VKAs) in atrial fibrillation (AF). Dosing is based on age, weight and renal function, without need of routine monitoring. METHODS AND RESULTS In two prospective, multicentre AF cohorts (Swiss-AF, BEAT-AF) patients were stratified as receiving VKAs or adequately-, under- or overdosed DOACs, according to label. Primary outcome was a composite of major adverse clinical events (MACE), defined as cardiovascular death, myocardial infarction (MI), ischaemic stroke and systemic embolism. Secondary outcomes included major bleeding. Adjustment for confounding was performed. Median follow-up was 4 years. Of 3236 patients, 1875 (58%) were on VKAs and 1361 (42%) were on DOACs, of which 1137 (83%) were adequately-, 134 (10%) over- and 90 (7%) under-dosed. Compared to adequately dosed individuals, overdosed patients were more likely to be older and female. Underdosing correlated with concomitant aspirin therapy and coronary artery disease. Both groups had higher CHA2DS2-VASc scores. Patients on overdosed DOACs had higher incidence of MACE (HR 1.75; CI 1.10-2.79; adjusted-HR: 1.22) and major bleeding (HR 1.99; CI 1.14-3.48; adjusted-HR: 1.51). Underdosing was not associated with a higher incidence of MACE (HR 0.94; CI 0.46-1.92; adjusted-HR 0.61) or major bleeding (HR 1.07; CI 0.46-2.46; adjusted-HR 0.82). After adjustment, all CIs crossed 1.0. CONCLUSION Inappropriate DOAC-dosing was more prevalent in multimorbid patients, but did not correlate with higher risks of adverse events after adjusting for confounders. DOAC prescription should follow label.
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Kubota K, Ooba N. Effectiveness and Safety of Reduced and Standard Daily Doses of Direct Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation: A Cohort Study Using National Database Representing the Japanese Population. Clin Epidemiol 2022; 14:623-639. [PMID: 35520279 PMCID: PMC9064485 DOI: 10.2147/clep.s358277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the effectiveness and safety of reduced or standard daily doses of direct oral anticoagulants (DOACs) with warfarin in Japanese patients with nonvalvular atrial fibrillation (NVAF). We used post-hoc analyses to identify patient groups that could benefit from reduced-dose DOACs. Patients and Methods Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan, we identified 944,776 patients with NVAF who had started an oral anticoagulant after at least one year of non-use between April 2011 and March 2016. We matched patients taking any, reduced, or standard doses of DOACs 1:1 with those taking warfarin. We measured treatment effectiveness based on admission due to stroke or systemic embolism (S/SE) and safety based on admission due to any bleeding (defined as major bleeding, MB). We compared both outcomes between DOACs and warfarin using the Cox proportional hazards model. We used post-hoc analysis to match patients receiving reduced-dose DOACs to those receiving standard-dose DOACs and compared treatment effectiveness and safety. Results More than half of patients receiving DOACs used a reduced dose. The occurrences of S/SE and MB in patients receiving any, reduced, or standard doses of DOACs were equal to or lower than those receiving warfarin. In the post-hoc analysis, the risk of S/SE and MB was similar between reduced and standard doses of DOACs except for those with a history of cerebral infarction and CHA2DS2-VASc score ≥3, where the risk of S/SE was lower for reduced doses of any and individual DOACs. Conclusion Findings from the current study are consistent with recent Asian and global studies but different from most studies conducted in North America and Europe, where patients receiving a reduced dose of DOACs had an increased risk of S/SE. Future studies should test the reproducibility of results from the current study.
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Affiliation(s)
- Kiyoshi Kubota
- NPO Drug Safety Research Unit Japan, Tokyo, Japan
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Funabashi, Chiba, Japan
- Correspondence: Kiyoshi Kubota, NPO Drug Safety Research Unit Japan, 6-2-9-2F Soto-Kanda, Chiyoda-ku, Tokyo, 101-0021, Japan, Tel +81-3-6284-4206, Fax +81-3-6284-4207, Email
| | - Nobuhiro Ooba
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Funabashi, Chiba, Japan
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Choi J, No JE, Lee JY, Choi SA, Chung WY, Ah YM, Yu YM. Efficacy and Safety of Clinically Driven Low-Dose Treatment with Direct Oral Anticoagulants in Asians with Atrial Fibrillation: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2022; 36:333-345. [PMID: 33725229 DOI: 10.1007/s10557-021-07171-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Although clinically driven low-dose (CDLD) treatment with direct oral anticoagulants (DOACs) is frequently administered to Asian patients with atrial fibrillation, clinical evidence confirming its efficacy remains insufficient. We evaluated the clinical efficacy and safety of CDLD treatment with DOACs compared to on-label dose treatment in Asian patients with atrial fibrillation and assessed the differences in the baseline characteristics between patients receiving these treatments. METHODS We searched the MEDLINE, CENTRAL, EMBASE, Web of Science, and Scopus databases for articles from inception through July 2020. RESULTS Thirteen studies were included in this meta-analysis. The baseline characteristics of the CDLD group were significantly different from those of the standard dose (STD) and standard low-dose (SLD) groups. The incidences of thromboembolic events (risk ratio [RR] 0.46, 95% confidence interval [CI] 0.29-0.73, p < 0.001) and major bleeding (RR 0.55, 95% CI 0.35-0.87, p = 0.01) in the CDLD group were lower than those in the SLD group; however, they were comparable with those in the STD group. The incidence of a composite endpoint in the CDLD group was not significantly different from that in the STD group but was significantly lower than that in the SLD group (RR 0.50, 95% CI 0.38-0.65, p < 0.001). CONCLUSION The clinical outcomes of CDLD treatment showed no difference compared to those of the STD treatment despite the vulnerable baseline characteristics of the CDLD group for thromboembolic and major bleeding events.
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Affiliation(s)
- Jillie Choi
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, 85 Songdogwahak-ro, Yeonsu-gu, Incheon, 21983, Republic of Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea
| | - Jae Eun No
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, 85 Songdogwahak-ro, Yeonsu-gu, Incheon, 21983, Republic of Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Soo An Choi
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Korea University, Sejong, Republic of Korea
| | - Woo-Young Chung
- Department of Internal Medicine, Seoul National University Boramae Medical Center and College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongsangbuk-do, 38541, Republic of Korea.
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, 85 Songdogwahak-ro, Yeonsu-gu, Incheon, 21983, Republic of Korea.
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea.
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6
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Meta-analysis comparing inappropriately low dose versus standard dose of direct oral anticoagulants in patients with atrial fibrillation. J Am Pharm Assoc (2003) 2021; 62:487-495.e2. [PMID: 34815185 DOI: 10.1016/j.japh.2021.10.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/10/2021] [Accepted: 10/22/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The appropriateness of direct oral anticoagulant (DOAC) dosing has been the issue in the real-world setting, and inappropriately lower DOAC dose may not be as effective or safe as the standard dose in patients with atrial fibrillation (AF). Multiple real-world studies compared the inappropriately lower DOAC dose versus the standard dose, but their main findings were contradictory. METHODS A meta-analysis was performed to compare the efficacy and safety of the inappropriately lower DOAC dose with the standard DOAC dose in patients with AF. Database searches through May 30, 2021, were performed using Medline and Google Scholar. The primary efficacy outcome was stroke or systemic embolism, and the primary safety outcome was major bleeding. The secondary outcome was all-cause mortality. RESULTS A total of 16 studies were included in this meta-analysis. It revealed that the inappropriately lower DOAC dose was significantly associated with a higher event rate of stroke or systemic embolism compared with the DOAC standard dose (odds ratio 1.21 [95% CI 1.02-1.43], P = 0.03, I2 = 66%). There was no significant difference in the major bleeding event rate between these groups (1.03, [0.92-1.15], P = 0.62; I2 = 27%). CONCLUSION The inappropriately lower DOAC dose should be avoided to optimize DOAC effectiveness in patients with AF.
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Cavillon Decaestecker M, Ferret L, Decaestecker K, Gautier S, Verdun S, Tsogli ES. Direct Oral Anticoagulants and Non-valvular Atrial Fibrillation: Compliance with Dose Level Guidelines in Patients Aged 80 Years and Over. Drugs Aging 2021; 38:939-950. [PMID: 34486094 DOI: 10.1007/s40266-021-00883-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are currently recommended as first-line or (after vitamin K antagonists) second-line therapy for preventing stroke and systemic embolism in patients with non-valvular atrial fibrillation. In patients aged 80 years and over, however, the fear of DOAC-associated bleeding and the complexity of DOAC dosing regimes may prompt physicians to prescribe inappropriate dose levels. OBJECTIVE The objective of this study was to determine compliance with French and European guidelines of doses of three DOACs (apixaban, dabigatran and rivaroxaban) prescribed to patients aged over 80 years in an indication of non-valvular atrial fibrillation, and to identify factors associated with poor compliance. METHODS We performed a retrospective single-centre study of patients aged over 80 years routinely treated with a DOAC (apixaban, dabigatran or rivaroxaban) for non-valvular atrial fibrillation at Valenciennes General Hospital (Valenciennes, France) between 1 January, 2016 and 31 December, 2017. We determined compliance with French and European guidelines of DOAC doses as a function of each patient's clinical and laboratory parameters, and thus classified the regime as being appropriately dosed, overdosed or underdosed. RESULTS A total of 703 patients (371 taking apixaban, 92 taking dabigatran and 240 taking rivaroxaban) were included in the study. We found that 274 patients (39%) had been prescribed an inappropriate DOAC regime, with underdosing in 241 cases (34%) and overdosing in 33 cases (5%). Underdosing mainly concerned the two most widely prescribed DOACs, i.e. apixaban (39% of all apixaban prescriptions were underdosed) and rivaroxaban (40%). Concomitant treatment with an antidepressant was associated with underdosing of rivaroxaban or apixaban (p = 0.0339). In contrast, initial management in a neurology department was associated with appropriate dosing (p = 0.000146) for both these DOACs. CONCLUSIONS Among patients with non-valvular atrial fibrillation aged 80 years and over, about 40% of DOAC prescriptions feature inappropriate dose levels. It might be possible to reduce inappropriate dosing by raising awareness among hospital-based and private-practice prescribers, providing prescription support tools for DOACs, and performing medication reconciliations and reviews at hospital and in private practice.
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Affiliation(s)
- Marie Cavillon Decaestecker
- Department of Polyvalent Medicine, Valenciennes General Hospital, 114 avenue Desandrouin, 59300, Valenciennes, France
| | - Laurie Ferret
- Clinical Research Unit-Clinical Pharmacy, Valenciennes General Hospital, Valenciennes, France
| | - Kevin Decaestecker
- Department of Neurology, Valenciennes General Hospital, Valenciennes, France
| | - Sophie Gautier
- Department of Pharmacology, Lille University Hospital, Lille, France
| | - Stéphane Verdun
- Biostatistics Department-Delegations for Clinical Research and Innovation, Lille Catholic Hospitals, Lille Catholic University, Lille, France
| | - Essé Sylvestre Tsogli
- Department of Polyvalent Medicine, Valenciennes General Hospital, 114 avenue Desandrouin, 59300, Valenciennes, France.
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Capiau A, De Backer T, Grymonprez M, Lahousse L, Van Tongelen I, Mehuys E, Boussery K. Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation according to the drug labelling and the EHRA Practical Guide. Int J Cardiol 2020; 328:97-103. [PMID: 33279589 DOI: 10.1016/j.ijcard.2020.11.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/11/2020] [Accepted: 11/25/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aimed to evaluate the prevalence of potential drug-drug interactions (DDIs) and the appropriateness of direct oral anticoagulant (DOAC) dosing according to both the Summary of Product Characteristics (SmPC) and the European Heart Rhythm Association (EHRA) Practical Guide in a 'real-world' sample of non-valvular atrial fibrillation (NVAF) patients. METHODS AND RESULTS Data of a cross-sectional observational study in a primary care sample of 654 long-term DOAC users were used for this sub-analysis. A total of 262 potential DDIs were identified in 220 patients (33.6%). Pharmacodynamic DDIs were present in 163 patients (24.9%) and pharmacokinetic DDIs in 82 patients (12.5%). One-third of patients (33.8%) received reduced DOAC dose. According to the dosing recommendations in the SmPC, 81.7% of DOACs were dosed appropriately. According to the EHRA recommendations, 76.6% of DOACs were dosed appropriately. Dosing recommendations were consistent for 90.7% of patients, with both the SmPC and EHRA Practical Guide considering DOACs dosed appropriately in 74.5% of patients, overdosed in 7.8%, underdosed in 7.6% and contraindicated in 0.8%. However, for the remaining 9.3% dosing recommendations differed between SmPC and EHRA. CONCLUSIONS This 'real-world' analysis of DOAC dosing demonstrated that in about one-third of NVAF patients potential DDIs were present. In 18.3% and 23.4% of patients, DOACs were dosed inappropriately according to the SmPC and EHRA Practical Guide respectively. In almost 10% of the study population dosing advice was inconsistent between both references. More research is needed to ensure appropriate DOAC dosing in this 'grey zone' population.
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Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium.
| | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Maxim Grymonprez
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Lies Lahousse
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Inge Van Tongelen
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
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Wakamatsu Y, Nagashima K, Watanabe R, Arai M, Yokoyama K, Matsumoto N, Otsuka T, Suzuki S, Hirata A, Murakami M, Takami M, Kimura M, Fukaya H, Nakahara S, Kato T, Hayashi H, Iwasaki YK, Shimizu W, Nakajima I, Harada T, Koyama J, Okumura K, Tokuda M, Yamane T, Tanimoto K, Momiyama Y, Nonoguchi N, Soejima K, Ejima K, Hagiwara N, Harada M, Sonoda K, Inoue M, Kumagai K, Hayashi H, Yazaki Y, Satomi K, Watari Y, Okumura Y. Clinical Outcomes of Off-Label Underdosing of Direct Oral Anticoagulants After Ablation for Atrial Fibrillation. Int Heart J 2020; 61:1165-1173. [DOI: 10.1536/ihj.20-335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yuji Wakamatsu
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | - Ryuta Watanabe
- Division of Cardiology, Nihon University Itabashi Hospital
| | - Masaru Arai
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | | | | | - Shinya Suzuki
- Department of Cardiology, The Cardiovascular Institute
| | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital
| | | | | | | | | | | | | | | | | | | | | | - Tomoo Harada
- St. Marianna University School of Medicine Hospital
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital
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Brook R, Aswapanyawongse O, Tacey M, Kitipornchai T, Ho P, Lim HY. Real‐world direct oral anticoagulant experience in atrial fibrillation: falls risk and low dose anticoagulation are predictive of both bleeding and stroke risk. Intern Med J 2020; 50:1359-1366. [DOI: 10.1111/imj.14640] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/10/2019] [Accepted: 09/11/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Rowena Brook
- Haematology Department Northern Health Melbourne Victoria Australia
| | | | - Mark Tacey
- The Northern Hospital Melbourne Victoria Australia
- Melbourne School of Population and Global Health The University of Melbourne Melbourne Victoria Australia
| | | | - Prahlad Ho
- Haematology Department Northern Health Melbourne Victoria Australia
- Northern Pathology Victoria Melbourne Victoria Australia
| | - Hui Y. Lim
- Haematology Department Northern Health Melbourne Victoria Australia
- Northern Pathology Victoria Melbourne Victoria Australia
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Dreucean D, Nguyen SN, Donahue KR, Salazar E, Ruegger MC. Evaluation of characteristics and dosing regimens in patients with new or recurrent thrombosis on apixaban and rivaroxaban. J Thromb Thrombolysis 2020; 52:161-169. [PMID: 33099722 DOI: 10.1007/s11239-020-02308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
Direct factor Xa inhibitors, such as apixaban and rivaroxaban, are widely used for treatment and prevention of venous thromboembolism; however, recent cases of therapeutic failure have been reported. Potential risk factors associated with therapeutic failure such as dose deviations outside of package labeling recommendations, and the use of direct factor Xa-specific inhibitor levels to guide clinical decision making continue to be areas of further investigation. Our study aimed to describe characteristics and dosing regimens in patients on apixaban or rivaroxaban who experienced a new or recurrent thrombosis. We performed a retrospective chart review on 190 patients on either apixaban or rivaroxaban presenting to our institution with new or breakthrough thromboembolism. Evaluation of prescribed anticoagulation regimens compared to package labeling recommendations, direct factor Xa inhibitor-specific anti-Xa levels, anticoagulation interruptions, use of parenteral bridge anticoagulation, final anticoagulation regimen disposition, and thrombosis-associated mortality were recorded. In patients presenting with breakthrough thromboembolism, 78% were on a regimen that matched package labeling recommendations. Anti-Xa levels were documented in 66 patients, the majority of which fell within institutional expected ranges at time of thrombosis. Therapy interruptions immediately prior to thrombosis were observed in 22% of patients and 21% of those patients received parenteral anticoagulation during interruption. Upon discharge, 46% of patients continued the same anticoagulation regimen with no changes. The mortality rate was 6%. In patients who present with new thromboembolism on apixaban or rivaroxaban, a thorough review of risks and benefits should be conducted to mitigate future risk of recurrent thrombosis.
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Affiliation(s)
- Diane Dreucean
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA.
| | - Steffany N Nguyen
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
| | - Kevin R Donahue
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
| | - Eric Salazar
- Department of Pathology and Genomic Medicine - Houston Methodist Hospital, 6565 Fannin St, Houston, TX, 77030, USA
| | - Melanie C Ruegger
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
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12
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De Simone V, Mugnolo A, Zanotto G, Morando G. Direct oral anticoagulants for patients aged over 80 years in nonvalvular atrial fibrillation: the impact of frailty. J Cardiovasc Med (Hagerstown) 2020; 21:562-569. [PMID: 32520853 DOI: 10.2459/jcm.0000000000000986] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In patients aged at least 80 years, atrial fibrillation is responsible for significant morbidity and mortality, with a high incidence of stroke. Four new direct oral anticoagulants (DOACs) have been introduced in Italy for the prevention of thromboembolism. Their safety and efficacy in the elderly have already been confirmed. Frailty is frequently associated with aging, but only a few studies have paid attention to interactions between frailty and anticoagulation therapy. METHODS We retrospectively evaluated the effectiveness and safety of DOACs in a population aged at least 80 years. Frailty was appraised using an adaptation of the Reported Edmonton Frail Scale, considering a value at least 8 (on a scale from 0 to 18). RESULTS The majority (644/731) of patients remained on DOACs for more than 1 year. A total of 19 patients experienced a thrombotic event while on anticoagulation (1.11 events per 100 person-years) and 26 patients a major bleeding episode (1.52 events per 100 person-years). The probability of interrupting therapy increased significantly with frailty [hazard ratio 2.91 with confidence interval (CI) 2.15-3.92 at univariate analysis, hazard ratio 2.80 with CI 2.03-3.86 at multivariate]; frailty showed a significant impact also on major bleeding (hazard ratio 3.28 with CI 1.45-7.37 at univariate analysis, hazard ratio 3.56 with CI 1.58-8.01 at multivariate). CONCLUSION Our study highlights how DOACs are a safe and effective option for anticoagulation, even in frail elderly people; the introduction of these drugs is leading to an increased use of anticoagulation therapy in this population. Prospective trials will be needed to reinforce these results and to consider new variables in the thrombotic and hemorrhagic risk scores underlying the prescription of DOACs.
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Affiliation(s)
- Vincenzo De Simone
- Department of Cardiology, Mater Salutis Hospital, Legnago, Verona, Italy
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13
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Santos J, António N, Rocha M, Fortuna A. Impact of direct oral anticoagulant off-label doses on clinical outcomes of atrial fibrillation patients: A systematic review. Br J Clin Pharmacol 2020; 86:533-547. [PMID: 31631392 DOI: 10.1111/bcp.14127] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/14/2019] [Accepted: 09/07/2019] [Indexed: 12/23/2022] Open
Abstract
AIMS Worldwide observational studies are evidencing discordance between guidelines and real-world practice regarding direct oral anticoagulant drug (DOAC) doses. This systematic review summarizes and evaluate DOACs use in real-world practice. METHODS This review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines searching PubMed (MEDLINE) and Medscape databases. RESULTS Data from 75 studies showed that most of the patients treated with DOACs for stroke prevention in atrial fibrillation received doses in accordance to the guidelines. However, a significant number of patients received off-label doses (25-50% in most of the studies evaluated). DOAC overdosing was associated with increased all-cause mortality and worse bleeding events while underdosing was associated with increased cardiovascular hospitalization and, particularly for apixaban, with a nearly 5-fold increased risk of stroke. CONCLUSION Patients prescribed with off-label DOAC doses did not receive the full benefit of anticoagulation and presented an increased risk of stroke, bleeding and/or adverse effects.
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Affiliation(s)
- Joana Santos
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Natália António
- Laboratory of Pharmacology, Faculty of Medicine, University of Coimbra, Portugal.,Cardiology Department, Coimbra Hospital and Universitary Centre, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Marília Rocha
- Pharmaceutical Service, Coimbra Hospital and Universitary Centre, Portugal
| | - Ana Fortuna
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal.,CIBIT/ICNAS - Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
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14
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Kanorskii SG. [How to maintain an adherence to oral anticoagulant in a patient with atrial fibrillation?]. KARDIOLOGIIA 2019; 59:76-83. [PMID: 31849302 DOI: 10.18087/cardio.2019.11.n724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/11/2019] [Indexed: 06/10/2023]
Abstract
Less onerous, compared with warfarin, treatment with direct oral anticoagulants (DOA) can lead to better adherence to treatment of patients with atrial fibrillation (AF). However, in a certain number of patients with AF, who were recommended by DOA, cardioembolic stroke recurs, which is largely due to the patients' failure to comply with medical recommendations. The appointment of DOA as first-line drugs does not guarantee a high adherence of patients with non-valvular AF. For elderly and old patients with AF and numerous comorbidities, the proposal of a simpler pharmacotherapy regimen is especially important. In a number of large modern studies performed in clinical practice, high adherence to rivaroxaban therapy has been established, which may be a result of taking this DOA 1 time per day, its safety and effectiveness.
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15
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Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants - A systematic review. PLoS One 2019; 14:e0213379. [PMID: 30925155 PMCID: PMC6440627 DOI: 10.1371/journal.pone.0213379] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/19/2019] [Indexed: 12/28/2022] Open
Abstract
Background Non-vitamin K antagonist oral anticoagulants (NOAC) are equally or potentially superior in terms of effectiveness in the prevention of ischemic stroke and carry a lower associated risk of intracranial hemorrhage compared to Vitamin K antagonists. Nevertheless, ischemic strokes also occur in patients who are being treated with NOAC. In those particular patients, knowledge about the underlying stroke etiology, clinical presentation, acute management, and complication rates is scarce. Objective Systematic literature review to provide a comprehensive clinical overview in terms of presentation, laboratory, imaging parameters and outcomes of patients suffering from acute cerebral ischemic events (i.e. TIA and acute ischemic stroke) while on treatment with a NOAC. Only if available, comparison to VKA is presented which was not the primary focus of this analysis. Data sources PubMed/MEDLINE, Scopus and EMBASE from January 1, 2006, to November 20, 2018. Study eligibility criteria 52 studies providing detailed information on a total of 12247 patients were included. We excluded case reports and case series with less than five patients. Study appraisal and synthesis method We systematically assessed study quality using a bias tool and pooled consistent data. Results Existing data indicates milder stroke severity and smaller infarct size of acute ischemic stroke on treatment with NOAC compared to stroke occurrence on Vitamin K antagonists (VKA). Established risk factors for ischemic events also play a role in stroke while on NOACs, albeit the underlying etiology remains poorly understood. Intravenous thrombolysis and endovascular therapy seem to be safe and effective, but patient selection for recanalization therapies is challenging. Limitations Limited quality of published data, duplicate cases, statistical issues of data pooling, possible incomplete retrieval of identified research and reporting bias might have limited our findings. Conclusions Acute ischemic events despite treatment with NOAC therapy are insufficiently investigated. Systematic review registration number PROSPERO: CRD42018074853.
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16
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Ruff C, Koukalova L, Haefeli WE, Meid AD. The Role of Adherence Thresholds for Development and Performance Aspects of a Prediction Model for Direct Oral Anticoagulation Adherence. Front Pharmacol 2019; 10:113. [PMID: 30837879 PMCID: PMC6389873 DOI: 10.3389/fphar.2019.00113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/29/2019] [Indexed: 11/23/2022] Open
Abstract
Patients who do not sufficiently adhere to their dosing regimens will, ultimately, do not get the full benefit of their medication. For example, if direct oral anticoagulants (DOAC) are not taken continuously, an intervention to improve adherence or maintain persistence will show direct effects on clinical outcomes. Usually, adherent patients are defined by taking ≥80% of their medication. The resulting binary adherence status from this threshold can as well be used for predictive classification. Thus, the threshold can determine the prediction model’s performance to identify patients at risk for poor adherence by this binary adherence status. In this perspective, we propose a plan for model development and performance considering the threshold’s role. Concerning development demands, we extracted predictors from a systematic literature search on DOAC adherence to be used as a core set of candidate predictors. Independently, we investigated how well a future model would technically have to perform by modeling drug intake and thromboembolic events based on a rivaroxaban pharmacokinetic-pharmacodynamic model. Using this simulation framework for different thresholds, we projected the impact of an imperfectly predicted adherence status on the event risk, and how imperfect sensitivity and specificity affect the cost balance if a supporting intervention was offered to patients classified as non-adherent. Our simulation results suggest applying a rather high threshold (90%) for discrimination between patients at low or high risk for non-adherence by a prediction model in order to assure cost-efficient implementation.
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Affiliation(s)
- Carmen Ruff
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Ludmila Koukalova
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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17
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Murata N, Okumura Y, Yokoyama K, Matsumoto N, Tachibana E, Kuronuma K, Oiwa K, Matsumoto M, Kojima T, Hanada S, Nomoto K, Arima K, Takahashi F, Kotani T, Ikeya Y, Fukushima S, Itoh S, Kondo K, Chiku M, Ohno Y, Onikura M, Hirayama A. Clinical Outcomes of Off-Label Dosing of Direct Oral Anticoagulant Therapy Among Japanese Patients With Atrial Fibrillation Identified From the SAKURA AF Registry. Circ J 2019; 83:727-735. [PMID: 30726797 DOI: 10.1253/circj.cj-18-0991] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Off-label dosing of direct oral anticoagulants (DOACs) is encountered clinically among patients with atrial fibrillation (AF), although data on the clinical outcomes of over- and under-dosing are lacking in Japan. Methods and Results: We examined the clinical outcomes of off-label DOAC dosing using the SAKURA AF Registry, a prospective multicenter registry in Japan. Among 3,237 enrollees, 1,676 under any of the 4 DOAC regimens were followed up for a median of 39.3 months: 746 (45.0%), appropriate standard-dose; 477 (28.7%), appropriate low-dose; 66 (4.0%), over-dose; and 369 (22.2%) under-dose. Compared with the standard-dose group, patients in the under- and over-dose groups were significantly older and had a higher stroke risk. After multivariate adjustment, stroke/systemic embolism (SE) and death events were equivalent between the standard- and under-dose groups, but major bleeding events tended to be lower in the under-dose group (hazard ratio [HR] 0.474, P=0.0739). Composite events (stroke/SE, major bleeding, or death) were higher in the over-dose than in the standard-dose group (HR 2.714, P=0.0081). CONCLUSIONS Clinical outcomes were not worse for under-dose than for standard-dose users among patients with different backgrounds. Over-dose users, however, were at higher risk for all clinical events and required careful follow-up. Further studies are needed to clarify the safety and effectiveness of off-label DOAC dosing in Japan.
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Affiliation(s)
| | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital
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18
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Appropriateness of direct oral anticoagulant dosing and its relation to drug levels in atrial fibrillation patients. J Thromb Thrombolysis 2019; 47:550-557. [DOI: 10.1007/s11239-019-01815-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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