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Maillard O, Bun R, Laanani M, Verga-Gérard A, Leroy T, Gault N, Estellat C, Noize P, Kaguelidou F, Sommet A, Lapeyre-Mestre M, Fourrier-Réglat A, Weill A, Quantin C, Tubach F. Use of the French National Health Data System (SNDS) in pharmacoepidemiology: A systematic review in its maturation phase. Therapie 2024:S0040-5957(24)00065-9. [PMID: 38834394 DOI: 10.1016/j.therap.2024.05.003] [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: 01/30/2024] [Revised: 04/14/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
AIM OF THE STUDY The French National Health Data System (SNDS) comprises healthcare data that cover 99% of the population (over 67 million individuals) in France. The aim of this study was to present an overview of published pharmacoepidemiological studies using the SNDS in its maturation phase. METHODS We conducted a systematic literature review of original research articles in the Pubmed and EMBASE databases from January 2012 until August 2018. RESULTS A total of 316 full-text articles were included, with an annual increase over the study period. Only 16 records were excluded after screening because they did not involve the SNDS but other French healthcare databases. The study design was clearly reported in only 66% of studies of which 57% were retrospective cohorts and 22% cross-sectional studies. The reported study objectives were drug utilization (65%), safety (22%) and effectiveness (9%). Almost all ATC groups were studied but the most frequent ones concerned the nervous system in 149 studies (49%), cardiovascular system drugs in 104 studies (34%) and anti-infectives for systemic use in 50 studies (16%). CONCLUSION The SNDS is of growing interest for studies on drug use and safety, which could be conducted more in specific populations, including children, pregnant women and the elderly, as these populations are often not included in clinical trials.
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Affiliation(s)
- Olivier Maillard
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Department of Public Health and Research, CHU de La Réunion, 97400 Saint-Pierre, Ile de La Reunion, France; Clinical Investigation Center, INSERM CIC 1410, CHU de La Réunion, 97400 Saint-Pierre, Ile de La Reunion, France.
| | - René Bun
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Department of Public Health and Research, CHU de La Réunion, 97400 Saint-Pierre, Ile de La Reunion, France; Clinical Investigation Center, INSERM CIC 1410, CHU de La Réunion, 97400 Saint-Pierre, Ile de La Reunion, France
| | - Moussa Laanani
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; French National Health Insurance, 75000 Paris, France
| | - Amandine Verga-Gérard
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; INSERM, CIC-EC 1433, 54100 Nancy, France
| | - Taylor Leroy
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; INSERM, CIC-EC 1433, 54100 Nancy, France
| | - Nathalie Gault
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; INSERM, CIC-EC 1425, hôpital Bichat, 75018 Paris, France
| | - Candice Estellat
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Sorbonne Université, INSERM, institut Pierre-Louis d'épidémiologie et de Santé publique, AP-HP, hôpital Pitié-Salpêtrière, département de Santé publique, centre de pharmacoépidémiologie (Cephepi), CIC-1901, 75000 Paris, France
| | - Pernelle Noize
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Université de Bordeaux, INSERM, BPH, U1219, Team AHeaD, CHU de Bordeaux, pôle de santé publique, service de pharmacologie médicale, 33000 Bordeaux, France
| | - Florentia Kaguelidou
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; INSERM, CIC-EC 1426, Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigations Center, hôpital Robert-Debré, 75019 Paris, France; UMR-1123, ECEVE, université Paris Diderot, Sorbonne Paris Cité, 75013 Paris, France
| | - Agnès Sommet
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Service de pharmacologie médicale et clinique, faculté de médecine, CIC 1436, CHU, université de Toulouse, 31000 Toulouse, France
| | - Maryse Lapeyre-Mestre
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Service de pharmacologie médicale et clinique, faculté de médecine, CIC 1436, CHU, université de Toulouse, 31000 Toulouse, France
| | - Annie Fourrier-Réglat
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Université de Bordeaux, INSERM, BPH, U1219, Team AHeaD, CHU de Bordeaux, pôle de santé publique, service de pharmacologie médicale, 33000 Bordeaux, France
| | - Alain Weill
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Epiphare (French National Medicines Agency ANSM and French National Health Insurance CNAM), 93200 Saint-Denis, France
| | - Catherine Quantin
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Service de biostatistiques et d'information médicale (DIM), CHU Dijon Bourgogne, INSERM, université de Bourgogne, CIC 1432, module épidémiologie clinique, 21000 Dijon, France; Université Paris-Saclay, UVSQ, Inserm, CESP, 94807 Villejuif, France
| | - Florence Tubach
- Réseau de recherche en épidémiologie clinique et en santé publique/French Clinical Research Infrastructure Network (RECaP F-CRIN) Inserm network, 54500 Vandoeuvre-lès-Nancy, France; Sorbonne Université, INSERM, institut Pierre-Louis d'épidémiologie et de Santé publique, AP-HP, hôpital Pitié-Salpêtrière, département de Santé publique, centre de pharmacoépidémiologie (Cephepi), CIC-1901, 75000 Paris, France
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Gendron N, Billoir P, Siguret V, Le Cam-Duchez V, Proulle V, Macchi L, Boissier E, Mouton C, De Maistre E, Gouin-Thibault I, Jourdi G. Is there a role for the laboratory monitoring in the management of specific antidotes of direct oral anticoagulants? Thromb Res 2024; 237:171-180. [PMID: 38626592 DOI: 10.1016/j.thromres.2024.04.005] [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: 01/03/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/18/2024]
Abstract
Given the growing number of patients receiving direct oral anticoagulant (DOAC), patients requiring rapid neutralization is also increasing in case of major bleedings or urgent surgery/procedures. Idarucizumab is commercialized as a specific antidote to dabigatran while andexanet alfa has gained the Food and Drug Administration and the European Medicines Agency approval as an oral anti-factor Xa inhibitors antidote. Other antidotes or hemostatic agents are still under preclinical or clinical development, the most advanced being ciraparantag. DOAC plasma levels measurement allows to appropriately select patient for antidote administration and may prevent unnecessary prescription of expensive molecules in some acute clinical settings. However, these tests might be inconclusive after some antidote administration, namely andexanet alfa and ciraparantag. The benefit of laboratory monitoring following DOAC reversal remains unclear. Here, we sought to provide an overview of the key studies evaluating the safety and efficacy of DOAC reversal using the most developed/commercialized specific antidotes, to discuss the potential role of the laboratory monitoring in the management of patients receiving DOAC specific antidotes and to highlight the areas that deserve further investigations in order to establish the exact role of laboratory monitoring in the appropriate management of DOAC specific antidotes.
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Affiliation(s)
- Nicolas Gendron
- Hematology Department, Assistance Publique Hôpitaux de Paris.Centre-Université de Paris (APHP.CUP), F-75015 Paris, France; Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France.
| | - Paul Billoir
- Normandie University, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Virginie Siguret
- Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France; Laboratory of Hematology, Lariboisière hospital, AP-HP. Nord, F-75010 Paris, France
| | - Véronique Le Cam-Duchez
- Normandie University, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Valérie Proulle
- Service Hématologie Biologique et UF d'Hémostase Clinique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris.Centre-Université de Paris (APHP.CUP), F-75015 Paris, France; Université Paris Cité, CRC, unité UMR_S1138, France
| | - Laurent Macchi
- University of Poitiers, INSERM 1313, IRMETIST, F-86000 Poitiers, France; CHU de Poitiers, laboratory of hematology, F-86000 Poitiers, France
| | - Elodie Boissier
- Laboratory of Hematology, University Hospital, Nantes, France
| | - Christine Mouton
- Hematology Laboratory, Hemostasis Department, Haut-Lévêque hospital, CHU, Bordeaux, France
| | | | - Isabelle Gouin-Thibault
- Univ Rennes, Rennes University Hospital, Inserm, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S, 1085, Rennes, France; Hematology Laboratory, Rennes University Hospital, Rennes, France
| | - Georges Jourdi
- Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France; Laboratory of Hematology, Lariboisière hospital, AP-HP. Nord, F-75010 Paris, France.
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Liaw J, Liaw D, Dave C. Initiation patterns of anticoagulants for atrial fibrillation among older UK adults with and without chronic kidney disease, 2010-2020. Open Heart 2024; 11:e002515. [PMID: 38302138 PMCID: PMC10831461 DOI: 10.1136/openhrt-2023-002515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND There is a paucity of data on the initiation patterns of anticoagulants among older atrial fibrillation patients with and without chronic kidney disease (CKD). SETTING AND METHODS We used the UK Clinical Practice Research Datalink (2010-2020) to conduct a retrospective cohort study to evaluate anticoagulant initiation patterns for older adults (≥65 years) with CKD (N=18 421) and without CKD (N=41 901), categorised by severity of CKD: stages 3a, 3b and 4, and initiation dose by respective direct oral anticoagulant (DOAC). RESULTS Over the study period, warfarin initiations sharply declined and were replaced by DOACs regardless of CKD status or stage. By 2020, patients with CKD were modestly more likely (8.8% difference) to initiate apixaban compared with those without CKD (58.8% vs 50.0%; p<0.01). Among patients with CKD, those with stages 3a and 3b CKD had higher apixaban initiations compared with stage 4 CKD (56.9% and 64.6% vs 52.9%, respectively; p<0.01). Conversely, patients with stage 4 CKD were over three times more likely to initiate warfarin (14.7%) compared with those with stage 3a (2.6%) and 3b (4.0%) CKD (p<0.01). Throughout the study period, there was a rise in the proportion of patients initiating the higher 10 mg daily dose for apixaban, with an increase of 20.6% (from 64.3% in 2013 to 84.9% in 2020; p value for trend <0.01) among patients without CKD, and 21.8% (53.1% to 74.9%; p<0.01), 24.4% (18.8% to 43.2%; p<0.01) and 18.5% (0.0% to 18.2%; p<0.01) among patients with stages 3a, 3b and 4 CKD, respectively. CONCLUSIONS AND RELEVANCE Initiation of DOACs increased regardless of CKD status and stage, although with a reduced magnitude in severe CKD. Apixaban emerged as the preferred agent, with a secular trend towards the higher initiation dose in all subgroups. These findings illuminate evolving trends and priorities in anticoagulant preferences among patients with and without CKD.
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Affiliation(s)
- Julia Liaw
- Centers for Pharmacoepidemiology and Treatment Sciences, Rutgers University, New Brunswick, New Jersey, USA
- Rutgers University, New Brunswick, New Jersey, USA
| | - Deborah Liaw
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Chintan Dave
- Rutgers University, New Brunswick, New Jersey, USA
- Department of Pharmacy Practice and Administration, Rutgers University, New Brunswick, New Jersey, USA
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Bentounes NK, Chocron R, Philippe A, Smadja DM, Gendron N. Impact of COVID-19 Pandemic on Temporal Trends of Hemostasis Test in France: A Retrospective Analysis of 9 Years of National Health Data. TH OPEN 2023; 7:e285-e288. [PMID: 37818324 PMCID: PMC10562010 DOI: 10.1055/a-2165-1249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/31/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Nûn K. Bentounes
- University Paris Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris. Centre-Université de Paris, Paris, France
| | - Richard Chocron
- Emergency Department, Assistance Publique Hôpitaux de Paris. Centre-Université de Paris, Paris, France
- University Paris Cité, Paris Cardiovascular Research Center (PARCC), INSERM, Paris, France
| | - Aurélien Philippe
- University Paris Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris. Centre-Université de Paris, Paris, France
| | - David M. Smadja
- University Paris Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris. Centre-Université de Paris, Paris, France
- French Clinical Research Infrastructure Network (F-CRIN), Investigation Network On Venous Thrombo-Embolism (INNOVTE), Saint-Étienne, France
| | - Nicolas Gendron
- University Paris Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris. Centre-Université de Paris, Paris, France
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Aarnio E, Huupponen R, Martikainen J, Korhonen MJ. Reimbursement and use of oral anticoagulants during 2014-2022 - A register-based study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 11:100284. [PMID: 37538990 PMCID: PMC10393798 DOI: 10.1016/j.rcsop.2023.100284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/05/2023] [Accepted: 05/28/2023] [Indexed: 08/05/2023] Open
Abstract
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.
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Affiliation(s)
- Emma Aarnio
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
- Institute of Biomedicine, University of Turku, FI-20014 University of Turku, Finland
| | - Risto Huupponen
- Institute of Biomedicine, University of Turku, FI-20014 University of Turku, Finland
| | - Janne Martikainen
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
| | - Maarit J. Korhonen
- Institute of Biomedicine, University of Turku, FI-20014 University of Turku, Finland
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Ip YMB, Lau KK, Ko H, Lau L, Yao A, Wong GLH, Yip TCF, Leng X, Chan H, Chan H, Mok V, Soo YOY, Seiffge D, Leung TW. Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant. Neurology 2023; 101:e358-e369. [PMID: 37225430 PMCID: PMC10435051 DOI: 10.1212/wnl.0000000000207422] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/03/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Ischemic stroke despite a direct oral anticoagulant (DOAC) is increasingly common and portends a high risk of subsequent ischemic stroke. The efficacy and safety of antithrombotic regimens after the condition are unclear. We aimed to compare the outcomes of patients with ischemic stroke despite DOACs with and without an alternative antithrombotic regimen and determine the risk factors of recurrent ischemic stroke while on anticoagulation. METHODS In a population-based, propensity score-weighted, retrospective cohort study, we compared the clinical outcomes of DOAC-to-warfarin switch, DOAC-to-DOAC switch (DOACswitch), or addition of antiplatelet agents, with those of unchanged DOAC regimen (DOACsame) among patients with nonvalvular atrial fibrillation (NVAF) who developed the first ischemic stroke despite a DOAC from January 1, 2015, to December 31, 2020, in Hong Kong. The primary outcome was recurrent ischemic stroke. Secondary outcomes were intracranial hemorrhage, acute coronary syndrome, and death. We performed competing risk regression analyses to compare the clinical endpoints and determined the predictors of recurrent ischemic stroke in an unweighted multivariable logistic regression model. RESULTS During the 6-year study period, among 45,946 patients with AF on a DOAC as stroke prophylaxis, 2,908 patients developed ischemic stroke despite a DOAC. A total of 2,337 patients with NVAF were included in the final analyses. Compared with DOACsame, warfarin (aHR 1.96, 95% CI 1.27-3.02, p = 0.002) and DOACswitch (aHR 1.62, 95% CI 1.25-2.11, p < 0.001) were associated with an increased risk of recurrent ischemic stroke. In the DOACsame group, adjunctive antiplatelet agent was not associated with a reduced risk of recurrent ischemic stroke. Diabetes mellitus, concurrent cytochrome P450/P-glycoprotein (CYP/P-gp) modulators, and large artery atherosclerotic disease (LAD) were predictors of recurrent ischemic stroke. DISCUSSION In patients with NVAF with ischemic stroke despite a DOAC, the increased risk of recurrent ischemic stroke with switching to warfarin called for caution against such practice, while the increased ischemic stroke with DOAC-to-DOAC switch demands further studies. Adjunctive antiplatelet agent did not seem to reduce ischemic stroke relapse. Because diabetes mellitus, the use of CYP/P-gp modulators, and LAD were predictors of recurrent ischemic stroke, further investigations should evaluate whether strict glycemic control, DOAC level monitoring, and routine screening for carotid and intracranial atherosclerosis may reduce ischemic stroke recurrence in these patients. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in patients with NVAF experiencing an ischemic stroke while being treated with a DOAC, continuing treatment with that DOAC is more effective at preventing recurrent ischemic stroke than switching to a different DOAC or to warfarin.
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Affiliation(s)
- Yiu Ming Bonaventure Ip
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Kui Kai Lau
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Ho Ko
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Lucas Lau
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Alan Yao
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Grace Lai-Hung Wong
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Terry Cheuk-Fung Yip
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Xinyi Leng
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Howard Chan
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Helen Chan
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Vincent Mok
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Yannie O Y Soo
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - David Seiffge
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Thomas W Leung
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland.
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7
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Chen Q, Toorop MMA, Tops LF, Lijfering WM, Cannegieter SC. Time Trends in Patient Characteristics, Anticoagulation Treatment, and Prognosis of Incident Nonvalvular Atrial Fibrillation in the Netherlands. JAMA Netw Open 2023; 6:e239973. [PMID: 37097630 PMCID: PMC10130953 DOI: 10.1001/jamanetworkopen.2023.9973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Importance The temporal trend in adverse events regarding stroke prevention for nonvalvular atrial fibrillation (NVAF) in the direct oral anticoagulant (DOAC) era was rarely investigated comprehensively, especially taking into account potential changes in patient characteristics and anticoagulation treatment. Objective To investigate time trends in patient characteristics, anticoagulation treatment, and prognosis of patients with incident NVAF in the Netherlands. Design, Setting, and Participants This retrospective cohort study assessed patients with incident NVAF initially recognized within a hospitalization between 2014 and 2018, using data from Statistics Netherlands. Participants were followed-up for 1 year from the hospital admission at which the incident NVAF diagnosis was made or until death, whichever occurred first. Data were analyzed from January 15, 2021, to March 8, 2023. Exposure Calendar year of the incident NVAF diagnosis, according to which the participants were categorized into 5 cohorts. Main Outcomes and Measures Outcomes of interest were baseline patient characteristics, anticoagulation treatment, and occurrence of ischemic stroke or major bleeding within the 1-year follow-up after incident NVAF. Results Between 2014 and 2018, 301 301 patients (mean [SD] age, 74.2 [11.9] years; 169 748 [56.3%] male patients) experienced incident NVAF in the Netherlands, each of whom was categorized into 1 of 5 cohorts by calendar year. Baseline patient characteristics were broadly the same between cohorts with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65 to 74 years, and sex category [female]) score of 2.9 (1.7). The median (IQR) proportion of days covered by OACs (ie, vitamin K antagonists or DOACs) within the 1-year follow-up increased from 56.99% (0%-86.30%) to 75.62% (0%-94.52%), and DOACs increased from 5102 patients (13.5%) to 32 314 patients (72.0%) among those who received OACs, gradually replacing VKAs as the first choice of OACs. Over the course of the study, there were statistically significant decreases in the 1-year cumulative incidence of ischemic stroke (from 1.63% [95% CI, 1.52%-1.73%] to 1.39% [95% CI, 1.30%-1.48%) and major bleeding (from 2.50% [95% CI, 2.37%-2.63%] to 2.07% [95% CI, 1.96%-2.19%]), and the association was consistent after adjusting for baseline patient characteristics and excluding those with preexisting chronic anticoagulation. Conclusions and Relevance This cohort study of patients with incident NVAF diagnosed between 2014 and 2018 in the Netherlands found similar baseline characteristics, increased OAC use with DOACs being favored over time, and improved 1-year prognosis. Comorbidity burden, potential underuse of anticoagulation medications, and specific subgroups of patients with NVAF remain directions for future investigations and further improvement.
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Affiliation(s)
- Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Myrthe M A Toorop
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- The Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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8
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Voss A, Smits E, Swart KMA, Balabanova Y, Brobert G, Suzart-Woischnik K, Herings RMC, Schink T, Haug U. Time Trends in Patient Characteristics of New Rivaroxaban Users with Atrial Fibrillation in Germany and the Netherlands. Drugs Real World Outcomes 2023:10.1007/s40801-022-00350-2. [PMID: 36725812 DOI: 10.1007/s40801-022-00350-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Use of the direct oral anticoagulant rivaroxaban has strongly increased in Europe since its market approval for non-valvular atrial fibrillation in 2011. Patients characteristics of rivaroxaban initiators may have changed over time but this has not been investigated so far. OBJECTIVE We aimed to describe time trends of patient baseline characteristics among new rivaroxaban users with non-valvular atrial fibrillation from 2011 to 2016/17 in two European countries. METHODS We used data from Germany (German Pharmacoepidemiological Research Database) and the Netherlands (PHARMO Database Network). We included new rivaroxaban users with (i) a first dispensing between 2011 and 2016/17, (ii) ≥ 2 years of age, and (iii) a diagnosis of non-valvular atrial fibrillation and described their baseline medication and comorbidity prior to starting rivaroxaban stratified by year of inclusion. RESULTS Overall, 130,652 new rivaroxaban users were included during the study period (Germany: N = 127,743, the Netherlands: N = 2909). The sex ratio and median age remained relatively stable over time. The proportion of patients without prior use of oral anticoagulants before initiation of rivaroxaban increased in both countries between 2011 and 2016/17 (Germany: from 51 to 76%, the Netherlands: from 57 to 85%). In Germany, we observed a relative decrease by 27% in the proportion of new rivaroxaban users with a history of ischemic stroke and by 18% in the proportion with a transient ischemic attack at baseline. No such a pattern was observed in the Netherlands. The proportion of patients with heart failure at baseline showed a three-fold increase in the Netherlands, while there was a relative decrease by 12% in Germany. CONCLUSIONS Patient characteristics of new rivaroxaban users with non-valvular atrial fibrillation changed between 2011 and 2016/17, but changes differed between countries. These patterns have methodological implications. They have to be considered in the interpretation of observational studies comparing effectiveness and safety of oral anticoagulants, especially regarding potential bias due to unmeasured confounding.
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Affiliation(s)
- Annemarie Voss
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Elisabeth Smits
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | - Karin M A Swart
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | | | | | | | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, the Netherlands
| | - Tania Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany. .,Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany.
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9
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Kravchenko OV, Boyce RD, Gomez-Lumbreras A, Kocis PT, Villa Zapata L, Tan M, Leonard CE, Andersen KM, Mehta H, Alexander GC, Malone DC. Drug-drug interaction between dexamethasone and direct-acting oral anticoagulants: a nested case-control study in the National COVID Cohort Collaborative (N3C). BMJ Open 2022; 12:e066846. [PMID: 36581417 PMCID: PMC9806069 DOI: 10.1136/bmjopen-2022-066846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The goal of this work is to evaluate if there is an increase in the risk of thromboembolic events (TEEs) due to concomitant exposure to dexamethasone and apixaban or rivaroxaban. Direct oral anticoagulants (DOACs), as well as corticosteroid dexamethasone, are commonly used to treat individuals hospitalised with COVID-19. Dexamethasone induces cytochrome P450-3A4 enzyme that also metabolises DOACs apixaban and rivaroxaban. This raises a concern about possible interaction between dexamethasone and DOACs that may reduce the efficacy of the DOACs and result in an increased risk of TEE. DESIGN We used nested case-control study design. SETTING This study was conducted in the National COVID Cohort Collaborative (N3C), the largest electronic health records repository for COVID-19 in the USA. PARTICIPANTS Study participants were adults over 18 years who were exposed to a DOAC for 10 or more consecutive days. Exposure to dexamethasone was at least 5 or more consecutive days. PRIMARY AND SECONDARY OUTCOME MEASURES Our primary exposure variable was concomitant exposure to dexamethasone for 5 or more days after exposure to either rivaroxaban or apixaban for 5 or more consecutive days. We used McNemar's Χ2 test and adjusted logistic regression to evaluate association between concomitant use of dexamethasone with either apixaban or rivaroxaban. RESULTS McNemar's Χ2 test did not find a discernible association of TEE in patients concomitantly exposed to dexamethasone and a DOAC (χ2=0.5, df=1, p=0.48). In addition, a conditional logistic regression model did not find an increase in the risk of TEE (adjusted OR 1.15, 95% CI 0.32 to 4.18). CONCLUSION This nested case-control study did not find evidence of an association between concomitant exposure to dexamethasone and a DOAC with an increase in risk of TEE. Due to small sample size, an association cannot be completely ruled out.
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Affiliation(s)
- Olga V Kravchenko
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Paul T Kocis
- Department of Pharmacology, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Malinda Tan
- Pharmacotherapy Outcomes Research Center, The University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Charles E Leonard
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen M Andersen
- Center for Drug Safety and Effectiveness, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hemalkumar Mehta
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel C Malone
- College of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
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10
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Bielecka B, Gorczyca-Głowacka I, Wożakowska-Kapłon B. Nine-Year Trends in Prevention of Thromboembolic Complications in Elderly Patients with Atrial Fibrillation Treated with NOACs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191911938. [PMID: 36231248 PMCID: PMC9565553 DOI: 10.3390/ijerph191911938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/16/2022] [Accepted: 09/18/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common disease in elderly patients and thromboembolic complication prophylaxis significantly improves the prognosis in these patients. The study assessed the frequency of individual non-vitamin K antagonist oral anticoagulant (NOAC) use among patients ≥75 years and attempted to identify factors predisposing to their prescription. METHODS The data of patients with non-valvular AF hospitalized in the reference cardiology center between 2011 and 2019 were analyzed. RESULTS Out of 1443 analyzed patients, 329 (22.8%) received apixaban, 618 (42.8%) dabigatran, and 496 (34.4%) rivaroxaban. The entire population mean age was 82.3 ± 5 years, and 57.9% were females. Independent predictors of apixaban use were age, and bleeding history. Hospitalization for the implantation/reimplantation of a cardiac implantable electronic device (CIED) reduced the chance of apixaban use. Hypertension was a predictor of dabigatran prescription. The chance of using dabigatran decreased with age. Hypertension and bleeding history decreased the chance of rivaroxaban application. CONCLUSIONS In hospitalized AF patients ≥75 years, dabigatran was the most frequently used NOAC. Age, comorbidities and bleeding risk determined the selection of individual NOACs.
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Affiliation(s)
- Bernadetta Bielecka
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Iwona Gorczyca-Głowacka
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland
- Correspondence: ; Tel.: +48-604-407-956
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland
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11
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Sotade OT, Jorm LR, Kushwaha VV, Yu J, Sedrakyan A, Falster MO, Pearson SA. Post-Discharge Antithrombotic Therapy Following Transcatheter Aortic Valve Implantation in Australian Patients. Heart Lung Circ 2022; 31:1144-1152. [PMID: 35637093 DOI: 10.1016/j.hlc.2022.04.048] [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: 01/13/2022] [Revised: 03/29/2022] [Accepted: 04/26/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Guidelines recommend antithrombotic therapy for patients following transcatheter aortic valve implantation (TAVI) to reduce the risk of ischaemic events and bioprosthetic valve thrombosis. OBJECTIVE To describe antithrombotic dispensing within 30 days of discharge for Australian patients receiving TAVI. METHODS We performed a state-wide retrospective cohort study using linked hospital and medicines dispensing data from January 2013 to December 2018 for all patients receiving TAVI in New South Wales, Australia. We identified patients dispensed oral anticoagulants (vitamin K antagonists [warfarin], direct oral anticoagulants [DOACs]) or clopidogrel within 30 days of discharge. We examined demographic and clinical predictors of antithrombotic dispensing. RESULTS Our cohort comprised 1,217 patients who underwent TAVI; median age was 84 years and 707 (58.1%) were male. Of these, 808 patients (66.4%) had an antithrombotic dispensed within 30 days of hospital discharge. One-third (33.7%) of these patients were dispensed an anticoagulant (16.1% warfarin; 17.6% DOACs) and two-thirds (66.3%) were dispensed clopidogrel. Patients undergoing TAVI were more likely to be dispensed an antithrombotic medicine within 30-days of hospital discharge if they had been dispensed antithrombotic medicines (RR 1.07; 95% CI 1.03-1.11) or angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers (RR 1.04; 95% CI 1.00-1.07) in the 6 months prior to admission. Patients with a history of haemorrhage were less likely to be dispensed an antithrombotic medicine within 30 days of hospital discharge (RR 0.93; 95% CI 0.89-0.98). CONCLUSIONS We observed gaps in best evidence pharmacotherapy for patients post-TAVI, with almost one third of patients not receiving antithrombotic medicines post-discharge. Further research is needed to quantify the impact of emerging clinical guidelines recommending single antiplatelet therapy, on adherence to best-practice care.
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Affiliation(s)
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Jennifer Yu
- Prince of Wales Hospital, Sydney, NSW, Australia
| | | | - Michael O Falster
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
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12
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Goudot FX, Martins-Meune E, Chenevier-Gobeaux C, Mourad JJ, Meune C. Real-life contemporary vitamin K antagonist is still associated with very low time in therapeutic range despite strict international normalized ratio monitoring: Results of big data analysis. J Clin Pharm Ther 2022; 47:1212-1217. [PMID: 35352367 DOI: 10.1111/jcpt.13656] [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: 10/21/2021] [Revised: 12/14/2021] [Accepted: 02/16/2022] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE This study aimed to determine the results of INR monitoring in patients on vitamin K antagonists (VKAs) and the time in therapeutic range (TTR) in 'real-world' settings. METHODS Retrospective analysis of 836,857 INR measurements performed in adults from February 2010 to August 2015 in two districts in the French Brittany region. RESULTS Of the 836,857 INR measurements, 94.9% were ordered by general practitioners and 2.0% by cardiologists. The number of tests increased by 10-year age categories up to the age-group of 80-90 years. The number of INR measurements increased from 169,636 in 2011 to 176,184 in 2012, but then decreased slightly to 162,597 in 2013 and 164,427 in 2014. Mean coefficient of variation of INR was 19.0%, and mean TTR was 29.0%. TTR was higher in women than in men (31% vs. 18%), in older than in younger patients (19.1% at 40 years and 38.6% at 100 years) and in patients with arrhythmias than in those with deep vein thrombosis/pulmonary embolism (44.4% versus 19.4%) (p < 10-5 for each comparison). Median interval between INR measurements was 14 days [7-28]; it was prolonged in men vs women, rural vs urban regions, older vs younger patients and when requested by GPs vs cardiologists. The interval was shorter for patients with INR outside the therapeutic range versus patients with INR within the therapeutic range (9 days [5-21] vs. 18 days [10-29], p < 10-10 ). WHAT IS NEW AND CONCLUSION VKAs are still frequently prescribed in this era of direct oral anticoagulants. The low TTR cannot be explained by inadequate INR monitoring.
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Affiliation(s)
- François-Xavier Goudot
- Cardiology Department, Avicenne University Hospital, APHP, Université Sorbonne Paris Nord, Bobigny, France
| | - Edith Martins-Meune
- Gerontology Department, Institut Hospitalier Franco-Britannique, Levallois-Perret, France
| | - Camille Chenevier-Gobeaux
- Automated Biological Diagnosis Department, Cochin University Hospital, APHP Centre, Université de Paris, Paris, France
| | - Jean-Jacques Mourad
- Department of Internal Medicine, ESH Excellence Centre, Saint-Joseph Hospital, Paris, France
| | - Christophe Meune
- Cardiology Department, Avicenne University Hospital, APHP, Université Sorbonne Paris Nord, Bobigny, France
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13
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Reyes JL, Herzog CA, Yan H, Roetker NS, Wetmore JB. Prescribing Patterns of Direct-Acting Oral Anticoagulants in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Retrospective Cohort Analysis. J Cardiovasc Pharmacol Ther 2022; 27:10742484221142220. [PMID: 36472155 DOI: 10.1177/10742484221142220] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association of patient and prescriber characteristics with use of warfarin versus direct-acting oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) and chronic kidney disease (CKD) is not well studied. METHODS The 20% Centers for Medicare & Medicaid Services Parts A, B, and D claims data from 2010 to 2017 were used to identify patients with stage 3, 4, or 5 CKD and AF who received a DOAC (apixaban, dabigatran, rivaroxaban) or warfarin. Prescribers were categorized as cardiologists, primary care providers (PCPs), and others. Using logistic regression, we estimated odds ratios (ORs) for the association of baseline characteristics and prescriber specialty with first use of a DOAC, relative to warfarin. RESULTS We identified 22,739 individuals with CKD who were newly initiated on oral anticoagulation for AF. New DOAC prescriptions increased from 490 in 2011 to 3261 in 2017, and displaced warfarin over time (1849, 2011; 945, 2017). By Q4 of 2014, cardiologists prescribed DOACs as initial treatment more frequently than warfarin, but non-cardiologists did not do so until 2015. As of 2017, apixaban was the most widely prescribed anticoagulant, comprising 56% and 50% of prescriptions by cardiologists and non-cardiologists, respectively. PCPs (OR 0.54, 0.51-0.58) and other providers (OR 0.55, 0.51-0.59) were less likely than cardiologists to prescribe DOACs. CONCLUSIONS DOAC prescriptions, particularly apixaban, increased over time and gradually displaced warfarin. The total number of patients with AF and CKD receiving anticoagulation increased over time. Cardiologists increased DOAC prescriptions more rapidly than non-cardiologists.
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Affiliation(s)
- Jorge L Reyes
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Charles A Herzog
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - James B Wetmore
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.,Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA
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14
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Pyykönen M, Linna M, Tykkyläinen M, Delmelle E, Laatikainen T. Patient-specific and healthcare real-world costs of atrial fibrillation in individuals treated with direct oral anticoagulant agents or warfarin. BMC Health Serv Res 2021; 21:1299. [PMID: 34856979 PMCID: PMC8641166 DOI: 10.1186/s12913-021-07125-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 10/01/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Anticoagulant therapies are used to prevent atrial fibrillation-related strokes, with warfarin and direct oral anticoagulant (DOAC) the most common. In this study, we incorporate direct health care costs, drug costs, travel costs, and lost working and leisure time costs to estimate the total costs of the two therapies. METHODS This retrospective study used individual-level patient data from 4000 atrial fibrillation (AF) patients from North Karelia, Finland. Real-world data on healthcare use was obtained from the regional patient information system and data on reimbursed travel costs from the database of the Social Insurance Institution of Finland. The costs of the therapies were estimated between June 2017 and May 2018. Using a Geographical Information System (GIS), we estimated travel time and costs for each journey related to anticoagulant therapies. We ultimately applied therapy and travel costs to a cost model to reflect real-world expenditures. RESULTS The costs of anticoagulant therapies were calculated from the standpoint of patient and the healthcare service when considering all costs from AF-related healthcare visits, including major complications arising from atrial fibrillation. On average, the annual cost per patient for healthcare in the form of public expenditure was higher when using DOAC therapy than warfarin therapy (average cost = € 927 vs. € 805). Additionally, the average annual cost for patients was also higher with DOAC therapy (average cost = € 406.5 vs. € 296.7). In warfarin therapy, patients had considerable more travel and time costs due the different implementation practices of therapies. CONCLUSION The results indicated that DOAC therapy had higher costs over warfarin from the perspectives of the patient and healthcare service in the study area on average. Currently, the cost of the DOAC drug is the largest determinator of total therapy costs from both perspectives. Despite slightly higher costs, the patients on DOAC therapy experienced less AF-related complications during the study period.
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Affiliation(s)
- Mikko Pyykönen
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, P.O Box 11000, 00076 Aalto, Finland
| | - Markku Tykkyläinen
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Eric Delmelle
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
- Joint Municipal Authority for North Karelia Social and Health Services, Tikkamäentie 16, 80210 Joensuu, Finland
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Finland
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15
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Why Did All Patients with Atrial Fibrillation and High Risk of Stroke Not Receive Oral Anticoagulants? Results of the Polish Atrial Fibrillation (POL-AF) Registry. J Clin Med 2021; 10:jcm10194611. [PMID: 34640629 PMCID: PMC8509343 DOI: 10.3390/jcm10194611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Most atrial fibrillation (AF) patients are at high risk of thromboembolic, and the use of oral anticoagulants (OACs) is advised in such cases. The aim of the study was to evaluate the frequency at which OACs were used in patients with AF and high risk thromboembolic complications, and identify factors that result in OACs not being used in the researched group of patients. Methods: The prospective, multicenter and non-interventional POL-AF registry is a study that includes AF patients from ten Polish cardiology centers. They were consecutively hospitalized between January and December of 2019. All the patients in the study were of high stroke risk. Results: A total of 3614 patients with AF and high stroke risk were included. Among the total study population, 91.5% received OAC therapy; antiplatelet therapy was prescribed for 3.7% of patients, heparin for 2.7%, and 2.1% of patients did not receive any stroke prevention therapy. Independent predictors of no OAC prescription were intracranial bleeding (OR 0.15, 95%CI 0.07–0.35, p < 0.001), gastrointestinal bleeding (OR 0.25, 95%CI 0.17–0.37, p < 0.001), cancer (OR 0.37, 95%CI 0.25–0.55, p < 0.001), hospitalization due to acute coronary syndrome (OR 0.48, 95%CI 0.33–0.69, p < 0.001), and anemia (OR 0.62, 95%CI 0.48–0.81, p < 0.001). Conclusions: Most AF patients with a high thromboembolic risk received OACs. The factors predisposing a lack of OAC use in these patients were conditions that significantly increased the risk of bleeding complications.
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16
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Toorop MMA, Chen Q, Tichelaar VYIG, Cannegieter SC, Lijfering WM. Predictors, time course, and outcomes of persistence patterns in oral anticoagulation for non-valvular atrial fibrillation: a Dutch Nationwide Cohort Study. Eur Heart J 2021; 42:4126-4137. [PMID: 34269375 PMCID: PMC8530535 DOI: 10.1093/eurheartj/ehab421] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/06/2021] [Accepted: 06/18/2021] [Indexed: 12/02/2022] Open
Abstract
Aims Persistence with direct oral anticoagulants (DOACs) has become a concern in non-valvular atrial fibrillation (NVAF) patients, but whether this affects prognosis is rarely studied. We investigated the persistence with oral anticoagulants (OACs) and its association with prognosis among a nationwide cohort of NVAF patients. Methods and results DOAC-naive NVAF patients who started to use DOACs for ischaemic stroke prevention between 2013 and 2018 were included using Dutch national statistics. Persistence with OACs was determined based on the presence of a 100-day gap between the last prescription and the end of study period. In 93 048 patients, 75.7% had a baseline CHA2DS2-VASc score of ≥2. The cumulative incidence of persistence with OACs was 88.1% [95% confidence interval (CI) 87.9–88.3%], 82.6% (95% CI 82.3–82.9%), 77.7% (95% CI 77.3–78.1%), and 72.0% (95% CI 71.5–72.5%) at 1, 2, 3, and 4 years after receiving DOACs, respectively. Baseline characteristics associated with better persistence with OACs included female sex, age range 65–74 years, permanent atrial fibrillation, previous exposure to vitamin K antagonists, stroke history (including transient ischaemic attack), and a CHA2DS2-VASc score ≥2. Non-persistence with OACs was associated with an increased risk of the composite outcome of ischaemic stroke and ischaemic stroke-related death [adjusted hazard ratio (aHR) 1.79, 95% CI 1.49–2.15] and ischaemic stroke (aHR 1.58, 95% CI 1.29–1.93) compared with being persistent with OACs. Conclusion At least a quarter of NVAF patients were non-persistent with OACs within 4 years, which was associated with poor efficacy of ischaemic stroke prevention. The identified baseline characteristics may help identify patients at risk of non-persistence.
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Affiliation(s)
- Myrthe M A Toorop
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
| | - Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
| | - Vladimir Y I G Tichelaar
- Department of Haematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands.,Department of Internal Medicine, Section of Thrombosis and Haemostasis, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
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17
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Shen NN, Zhang C, Wang N, Wang JL, Gu ZC, Han H. Effectiveness and Safety of Under or Over-dosing of Direct Oral Anticoagulants in Atrial Fibrillation: A Systematic Review and Meta-analysis of 148909 Patients From 10 Real-World Studies. Front Pharmacol 2021; 12:645479. [PMID: 33815125 PMCID: PMC8012667 DOI: 10.3389/fphar.2021.645479] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background: In routine clinical practice, non-standard doses of direct oral anticoagulants (DOACs) are commonly used in patients with atrial fibrillation (AF). However, data on the clinical outcomes of non-standard doses of DOACs are limited. Methods: The MEDLINE, Embase, and Cochrane Library databases were systematically searched from their inception until 30 June 2020 for studies that reported the effectiveness or safety outcomes of non-standard doses of DOACs compared with on-label doses of DOACs in patients with atrial fibrillation. Non-standard doses of DOACs were defined as under or over-dose of DOACs based on the recommended standard doses in drug labels. A random-effects meta-analysis was performed to calculate the pooled hazard ratio and associated 95% confidence interval (95% confidence interval). Subgroup analyses were conducted according to individual DOACs and different geographic regions. Results: Ten articles involving 148,909 patients with AF were included. There were no significant differences between under-dosing and on-label dosing with respect to stroke/systematic embolism (HR: 1.01, 95% CI: 0.93–1.09), major bleeding (HR: 0.98, 95% CI: 0.77–1.19), intracranial haemorrhage (HR: 1.07, 95% CI: 0.74–1.40), gastrointestinal bleeding (HR: 1.10, 95% CI: 0.82–1.39), and myocardial infarction (HR: 1.07, 95% CI: 0.89–1.25), except for an increased risk of death (HR: 1.37, 95% CI: 1.01–1.73). We observed a significant association between over-dosing of DOACs and increased risk of stroke/systematic embolism (HR: 1.18, 95% CI: 1.04–1.32), major bleeding (HR: 1.16, 95% CI: 1.03–1.29), and death (HR: 1.21, 95% CI: 1.03–1.38) compared with on-label dosing. Furthermore, over-dosing of DOACs increased the risk of stroke/systematic embolism (HR: 1.16; 95% CI: 1.00–1.33) and major bleeding events (HR: 1.18; 95% CI: 1.00–1.37) in Asian patients. Conclusion: A reduced dose of DOACs might be safely and effectively used in clinical practice, especially in Asian patients, whereas high-dose DOACs might not be well tolerated by Asian patients.
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Affiliation(s)
- Nan-Nan Shen
- Department of Pharmacy, Affiliated Hospital of Shaoxing University, Shao Xing, China.,Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chi Zhang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia-Liang Wang
- Department of Pharmacy, Affiliated Hospital of Shaoxing University, Shao Xing, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hua Han
- School of Medicine, Tongji University, Shanghai, China
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18
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Hempenius M, Groenwold RHH, Souverein PC, de Boer A, Klungel OH, Gardarsdottir H. Impact of anticoagulant exposure misclassification on the bleeding risk of direct oral anticoagulants. Br J Clin Pharmacol 2021; 87:3508-3517. [PMID: 33543516 PMCID: PMC8451929 DOI: 10.1111/bcp.14764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 12/04/2022] Open
Abstract
Aims Drug exposure status based on routinely collected data might be misclassified when the database contains only prescriptions from 1 type of prescriber (e.g. general practitioner and not specialist). This study aims to quantify the impact of such exposure misclassification on the risk of major bleeding and stroke/transient ischaemic attack (TIA)associated with direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs). Methods Incident anticoagulant users (>12 mo free of anticoagulation use) in the Dutch PHARMO Database Network between 2008 and 2017 were included. Drug exposure was assessed using pharmacy dispensing information. The risks of hospital admission of major bleeding for DOAC vs. VKA users was assessed with Cox regression analysis, where exposure was based on all dispensings, on general practitioner (GP)‐prescribed dispensings only or on specialist‐prescribed dispensings only. Hazard ratios (HRs) were estimated also for hospitalization for gastrointestinal bleeding, intracranial bleeding and stroke/TIA. Results We included 99 182 VKA‐initiators and 21 795 DOAC‐initiators. Use of DOAC was associated with a lower risk of major bleeding compared to VKA use; HR 0.79 (95% confidence interval 0.70–0.90), 0.78 (0.68–0.91) and 0.62 (0.50–0.76), for exposure based on complete dispensing information, only GP‐ and only specialist‐prescribed dispensings, respectively. Similar results were found for the other bleeding outcomes. For stroke/TIA the HRs were 0.96 (0.84–1.09), 1.00 (0.84–1.18) and 0.72 (0.58–0.90), respectively. Conclusion Including only GP‐prescribed anticoagulant dispensings in this case did not materially impact the effect estimates compared to including all anticoagulant dispensings. Including only specialist‐prescribed dispensings, however, strengthened the effect estimates.
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Affiliation(s)
- Mirjam Hempenius
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, Division Laboratory and Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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19
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Trends in Stroke Prevention between 2014 and 2018 in Hospitalized Atrial Fibrillation Patients. Cardiol Res Pract 2021; 2021:6657776. [PMID: 33628491 PMCID: PMC7886594 DOI: 10.1155/2021/6657776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/08/2021] [Accepted: 01/28/2021] [Indexed: 12/02/2022] Open
Abstract
In recent years, significant changes in stroke prophylaxis in patients with atrial fibrillation (AF) have been observed. Non-vitamin K antagonist oral anticoagulants (NOACs) are more commonly used in the prevention of thromboembolic complications in patients with AF. The aim of the study was to evaluate recommended stroke prophylaxis in patients with AF and to identify predictors of using NOACs in patients treated with anticoagulant therapy. The present study was a retrospective, observational, single-center study which included consecutively hospitalized patients in the reference cardiology center from January 2014 to December 2018. In the study group of 4027 patients with AF, to prevent thromboembolic complications, OACs were used in 3680 patients (91.4%), an antiplatelet drug(s) was used in 124 patients (3.1%), and 223 patients (5.5%) did not undergo any thromboembolic event prevention. In the group of 3680 patients treated with OACs, 2311 patients (62.8%) received NOACs and 1639 patients (37.2%), VKAs. Independent predictors of the use of NOACs were age (OR, 1.02; 95% CI, 1.01–1.03; P < 0.001), a previous thromboembolic event (OR, 1.29; 95% CI, 1.01–1.65; P=0.04), nonpermanent AF (OR, 1.61; 95% CI, 1.34–1.93; P < 0.001), and eGFR (OR, 1.22; 95% CI, 1.02–1.46; P=0.03). Between 2014 and 2018, an increase of patients treated with OACs, mainly with NOACs, was observed. Age, past thromboembolic complications, nonpermanent AF, and preserved renal function determined the choice of NOACs.
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20
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Individualised Risk Assessments for Recurrent Venous Thromboembolism: New Frontiers in the Era of Direct Oral Anticoagulants. HEMATO 2021. [DOI: 10.3390/hemato2010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality and is associated with high recurrence rates. The introduction of direct oral anticoagulants (DOACs) in the 2010s has changed the landscape of VTE management. DOACs have become the preferred anticoagulant therapy for their ease of use, predictable pharmacokinetics, and improved safety profile. Increasingly, guidelines have recommended long term anticoagulation for some indications such as following first unprovoked major VTE, although an objective individualised risk assessment for VTE recurrence remains elusive. The balance of preventing VTE recurrence needs to be weighed against the not insignificant bleeding risk, which is cumulative with prolonged use. Hence, there is a need for an individualised, targeted approach for assessing the risk of VTE recurrence, especially in those patients in whom the balance between benefit and risk of long-term anticoagulation is not clear. Clinical factors alone do not provide the level of discrimination required on an individual level. Laboratory data from global coagulation assays and biomarkers may provide enhanced risk assessment ability and are an active area of research. A review of the prediction models and biomarkers for assessing VTE recurrence risk is provided, with an emphasis on contemporary developments in the era of DOACs and global coagulation assays.
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21
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Orlowski A, Gale CP, Ashton R, Petrungaro B, Slater R, Nadarajah R, Cowan JC, Buck J, Smith W, Wu J. Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation. Heart 2021; 107:47-53. [PMID: 33122302 PMCID: PMC7788263 DOI: 10.1136/heartjnl-2020-317006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/13/2020] [Accepted: 08/18/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To assess temporal clinical and budget impacts of changes in atrial fibrillation (AF)-related prescribing in England. METHODS Data on AF prevalence, AF-related stroke incidence and prescribing for all National Health Service general practices, hospitals and registered patients with hospitalised AF-related stroke in England were obtained from national databases. Stroke care costs were based on published data. We compared changes in oral anticoagulation prescribing (warfarin or direct oral anticoagulants (DOACs)), incidence of hospitalised AF-related stroke, and associated overall and per-patient costs in the periods January 2011-June 2014 and July 2014-December 2017. RESULTS Between 2011-2014 and 2014-2017, recipients of oral anticoagulation for AF increased by 86.5% from 1 381 170 to 2 575 669. The number of patients prescribed warfarin grew by 16.1% from 1 313 544 to 1 525 674 and those taking DOACs by 1452.7% from 67 626 to 1 049 995. Prescribed items increased by 5.9% for warfarin (95% CI 2.9% to 8.9%) but by 2004.8% for DOACs (95% CI 1848.8% to 2160.7%). Oral anticoagulation prescription cost rose overall by 781.2%, from £87 313 310 to £769 444 028, (£733,466,204 with warfarin monitoring) and per patient by 50.7%, from £293 to £442, giving an incremental cost of £149. Nevertheless, as AF-related stroke incidence fell by 11.3% (95% CI -11.5% to -11.1%) from 86 467 in 2011-2014 to 76 730 in 2014-2017 with adjustment for AF prevalence, the overall per-patient cost reduced from £1129 to £840, giving an incremental per-patient saving of £289. CONCLUSIONS Despite nearly one million additional DOAC prescriptions and substantial associated spending in the latter part of this study, the decline in AF-related stroke led to incremental savings at the national level.
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Affiliation(s)
- Andi Orlowski
- The Health Econimics Unit, West Bromwich, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Rachel Ashton
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Bruno Petrungaro
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Ruth Slater
- Business Intelligence, Imperial College Health Partners, London, UK
| | | | | | - Jackie Buck
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Wayne Smith
- The Health Econimics Unit, West Bromwich, UK
- Business Intelligence, Imperial College Health Partners, London, UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Division of Clinical and Translational Research, School of Dentistry, University of Leeds, Leeds, UK
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22
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Different Risk Profiles of European Patients Using Direct Oral Anticoagulants or Vitamin K Antagonists: a Rapid Review. CURR EPIDEMIOL REP 2020. [DOI: 10.1007/s40471-020-00257-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Purpose of Review
We investigated the risk profiles of patients using direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) in European cohort studies to estimate the importance of potential (measured or unmeasured) confounding factors in analyses comparing these drugs. We searched MEDLINE and EMBASE (2008–2018) for relevant studies and extracted information on age, sex, comorbidity, Charlson comorbidity index, HAS-BLED score (assessing risk of bleeding) and CHA2DS2-VASc score (assessing risk of stroke).
Recent Findings
Overall, 66 studies with 2,808,757 patients were included. Most patients were from France (37%), Denmark (24%) and Germany (23%). In 56 studies (85%), the focus was on patients with atrial fibrillation. Of the 43 studies comparing DOAC with VKA users, 33% reported a higher and 16% a lower age of DOAC compared with VKA users. The mean age varied by about 1 year in most of these studies. Rivaroxaban was used in the widest age range. Patients with DOAC more often had a history of stroke or bleedings, and patients with VKA more often had a history of diabetes, renal failure, cancer, heart failure or other heart diseases. Most studies did not observe differences regarding the HAS-BLED score or the CHA2DS2-VASc score between groups.
Summary
Our review suggests that there are relevant differences in the risk profiles of DOAC versus VKA users and between users of individual DOACs. Reported HAS-BLED or CHA2DS2-VASc scores did not reflect these differences. These patterns require careful consideration in the interpretation of observational studies comparing the effectiveness and the risks of these drugs, also when comparing the results of studies conducted in different countries.
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23
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Gorczyca I, Jelonek O, Uziębło-Życzkowska B, Chrapek M, Maciorowska M, Wójcik M, Błaszczyk R, Kapłon-Cieślicka A, Gawałko M, Budnik M, Tokarek T, Rajtar-Salwa R, Bil J, Wojewódzki M, Szpotowicz A, Bednarski J, Bakuła-Ostalska E, Tomaszuk-Kazberuk A, Szyszkowska A, Wełnicki M, Mamcarz A, Wożakowska-Kapłon B. Trends in the Prescription of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation: Results of the Polish Atrial Fibrillation (POL-AF) Registry. J Clin Med 2020; 9:jcm9113565. [PMID: 33167503 PMCID: PMC7694480 DOI: 10.3390/jcm9113565] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Current guidelines do not suggest in which groups of patients with atrial fibrillation (AF) individual non-vitamin K antagonist oral anticoagulants (NOACs) should be used for the prevention of thromboembolic complications. The aim of this study was to evaluate the frequency of use of apixaban, dabigatran, and rivaroxaban, and attempt to identify factors predisposing their administration. Methods: The Polish Atrial Fibrillation (POL-AF) registry is a prospective, non-interventional study, including consecutive patients with AF hospitalized in ten Polish cardiology centers during the period ranging from January to December 2019. In this study, all patients were treated with NOACs. Results: Among the 2971 patients included in the analysis, 40.4% were treated with rivaroxaban, 32% with apixaban, and 27.6% with dabigatran. The mean age of the total population was 72 ± 11.5 years and 43% were female. A reduced dose of NOAC was used in 35% of patients treated with apixaban, 39.7% of patients treated with dabigatran, and 34.4% of patients treated with rivaroxaban. Independent predictors of the use of apixaban were previous bleeding (OR 2.37, CI 1.67–3.38), GFR < 60 mL/min (OR 1.38, CI 1.25–1.64), heart failure (OR 1.38, CI 1.14–1.67) and age (per 5 years) (OR 1.14, CI 1.09–1.19). GFR < 60 mL/min (OR 0.79, CI 0.66–0.95), female (OR 0.8, CI 0.67–0.96) and age (per 5 years) (OR 0.95, CI 0.91–0.99) diminished the chance of using dabigatran. Previous bleeding (OR 0.43, CI 0.28–0.64), vascular disease (OR 0.84, CI 0.70–0.99), and age (per 5 years) (OR 0.94, CI 0.90–0.97) diminished the chance of choosing rivaroxaban. Conclusions: In hospitalized patients with AF, the most frequently chosen NOAC was rivaroxaban. Apixaban was chosen more often in patients after bleeding, and in those who were advanced in years, with heart failure and impaired renal function. Impaired renal function and female gender were factors that diminished the chance of using dabigatran. Previous bleeding and vascular disease was the factor that diminished the chance of using rivaroxaban. Dabigatran and rivaroxaban have been used less frequently in elderly patients.
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Affiliation(s)
- Iwona Gorczyca
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Olga Jelonek
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Beata Uziębło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland;
- Correspondence: ; Tel.: +48-261-816-376
| | - Magdalena Chrapek
- Faculty of Natural Sciences, The Jan Kochanowski University, 25-369 Kielce, Poland;
| | - Małgorzata Maciorowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | - Maciej Wójcik
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.W.); (R.B.)
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.W.); (R.B.)
| | - Agnieszka Kapłon-Cieślicka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Monika Gawałko
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Monika Budnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Tomasz Tokarek
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (T.T.); (R.R.-S.)
| | - Renata Rajtar-Salwa
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (T.T.); (R.R.-S.)
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (J.B.); (M.W.)
| | - Michał Wojewódzki
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (J.B.); (M.W.)
| | - Anna Szpotowicz
- Department of Cardiology, Regional Hospital, 27-400 Ostrowiec Swiętokrzyski, Poland;
| | - Janusz Bednarski
- Department of Cardiology, St John Paul II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland; (J.B.); (E.B.-O.)
| | - Elwira Bakuła-Ostalska
- Department of Cardiology, St John Paul II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland; (J.B.); (E.B.-O.)
| | - Anna Tomaszuk-Kazberuk
- Department of Cardiology, Medical University, 15-276 Bialystok, Poland; (A.T.-K.); (A.S.)
| | - Anna Szyszkowska
- Department of Cardiology, Medical University, 15-276 Bialystok, Poland; (A.T.-K.); (A.S.)
| | - Marcin Wełnicki
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, 02-091 Warsaw, Poland; (M.W.); (A.M.)
| | - Artur Mamcarz
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, 02-091 Warsaw, Poland; (M.W.); (A.M.)
| | - Beata Wożakowska-Kapłon
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
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Roşian AN, Iancu M, Trifa AP, Roşian ŞH, Mada C, Gocan CP, Niţă T, Istratoaie S, Boarescu PM, Buzoianu AD. An Exploratory Association Analysis of ABCB1 rs1045642 and ABCB1 rs4148738 with Non-Major Bleeding Risk in Atrial Fibrillation Patients Treated with Dabigatran or Apixaban. J Pers Med 2020; 10:E133. [PMID: 32961964 PMCID: PMC7565454 DOI: 10.3390/jpm10030133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 12/14/2022] Open
Abstract
(1) Background: The approach of bleeding complications in patients treated with non-vitamin K oral anticoagulants (NOACs) represents an important issue in clinical practice. Both dabigatran and apixaban are substrates for P-glycoprotein and, therefore, ABCB1 gene variations may be useful in individualizing NOACs treatment, especially in high-risk patients. (2) Methods: ABCB1 rs1045642 and rs4148738 were determined in 218 atrial fibrillation patients treated with dabigatran or apixaban (70.94 ± 9.04 years; 51.83% men). (3) Results: Non-major bleeding appeared in 7.34% NOACs-treated patients. The logistic tested models based on the four genetic models revealed no significant association between the variant genotype of two ABCB1 SNPs and the risk of bleeding (p > 0.05). Among the four two-locus haplotypes, TA and CA haplotypes had the highest frequency in NOACs-treated patients with bleeding, involving a possible positive association with the susceptibility of bleeding complications (OR = 1.04 and OR = 1.91, respectively). The logistic model found no significant association of estimated haplotypes with bleeding (p > 0.05) except for the TG haplotype which had a trend toward statistical significance (p = 0.092). Among the risk factors for bleeding, only age > 70 years and stroke/TIA showed a tendency toward statistical significance. (4) Conclusions: We found no significant associations between the studied ABCB1 variant genotypes with non-major bleeding risk in NOACs-treated patients. A trend of association between TG haplotype with bleeding risk was observed, implying a protective role of this haplotype against bleeding in patients treated with dabigatran or apixaban.
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Affiliation(s)
- Adela-Nicoleta Roşian
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 23 Gheorghe Marinescu Street, 400337 Cluj-Napoca, Romania; (A.-N.R.); (S.I.); (A.D.B.)
- “Niculae Stăncioiu” Heart Institute Cluj-Napoca, 19-21 Calea Moților Street, 400001 Cluj-Napoca, Romania; (C.M.); (C.P.G.); (T.N.)
| | - Mihaela Iancu
- Department of Medical Informatics and Biostatistics, “Iuliu Hațieganu” University of Medicine and Pharmacy, 6 Louis Pasteur, 400349 Cluj-Napoca, Romania;
| | - Adrian Pavel Trifa
- Department of Genetics, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 6 Louis Pasteur Street, 400349 Cluj-Napoca, Romania;
| | - Ştefan Horia Roşian
- “Niculae Stăncioiu” Heart Institute Cluj-Napoca, 19-21 Calea Moților Street, 400001 Cluj-Napoca, Romania; (C.M.); (C.P.G.); (T.N.)
- Department of Cardiology—Heart Institute, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 19-21 Calea Moților Street, 400001 Cluj-Napoca, Romania
| | - Cristina Mada
- “Niculae Stăncioiu” Heart Institute Cluj-Napoca, 19-21 Calea Moților Street, 400001 Cluj-Napoca, Romania; (C.M.); (C.P.G.); (T.N.)
| | - Cornelia Paula Gocan
- “Niculae Stăncioiu” Heart Institute Cluj-Napoca, 19-21 Calea Moților Street, 400001 Cluj-Napoca, Romania; (C.M.); (C.P.G.); (T.N.)
| | - Teodora Niţă
- “Niculae Stăncioiu” Heart Institute Cluj-Napoca, 19-21 Calea Moților Street, 400001 Cluj-Napoca, Romania; (C.M.); (C.P.G.); (T.N.)
| | - Sabina Istratoaie
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 23 Gheorghe Marinescu Street, 400337 Cluj-Napoca, Romania; (A.-N.R.); (S.I.); (A.D.B.)
| | - Paul-Mihai Boarescu
- Department of Pathophysiology, Iuliu Haţieganu University of Medicine and Pharmacy Cluj-Napoca, 2-4 Victor Babeş Street, 400012 Cluj-Napoca, Romania;
| | - Anca Dana Buzoianu
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 23 Gheorghe Marinescu Street, 400337 Cluj-Napoca, Romania; (A.-N.R.); (S.I.); (A.D.B.)
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25
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Mongkhon P, Alwafi H, Fanning L, Lau WCY, Wei L, Kongkaew C, Wong ICK. Patterns and factors influencing oral anticoagulant prescription in people with atrial fibrillation and dementia: Results from UK primary care. Br J Clin Pharmacol 2020; 87:1056-1068. [PMID: 32643166 DOI: 10.1111/bcp.14464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 06/21/2020] [Accepted: 06/25/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS Oral anticoagulant (OAC) is recommended for preventing stroke in atrial fibrillation (AF). However, the OAC utilisation in AF patients with dementia or cognitive impairment (CI) is limited. This study aimed to examine the prevalence of OAC prescriptions in AF patients with dementia/CI and to identify factors associated with OAC treatment within 180 days after dementia/CI diagnosis. METHODS Using The Health Improvement Network database, the annual trends of OAC between 2000 and 2015 were calculated. Multivariable logistic regression was performed to identify factors associated with OAC treatment. RESULTS The prevalence rate of OAC prescriptions increased from 6.1% in 2000 to 45.9% in 2015. Among OAC users, the proportion of direct oral anticoagulants (DOACs) use increased significantly from 0.1% in 2011 to 33.8% in 2015 (P-trend < 0.001), while the proportion of vitamin K antagonist use decreased by 28.6% from 100% in 2000 to 71.4% in 2015 (P-trend < 0.001). In the multivariable analysis, younger age, very old age, female sex, higher Charlson Comorbidity Index, having a HAS-BLED score ≥3, a history of intracranial bleeding, falls and polypharmacy were significantly associated with lower odds of receiving OAC. CONCLUSIONS In UK primary care, OAC use increased from 2000 to 2015 in AF patients with dementia/CI, with a substantial increase in use of DOACs. Characteristics related to frailty are associated with lower odds of OAC prescription. Given the increasing use of DOACs in patients with dementia/CI, further studies are needed to investigate the safety and effectiveness of DOACs in this important patient group.
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Affiliation(s)
- Pajaree Mongkhon
- Centre for Safety and Quality in Health, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Thailand.,Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Hassan Alwafi
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Laura Fanning
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Wallis C Y Lau
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Chuenjid Kongkaew
- Centre for Safety and Quality in Health, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Thailand.,Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Ian C K Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.,Centre for Medication Optimisation Research and Education (CMORE), University College London Hospital, UK.,The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, China
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26
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Gattellari M, Hayen A, Leung DYC, Zwar NA, Worthington JM. Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial. BMC FAMILY PRACTICE 2020; 21:102. [PMID: 32513116 PMCID: PMC7281948 DOI: 10.1186/s12875-020-01175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.
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Affiliation(s)
- Melina Gattellari
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia. .,Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, New South Wales, 2170, Australia.
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales, 2007, Australia
| | - Dominic Y C Leung
- South Western Sydney Clinical School UNSW, Liverpool, Australia.,Department of Cardiology, Liverpool Health Service, Sydney South West Local Health District, Clinical Services Building, Elizabeth Street, Liverpool (Sydney), New South Wales, 2170, Australia
| | - Nicholas A Zwar
- Faculty of Health, Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - John M Worthington
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia.,South Western Sydney Clinical School UNSW, Liverpool, Australia
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27
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Fralick M, Colacci M, Schneeweiss S, Huybrechts KF, Lin KJ, Gagne JJ. Effectiveness and Safety of Apixaban Compared With Rivaroxaban for Patients With Atrial Fibrillation in Routine Practice: A Cohort Study. Ann Intern Med 2020; 172:463-473. [PMID: 32150751 DOI: 10.7326/m19-2522] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Apixaban and rivaroxaban are the most commonly prescribed direct oral anticoagulants for adults with atrial fibrillation, but head-to-head data comparing their safety and effectiveness are lacking. Objective To compare the safety and effectiveness of apixaban versus rivaroxaban for patients with nonvalvular atrial fibrillation. Design New-user, active-comparator, retrospective cohort study. Setting A U.S. nationwide commercial health care claims database from 28 December 2012 to 1 January 2019. Patients Adults newly prescribed apixaban (n = 59 172) or rivaroxaban (n = 40 706). Measurements The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial hemorrhage or gastrointestinal bleeding. Results 39 351 patients newly prescribed apixaban were propensity score matched to 39 351 patients newly prescribed rivaroxaban. Mean age was 69 years, 40% of patients were women, and mean follow-up was 288 days for new apixaban users and 291 days for new rivaroxaban users. The incidence rate of ischemic stroke or systemic embolism was 6.6 per 1000 person-years for adults prescribed apixaban compared with 8.0 per 1000 person-years for those prescribed rivaroxaban (hazard ratio [HR], 0.82 [95% CI, 0.68 to 0.98]; rate difference, 1.4 fewer events per 1000 person-years [CI, 0.0 to 2.7]). Adults prescribed apixaban also had a lower rate of gastrointestinal bleeding or intracranial hemorrhage (12.9 per 1000 person-years) compared with those prescribed rivaroxaban (21.9 per 1000 person-years), corresponding to an HR of 0.58 (CI, 0.52 to 0.66) and a rate difference of 9.0 fewer events per 1000 person-years (CI, 6.9 to 11.1). Limitation Unmeasured confounding, incomplete laboratory data. Conclusion In routine care, adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban. Primary Funding Source Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital.
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Affiliation(s)
- Michael Fralick
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and Sinai Health System and University of Toronto, Toronto, Ontario, Canada (M.F.)
| | - Michael Colacci
- Sinai Health System and University of Toronto, Toronto, Ontario, Canada (M.C.)
| | - Sebastian Schneeweiss
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
| | - Krista F Huybrechts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
| | - Kueiyu Joshua Lin
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
| | - Joshua J Gagne
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
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28
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Kezerle L, Tsadok MA, Berliner Senderey A, Hoshen M, Leventer‐Roberts M, Reges O, Leibowitz M, Haim M. Use of oral anticoagulation therapy in the first 3 months after the diagnosis of atrial fibrillation in Israel: A population‐based study. J Cardiovasc Electrophysiol 2020; 31:1356-1363. [DOI: 10.1111/jce.14452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical CenterBen‐Gurion University of the NegevBeer Sheva Israel
| | - Meytal A. Tsadok
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Adi Berliner Senderey
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Moshe Hoshen
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Maya Leventer‐Roberts
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Orna Reges
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
- Department of Health Systems ManagementAriel University Israel
| | - Morton Leibowitz
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical CenterBen‐Gurion University of the NegevBeer Sheva Israel
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29
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Probst MA, Gupta M, Hendey GW, Rodriguez RM, Winkel G, Loo GT, Mower WR. Prevalence of Intracranial Injury in Adult Patients With Blunt Head Trauma With and Without Anticoagulant or Antiplatelet Use. Ann Emerg Med 2020; 75:354-364. [PMID: 31959538 DOI: 10.1016/j.annemergmed.2019.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/09/2019] [Accepted: 10/02/2019] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE We determine the prevalence of significant intracranial injury among adults with blunt head trauma who are receiving preinjury anticoagulant or antiplatelet medications. METHODS This was a multicenter, prospective, observational study conducted from December 2007 to December 2015. Patients were enrolled in 3 emergency departments (EDs) in the United States. Adults with blunt head trauma who underwent neuroimaging in the ED were included. Use of preinjury aspirin, clopidogrel, and warfarin was recorded. Data on direct oral anticoagulants were not specifically recorded. The primary outcome was prevalence of significant intracranial injury on neuroimaging. The secondary outcome was receipt of neurosurgical intervention. RESULTS Among 9,070 patients enrolled in this study, the median age was 53.8 years (interquartile range 34.7 to 74.3 years) and 60.7% were men. A total of 1,323 patients (14.6%) were receiving antiplatelet medications or warfarin, including 635 receiving aspirin alone, 109 clopidogrel alone, and 406 warfarin alone. Compared with that of patients without any coagulopathy, the relative risk of significant intracranial injury was 1.29 (95% confidence interval [CI] 0.88 to 1.87) for patients receiving aspirin alone, 0.75 (95% CI 0.24 to 2.30) for those receiving clopidogrel alone, and 1.88 (95% CI 1.28 to 2.75) for those receiving warfarin alone. The relative risk of significant intracranial injury was 2.88 (95% CI 1.53 to 5.42) for patients receiving aspirin and clopidogrel in combination. CONCLUSION Patients receiving preinjury warfarin or a combination of aspirin and clopidogrel were at increased risk for significant intracranial injury, but not those receiving aspirin alone. Clinicians should have a low threshold for neuroimaging when evaluating patients receiving warfarin or a combination of aspirin and clopidogrel.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Malkeet Gupta
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA; Antelope Valley Hospital Emergency Department, Lancaster, CA
| | - Gregory W Hendey
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA; UCSF Fresno, Community Regional Medical Center, Fresno, CA
| | - Robert M Rodriguez
- Zuckerberg San Francisco General Hospital, Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| | - Gary Winkel
- Department of Oncological Sciences, Mount Sinai School of Medicine, New York, NY
| | - George T Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William R Mower
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA
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30
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Relationship between the Renal Function and Adverse Clinical Events in Patients with Atrial Fibrillation: A Japanese Multicenter Registry Substudy. J Clin Med 2020; 9:jcm9010167. [PMID: 31936260 PMCID: PMC7019418 DOI: 10.3390/jcm9010167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist, but the real-world data after approval of direct oral anticoagulants (DOACs) are still lacking in Japan. We investigated the association of the baseline renal function and adverse clinical events and risk of adverse clinical events with DOACs compared to warfarin for each renal functional level in Japanese AF patients. METHODS The present substudy was based on the SAKURA AF Registry, a Japanese multicenter observational registry (median follow-up period: 39 months). The creatinine clearance (CrCl) values were estimated by the Cockcroft-Gault formula, and divided into normal renal function, and mild and moderate-severe CKD (CrCl ≥ 80, 50-79, <50 mL/min). RESULTS In the SAKURA AF Registry, the baseline CrCl data were available for 3242 patients (52% for DOAC and 48% for warfarin user). The relative risk of adverse clinical events was significantly higher in the patients with a CrCl < 50 mL/min as compared to those with a CrCl ≥ 80 mL/min (adjusted HRs: 2.53 for death, 2.53 for cardiovascular [CV] events, 2.13 for strokes, and 1.83 for major bleeding). Risks of all adverse clinical events were statistically even between DOAC and warfarin users for each renal function level. CONCLUSION Moderate-severe CKD was associated with a higher mortality, CV events, strokes, and major bleeding than normal renal function. The safety and effectiveness of DOACs over warfarin were similar for each renal function level. By a worsening renal function, the incidence of adverse clinical events increased, especially deaths and CV events as compared to strokes and major bleeding.
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31
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Barben J, Menu D, Rosay C, Vovelle J, Mihai AM, Nuss V, d'Athis P, Putot A, Manckoundia P. The prescription of direct oral anticoagulants in the elderly: An observational study of 19 798 Ambulatory subjects. Int J Clin Pract 2020; 74:e13420. [PMID: 31532052 DOI: 10.1111/ijcp.13420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/01/2019] [Accepted: 09/13/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Direct oral anticoagulants (DOACs) are increasingly prescribed to elderly people, but the epidemiologic data for this population remains scarce. We compared the elderly population taking DOACs and those not taking DOACs (noDOAC). METHOD We included individuals over 75 years old, affiliated to Mutualité Sociale Agricole of Burgundy (a French regional health insurance agency), who had been refunded for a prescribed DOAC between 1st and 30th September 2017. The DAOC group (DAOCG) and noDOAC group (noDOACG) were compared in terms of demographic conditions, registered chronic diseases (RCD), and number and types of prescribed drugs. In the DOACG, we compared the type of prescribing physician and laboratory monitoring for novel prescriptions (initial) and prescription refills (≥ 3 months). RESULTS Of the 19 798 included patients, 1518 (7.7%) were prescribed DAOCs and 18 280 (92.3%) were not. Mean and median age was 85 years in the 2 groups (DOACG and noDOACG). In the DOACG, there were more men (50% vs 40.2%), more RCD (88.9% vs 68.7%) and more drugs per prescription (6 ± 2.8 vs 5 ± 2.9) (All P < .01). The DOACG also took more antihypertensive drugs. The most commonly prescribed DOACs were apixaban (42.9%) followed by rivaroxaban (38.4%) and dabigatran (18.6%). Complete blood count, serum creatinine and coagulation function tests were requested for 69.4%, 75% and 22.2%, respectively, of patients prescribed DAOCs. CONCLUSIONS The DOACG had more RCD and drugs per prescription than the noDOACG; routine laboratory monitoring was insufficient. What's known Platelet aggregation inhibitors (low-dose) are recommended for secondary prevention of cardiovascular events in patients suffering from symptomatic atherosclerosis. The main risk of this treatment is bleeding. What's new A prescription for platelet aggregation inhibitors was found in 34% of geriatric inpatients in this prospective study. Compliance to guidelines was better for symptomatic peripheral artery disease than for primary prevention in accordance with recent publications. Geriatric comorbidities had no impact on the prescription of platelet aggregation inhibitors. Underuse of platelet aggregation inhibitors was observed in 11.3% of cases and overuse in 13.7% of cases.
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Affiliation(s)
- Jérémy Barben
- "Pôle Personnes Âgées", Hospital of Champmaillot, University Hospital, Dijon, France
| | - Didier Menu
- "Mutualité Sociale Agricole" of Burgundy, Dijon, France
| | - Clémentine Rosay
- "Pôle Personnes Âgées", Hospital of Champmaillot, University Hospital, Dijon, France
| | - Jérémie Vovelle
- "Pôle Personnes Âgées", Hospital of Champmaillot, University Hospital, Dijon, France
| | - Anca-Maria Mihai
- "Pôle Personnes Âgées", Hospital of Champmaillot, University Hospital, Dijon, France
| | - Valentine Nuss
- "Pôle Personnes Âgées", Hospital of Champmaillot, University Hospital, Dijon, France
| | - Philippe d'Athis
- Department of Medical Information, University Hospital, Dijon, France
| | - Alain Putot
- "Pôle Personnes Âgées", Hospital of Champmaillot, University Hospital, Dijon, France
| | - Patrick Manckoundia
- "Pôle Personnes Âgées", Hospital of Champmaillot, University Hospital, Dijon, France
- UMR Inserm/U1093 Cognition, Action, Sensorimotor Plasticity, University of Burgundy and Franche Comté, Dijon, France
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Bialkowski W, Tan S, Mast AE, Kiss JE, Kor D, Gottschall J, Wu Y, Roubinian N, Triulzi D, Kleinman S, Choi Y, Brambilla D, Zimrin A. Equivalent inpatient mortality among direct-acting oral anticoagulant and warfarin users presenting with major hemorrhage. Thromb Res 2020; 185:109-118. [PMID: 31794885 PMCID: PMC7035631 DOI: 10.1016/j.thromres.2019.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/21/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Extrapolation of clinical trial results comparing warfarin and direct-acting oral anticoagulant (DOAC) users experiencing major hemorrhage to clinical care is challenging due to differences seen among non-randomized oral anticoagulant users, bleed location, and etiology. We hypothesized that inpatient all-cause-mortality among patients presenting with major hemorrhage differed based on the home-administered anticoagulant medication class, DOAC versus warfarin. METHODS More than 1.5 million hospitalizations were screened and 3731 patients with major hemorrhage were identified in the REDS-III Recipient Database. Propensity score matching and stratification were used to account for potentially confounding factors. RESULTS Inpatient all-cause-mortality was lower for DOAC (HR = 0.60, 95%CI 0.45-0.80, p = 0.0005) before accounting for confounding and competing events. Inpatient all-cause-mortality for 1266 propensity-score-matched patients compared using proportional hazards regression did not differ (HR = 0.84, 95%CI 0.58-1.22, p = 0.36). Inpatient all-cause-mortality in stratified analyses (warfarin as reference) produced: HR = 0.69 (95%CI 0.31-1.55) for traumatic head injuries; HR = 1.10 (95%CI 0.62-1.95) for non-traumatic head injuries; HR = 0.62 (95%CI 0.20-1.94) for traumatic, non-head injuries; and HR = 0.69 (95%CI 0.29-1.63) for non-traumatic, non-head injuries. Mean time to discharge was shorter for DOAC (HR = 1.17, 95%CI 1.05-1.30, p = 0.0034) in the propensity score matched analysis. Plasma transfusion occurred in 42% of warfarin hospitalizations and 11% of DOAC hospitalizations. Vitamin K was administered in 63% of warfarin hospitalizations. CONCLUSIONS After accounting for differences in patient characteristics, location of bleed, and traumatic injury, inpatient survival was no different in patients presenting with major hemorrhage while on DOAC or warfarin.
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Affiliation(s)
| | - Sylvia Tan
- Research Triangle International, MD, USA
| | | | | | - Daryl Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, MN, USA
| | | | - Yanyun Wu
- Bloodworks Northwest, Washington, USA; School of Medicine, Yale University, CT, USA
| | | | | | | | - Young Choi
- School of Medicine, Yale University, CT, USA
| | | | - Ann Zimrin
- School of Medicine, University of Maryland, MD, USA
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Gabet A, Chatignoux E, Billionnet C, Maura G, Giroud M, Béjot Y, Olié V. Annual rate of newly treated atrial fibrillation by age and gender in France, 2010-2016. Eur J Epidemiol 2019; 35:1139-1147. [PMID: 31873812 DOI: 10.1007/s10654-019-00594-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022]
Abstract
Few studies are available on atrial fibrillation (AF) burden at a whole country scale. The objective was to estimate the rate of AF patients newly treated with oral anticoagulants (OAC) in France each year between 2010 and 2016 and to describe age and gender differences. We used the French national health data system. For each year between 2010 and 2016, we identified patients aged over 20 initiating OAC. OAC indicated for the treatment of AF was determined by hospitalization diagnoses, specific procedures and registered long-term disease status, or a multiple imputation process for patients with no recorded information as to why they initiated OAC. Among the 421,453 individuals initiating OAC treatment in 2016, the estimated number of newly treated AF patients was 210,131, women accounting for 46%, patients under 65 years old 17%, and 21.4% of patients living in most deprived area. Age-standardized rates reached 400/100,000 inhabitants. Approximately 19% of patients were recently hospitalized for heart failure and 7% for stroke. Age-standardized rates increased by 35% over the study period in both genders, with a marked increase in patients under 55 (+ 41%) and those over 85 years old (+ 60%). Annual rates of AF patients newly treated with OAC increased by 35% between 2010 and 2016. Important differences in rates were observed according to age, gender and the deprivation level of the living area.
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Affiliation(s)
- Amélie Gabet
- Department of Non-Communicable Diseases, Santé Publique France, Saint Maurice, France.
| | - Edouard Chatignoux
- Department of Non-Communicable Diseases, Santé Publique France, Saint Maurice, France
| | - Cécile Billionnet
- Department of Studies in Public Health, French National Health Insurance, Paris, France
| | - Géric Maura
- Department of Studies in Public Health, French National Health Insurance, Paris, France
- Team Pharmacoepidemiology, Inserm, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - Maurice Giroud
- Dijon Stroke Registry, EA 7460, University Hospital of Burgundy, Dijon, France
| | - Yannick Béjot
- Dijon Stroke Registry, EA 7460, University Hospital of Burgundy, Dijon, France
| | - Valérie Olié
- Department of Non-Communicable Diseases, Santé Publique France, Saint Maurice, France
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Butt JH, De Backer O, Olesen JB, Gerds TA, Havers-Borgersen E, Gislason GH, Torp-Pedersen C, Søndergaard L, Køber L, Fosbøl EL. Vitamin K antagonists vs. direct oral anticoagulants after transcatheter aortic valve implantation in atrial fibrillation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 7:11-19. [PMID: 31665260 DOI: 10.1093/ehjcvp/pvz064] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/02/2019] [Accepted: 10/23/2019] [Indexed: 01/21/2023]
Abstract
AIMS To examine the risk of arterial thromboembolism, bleeding, and all-cause mortality in atrial fibrillation (AF) patients treated with direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs) undergoing transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS In this nationwide observational cohort study, 735 patients undergoing TAVI from 1 January 2012 to 30 June 2017 with a history of AF and who were treated with oral anticoagulants were identified using data from Danish nationwide registries. Of these, 219 (29.8%) and 516 (70.2%) patients were treated with DOACs and VKAs, respectively. The DOAC group was characterized by a higher prevalence of previous arterial thromboembolism and a lower prevalence of chronic kidney disease compared with the VKA group. The distribution of age, sex, CHA2DS2-VASc and HAS-BLED scores, and concomitant antiplatelet therapy was similar between groups. Compared with VKA, treatment with DOACs was not associated with a significantly different 3-year absolute risk of arterial thromboembolism [9.6% (95% confidence interval, CI 4.7-16.5%) vs. 7.4% (95% CI 4.9-10.5%) in the DOAC and VKA group, respectively], bleeding [14.3% (95% CI 7.6-22.9%) vs. 13.3% (95% CI 9.9-17.1%)], or all-cause mortality [32.7% (95% CI 21.8-44.0%) vs. 32.0% (95% CI 26.8-37.3%)]. In adjusted analyses, treatment with DOACs, when compared with VKAs, was not associated with a significantly different rate of arterial thromboembolism [hazard ratio (HR) 1.23 (95% CI 0.58-2.59)], bleeding [HR 1.14 (95% CI 0.63-2.06)], or all-cause mortality [HR 0.93 (95% CI 0.61-1.40)]. CONCLUSION In patients with AF undergoing TAVI, treatment with DOACs was not associated with a significantly different risk of arterial thromboembolism, bleeding, or all-cause mortality compared with VKA.
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Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jonas B Olesen
- Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Thomas A Gerds
- Department of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark.,The Danish Heart Foundation, Copenhagen, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Eva Havers-Borgersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark.,The Danish Heart Foundation, Copenhagen, Vognmagergade 7, 1120 Copenhagen, Denmark
| | | | - Lars Søndergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Butt JH, Li A, Xian Y, Peterson ED, Garcia D, Torp-Pedersen C, Køber L, Fosbøl EL. Direct oral anticoagulant- versus vitamin K antagonist-related gastrointestinal bleeding: Insights from a nationwide cohort. Am Heart J 2019; 216:117-124. [PMID: 31425898 DOI: 10.1016/j.ahj.2019.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/19/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of the study was to examine the association between the type of preceding oral anticoagulant use (warfarin or direct oral anticoagulants [DOACs]) and in-hospital mortality among patients admitted with gastrointestinal bleeding. METHODS In this observational cohort study, all patients admitted with a first-time gastrointestinal bleeding from January 2011 to March 2017 while receiving any oral anticoagulant therapy prior to admission were identified using data from Danish nationwide registries. The risk of in-hospital mortality according to type of oral anticoagulation therapy was examined by multivariable logistic regression models. RESULTS Among 5,774 patients admitted with gastrointestinal bleeding (median age, 78 years [25th-75th percentile, 71-85 years]; 56.8% men), 2,038 (35.3%) were receiving DOACs and 3,736 (64.7%) were receiving warfarin prior to admission. The unadjusted in-hospital mortality rates were 7.5% for DOAC (7.2% for dabigatran, 6.4% for rivaroxaban, and 10.1% for apixaban) and 6.5% for warfarin. After adjustment for baseline demographic and clinical characteristics, there was no statistically significant difference in in-hospital mortality between prior use of any DOAC and warfarin (unadjusted odds ratio [OR] 1.18 [95% CI 0.95-1.45], adjusted OR 0.97 [95% CI 0.77-1.24]). Similar results were found for each individual DOAC as compared with warfarin (dabigatran: unadjusted OR 1.12 [95% CI 0.84-1.49], adjusted OR 0.96 [95% CI 0.71-1.30]); rivaroxaban: unadjusted OR 0.98 [95% CI 0.71-1.37], adjusted OR 0.84 [95% CI 0.59-1.21]; and apixaban: unadjusted OR 1.62 [95% CI 0.84-1.49], adjusted OR 1.22 [95% CI 0.83-1.79]). CONCLUSIONS Among patients admitted with gastrointestinal bleeding, there was no statistically significant difference in in-hospital mortality between prior use of DOAC and warfarin.
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Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Ang Li
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC
| | | | - David Garcia
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Song HY, Son KB, Shin JY, Bae S. Utilization of oral anticoagulants in Korean nonvalvular atrial fibrillation patients. Int J Clin Pharm 2019; 41:1434-1441. [PMID: 31522377 DOI: 10.1007/s11096-019-00901-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022]
Abstract
Background Although the majority of clinical guidelines indicate the use of NOAC (nonvitamin K antagonist oral anticoagulant) over vitamin K antagonist in nonvalvular atrial fibrillation patients, there is no information on real-world prescription factors that lead to a specific type of oral anticoagulant selection. Objective To evaluate the prescription factors for choosing a specific oral anticoagulant for nonvalvular atrial fibrillation patients in Korea. Setting Nationwide sampled database in South Korea. Methods In this study, we defined nonvalvular atrial fibrillation patients as having one or more hospitalizations or two or more out-patient visits with a stroke risk score (CHA2DS2-VASc scores) ≥ 2 eligible for oral anticoagulant therapy from Jan 1st, 2016 to Dec 31st, 2016. Baseline characteristics were analyzed, including sex, age, comorbidities, CHA2DS2-VASc, bleeding risk score (mHAS-BLED), prescribing specialty, insurance type, medical institution type and location. Univariate and multivariate logistic regression analyses were conducted for being prescribed NOAC compared with vitamin K antagonist. Main outcome measure Adjusted odds ratio of the NOAC group and vitamin K antagonist group. Results Of 9,226 patients eligible for oral anticoagulant therapy, 4999 patients (54.2%) received oral anticoagulant therapy, and 4517 patients took NOAC or vitamin K antagonist only during the study period. Prior stroke, transient ischemic attack, thromboembolism, thyroid disease, dyslipidemia, cancer, mHAS-BLED ≥ 5, in-patient care, and specialty in internal medicine and neurology were positive predictors of NOAC use over vitamin K antagonist, whereas young age (≤64), renal dysfunction, and secondary care institution were negative predictors of NOAC use over vitamin K antagonist. Conclusions The presence of comorbidities was linked to NOAC use over vitamin K antagonist, which is different from prescription factor studies in other countries and requires further study.
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Affiliation(s)
- Hye-Yoon Song
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Kyung-Bok Son
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - SeungJin Bae
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea.
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Kjerpeseth LJ, Selmer R, Ariansen I, Karlstad Ø, Ellekjær H, Skovlund E. Comparative effectiveness of warfarin, dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation: A nationwide pharmacoepidemiological study. PLoS One 2019; 14:e0221500. [PMID: 31449560 PMCID: PMC6709911 DOI: 10.1371/journal.pone.0221500] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To compare effectiveness and safety of warfarin and the direct oral anticoagulants (DOAC) dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation in routine care. METHODS From nationwide registries, we identified treatment-naïve patients initiating warfarin, dabigatran, rivaroxaban or apixaban for non-valvular atrial fibrillation from July 2013 to December 2015 in Norway. We assessed prescription duration using reverse waiting time distribution. Adjusting for confounding in a Cox proportional hazards model, we estimated one-year risks for ischemic stroke, transient ischemic attack (TIA) or systemic embolism, major or clinically relevant non-major bleeding; intracranial; gastrointestinal; and other bleeding. We censored at switch of treatment or 365 days of follow-up. RESULTS We included 30,820 treatment-naïve patients. Compared to warfarin, the adjusted hazard ratios (HR) for ischemic stroke, TIA or systemic embolism were 0.96 (95% CI 0.71-1.28) for dabigatran, 1.12 (95% CI 0.87-1.45) for rivaroxaban and 0.97 (95% CI 0.75-1.26) for apixaban. Corresponding hazard ratios for major or clinically relevant non-major bleeding were 0.73 (95% CI 0.62-0.86) for dabigatran, 0.97 (95% CI 0.84-1.12) for rivaroxaban and 0.71 (95% CI 0.62-0.82) for apixaban. Statistically significant differences of other safety outcomes compared to warfarin were fewer intracranial bleedings with dabigatran (HR 0.28, 95% CI 0.14-0.56), rivaroxaban (HR 0.40, 95% CI 0.23-0.69) and apixaban (HR 0.56, 95% CI 0.34-0.92); fewer gastrointestinal bleedings with apixaban (HR 0.70, 95% CI 0.52-0.93); and fewer other bleedings with dabigatran (HR 0.67, 95% CI 0.55-0.81) and apixaban (HR 0.70, 95% CI 0.59-0.83). CONCLUSION After 1 year follow-up in treatment-naïve patients initiating oral anticoagulation for non-valvular atrial fibrillation, all DOACs were similarly effective as warfarin in prevention of ischemic stroke, TIA or systemic embolism. Safety from bleedings was similar or better, including fewer intracranial bleedings with all direct oral anticoagulants, fewer gastrointestinal bleedings with apixaban and fewer other bleedings with dabigatran and apixaban.
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Affiliation(s)
- Lars J. Kjerpeseth
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
- * E-mail:
| | - Randi Selmer
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Inger Ariansen
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Øystein Karlstad
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Stroke Unit, Department of Internal Medicine, St. Olav’s Hospital, Trondheim, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
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Rose AJ, Goldberg R, McManus DD, Kapoor A, Wang V, Liu W, Yu H. Anticoagulant Prescribing for Non-Valvular Atrial Fibrillation in the Veterans Health Administration. J Am Heart Assoc 2019; 8:e012646. [PMID: 31441364 PMCID: PMC6755851 DOI: 10.1161/jaha.119.012646] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Direct acting oral anticoagulants (DOACs) theoretically could contribute to addressing underuse of anticoagulation in non‐valvular atrial fibrillation (NVAF). Few studies have examined this prospect, however. The potential of DOACs to address underuse of anticoagulation in NVAF could be magnified within a healthcare system that sharply limits patients’ exposure to out‐of‐pocket copayments, such as the Veterans Health Administration (VA). Methods and Results We used a clinical data set of all patients with NVAF treated within VA from 2007 to 2016 (n=987 373). We examined how the proportion of patients receiving any anticoagulation, and which agent was prescribed, changed over time. When first approved for VA use in 2011, DOACs constituted a tiny proportion of all prescriptions for anticoagulants (2%); by 2016, this proportion had increased to 45% of all prescriptions and 67% of new prescriptions. Patient characteristics associated with receiving a DOAC, rather than warfarin, included white race, better kidney function, fewer comorbid conditions overall, and no history of stroke or bleeding. In 2007, before the introduction of DOACs, 56% of VA patients with NVAF were receiving anticoagulation; this dipped to 44% in 2012 just after the introduction of DOACs and had risen back to 51% by 2016. Conclusions These results do not suggest that the availability of DOACs has led to an increased proportion of patients with NVAF receiving anticoagulation, even in the context of a healthcare system that sharply limits patients’ exposure to out‐of‐pocket copayments.
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Affiliation(s)
- Adam J Rose
- RAND Corporation Boston MA.,Section of General Internal Medicine Boston University School of Medicine Boston MA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences University of Massachusetts Medical School Worcester MA
| | - David D McManus
- Department of Medicine University of Massachusetts Medical School Worcester MA
| | - Alok Kapoor
- Department of Medicine University of Massachusetts Medical School Worcester MA
| | | | | | - Hong Yu
- University of Massachusetts Lowell MA.,Edith Nourse Rogers Memorial VA Medical Center Bedford MA
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Perioperative Management of Direct Oral Anticoagulants in Intracranial Surgery. J Neurosurg Anesthesiol 2019; 32:300-306. [PMID: 31306260 DOI: 10.1097/ana.0000000000000629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of direct oral anticoagulants is increasing rapidly, because of perceived benefits over older agents, such as predictable pharmacokinetics and a reduced risk of bleeding. Elderly patients, who are more likely to be prescribed these drugs, are also presenting for neurosurgical procedures more often. The combination of these factors will result in neurosurgeons and neuroanesthesiologists encountering patients prescribed direct oral anticoagulants on an increasingly frequent basis. This review provides a summary of the current evidence pertaining to the perioperative management of these drugs, in the context of elective and emergency intracranial surgery. It highlights emerging therapies, including specific antidotes, as well as areas where the evidence base is likely to improve in the future.
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Artime E, Qizilbash N, Garrido-Estepa M, Vora P, Soriano-Gabarró M, Asiimwe A, Pocock S. Are risk minimization measures for approved drugs in Europe effective? A systematic review. Expert Opin Drug Saf 2019; 18:443-454. [PMID: 31032651 DOI: 10.1080/14740338.2019.1612875] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objectives: The effectiveness of risk minimization measures (RMMs) requires evaluation. This study aims to evaluate the results of cross-sectional surveys assessing the effectiveness of RMMs in Europe (EU RM Surveys) and review the regulatory consequences. Methods: The authors searched for study reports and manuscripts of completed EU RM surveys in the EU PAS Register, MEDLINE, and Google between 01/2011 and 01/2018. Regulatory responses were extracted from Assessment Reports. Random effects models to combine proportions were used. Results: Twenty-four EU RM surveys were identified. Twenty-three studies targeted health-care professionals (HCPs). The pre-specified sample size was reached in 52% of studies. HCP participation was 5% defined as completers/invited and 89% for completers/eligible. Receipt of materials was recalled by 60% of HCPs and 77% of items scored knowledge >60%. Eight studies targeted patients/caregivers. The pre-specified sample size was reached in only two. Participation was 93%, defined as completers/eligible. Materials were received by 50-80% of patients and read by over 90%. Patients only scored knowledge >60% in 38% of items. Further action was requested by regulators in 59% of studies. Conclusion: Surveys are necessary to evaluate many RMMs. Challenges remain in the design, conduct, and reporting of these studies which may benefit from the use of standard definitions and further guidance on reporting. EU PAS Register: http://www.encepp.eu/encepp/viewResource.htm?id=23435.
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Affiliation(s)
| | - Nawab Qizilbash
- OXON Epidemiology, Madrid, Spain
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, London, UK
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Maura G, Billionnet C, Drouin J, Weill A, Neumann A, Pariente A. Oral anticoagulation therapy use in patients with atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants: findings from the French healthcare databases, 2011-2016. BMJ Open 2019; 9:e026645. [PMID: 31005934 PMCID: PMC6500377 DOI: 10.1136/bmjopen-2018-026645] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES To describe (i) the trend in oral anticoagulant (OAC) use following the introduction of non-vitamin K antagonist oral anticoagulant (NOAC) therapy for stroke prevention in atrial fibrillation (AF) patients and (ii) the current patterns of use of NOAC therapy in new users with AF in France. DESIGN (i) Repeated cross-sectional study and (ii) population-based cohort study. SETTING French national healthcare databases (50 million beneficiaries). PARTICIPANTS (i) Patients with identified AF in 2011, 2013 and 2016 and (ii) patients with AF initiating OAC therapy in 2015-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: (i) Trend in OAC therapy use in patients with AF and (ii) patterns of use of NOAC therapy in new users with AF. RESULTS Between 2011 and 2016, use of OAC therapy moderately increased (+16%), while use of antiplatelet therapy decreased (-22%) among all patients with identified AF. In 2016, among the 1.1 million AF patients, 66% used OAC therapy and were more likely to be treated by vitamin K antagonist (VKA) than NOAC therapy, including patients at higher risk of stroke (63.5%), while 33% used antiplatelet therapy. Among 192 851 new users of OAC therapy in 2015-2016 with identified AF, NOAC therapy (66.3%) was initiated more frequently than VKA therapy, including in patients at higher risk of stroke (57.8%). Reduced doses were prescribed in 40% of NOAC new users. Several situations of inappropriate use at NOAC initiation were identified, including concomitant use of drugs increasing the risk of bleeding (one in three new users) and potential NOAC underdosing. CONCLUSIONS OAC therapy use in patients with AF remains suboptimal 4 years after the introduction of NOACs for stroke prevention in France and improvement in appropriate prescribing regarding NOAC initiation is needed. However, NOAC therapy is now the preferred drug class for initiation of OAC therapy in patients with AF, including in patients at higher risk of stroke.
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Affiliation(s)
- Géric Maura
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
| | - Cécile Billionnet
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Jérôme Drouin
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Alain Weill
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Anke Neumann
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Antoine Pariente
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
- CHU Bordeaux, Bordeaux, France
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Kartas A, Samaras A, Vasdeki D, Dividis G, Fotos G, Paschou E, Forozidou E, Tsoukra P, Kotsi E, Goulas I, Efthimiadis G, Giamouzis G, Karvounis H, Tzikas A, Giannakoulas G. Hospitalization affects the anticoagulation patterns of patients with atrial fibrillation. J Thromb Thrombolysis 2019; 48:225-232. [DOI: 10.1007/s11239-019-01832-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Kuronuma K, Okumura Y, Yokoyama K, Matsumoto N, Tachibana E, Oiwa K, Matsumoto M, Kojima T, Hanada S, Nomoto K, Arima K, Takahashi F, Kotani T, Ikeya Y, Fukushima S, Itou S, Kondo K, Chiku M, Ohno Y, Onikura M, Hirayama A. Different determinants of vascular and nonvascular deaths in patients with atrial fibrillation: A SAKURA AF Registry substudy. J Cardiol 2018; 73:210-217. [PMID: 30591323 DOI: 10.1016/j.jjcc.2018.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 11/29/2018] [Accepted: 12/08/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence and causes of death among patients in Japan treated for atrial fibrillation (AF), a major determinant of strokes and death, with direct oral anticoagulants (DOACs) are unclear. This study's aim was two-fold: to compare the incidence and causes of death between DOAC and warfarin users in Japan and to identify the factors associated with vascular and nonvascular death in the Japanese AF population. METHODS The study was based on the SAKURA AF registry, in which clinical events were tracked in 3267 enrollees from 63 institutions for 2-4 years. Enrollees included warfarin users (n=1577) and users of any of 4 DOACs (n=1690). The incidence, cause, and major determinants of death were analyzed. RESULTS During a median 39.3-month follow-up, 200 patients died, with most succumbing to cardiac death (25%), malignancies (21%), or respiratory infections (20%). There was no significant difference in deaths from any cause between warfarin and DOAC users (108 vs. 92 patients, p=0.34). An age ≥75 years was found to be a major determinant of death, but the relative risk (vs. <75 years) was greater for nonvascular death (hazard ratio: 2.85 and 4.97 for age 75-84 and ≥85 years, respectively) than vascular death (2.14 and 2.98 for 75-84 and ≥85 years, respectively). Heart failure, renal dysfunction, and the type of institution were major determinants of vascular death, and a male sex, weight <50kg, and anemia were major determinants of nonvascular death. CONCLUSIONS The results of our AF registry-based study, in which two thirds of the enrolled patients succumbed to cardiac death, malignancies, or respiratory infections within 2- 4 years and use of DOACs rather than warfarin did not reduce the mortality, indicated that a management of AF that includes prophylaxis for vascular and nonvascular events in addition to strokes is warranted.
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Affiliation(s)
| | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan.
| | | | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | | | - Koji Oiwa
- Yokohama Chuo Hospital, Kanagawa, Japan
| | | | | | - Shoji Hanada
- Asakadai Central General Hospital, Saitama, Japan
| | | | - Ken Arima
- Kasukabe Municipal Hospital, Saitama, Japan
| | | | | | | | | | | | | | | | | | | | - Atsushi Hirayama
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan
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Mentias A, Shantha G, Chaudhury P, Vaughan Sarrazin MS. Assessment of Outcomes of Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation and Multiple Chronic Conditions: A Comparative Effectiveness Analysis. JAMA Netw Open 2018; 1:e182870. [PMID: 30646182 PMCID: PMC6324495 DOI: 10.1001/jamanetworkopen.2018.2870] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Comparative effectiveness and safety of oral anticoagulants in patients with atrial fibrillation (AF) and multiple chronic conditions (MCC) are unknown. OBJECTIVE To determine whether there are differences in efficacy and safety of dabigatran, rivaroxaban, and warfarin regarding stroke prevention and bleeding rates, respectively, in elderly patients with AF with MCC. DESIGN, SETTING, AND PARTICIPANTS This retrospective comparative effectiveness analysis included data from the population-based Medicare beneficiaries database, evaluating patients with new AF diagnosed from January 1, 2010, to December 31, 2013, who initiated an oral anticoagulant within 90 days of diagnosis. Patients with CHA2DS2-VASc scores of 1 to 3, 4 to 5, and 6 or higher; HAS-BLED scores of 0 to 1, 2, and 3 or higher; and Gagne comorbidity scores of 0 to 2, 3 to 4, and 5 or higher were categorized as having low, moderate, or high morbidity, respectively. Within morbidity categories, patients receiving dabigatran, rivaroxaban, or warfarin were matched using a 3-way propensity matching, and the relative hazards of stroke, major hemorrhage (MH), and death were evaluated. Data analysis included follow-up from the date of initial anticoagulant use through December 31, 2013. EXPOSURES Rivaroxaban (20 mg once daily), dabigatran (150 mg twice daily), or warfarin therapy. MAIN OUTCOMES AND MEASURES Ischemic stroke, MH, and death. RESULTS The study cohort included 21 979 patients using dabigatran (mean [SD] age, 75.8 [6.4] years; 51.1% female), 23 177 using rivaroxaban (mean [SD] age, 75.8 [6.4] years; 49.9% female), and 101 715 using warfarin (mean [SD] age, 78.5 [7.2] years; 57.3% female). In the propensity-matched cohorts, there were no differences in stroke rates between the 3 oral anticoagulant groups. Dabigatran users had lower hazard of MH compared with warfarin users among patients with low MCC (hazard ratio [HR], 0.62; 95% CI, 0.47-0.83; P < .001; for MCC defined as low CHA2DS2-VASc score), and similar risk in patients with moderate to high MCC. While there was no difference in MH between rivaroxaban and warfarin users, rivaroxaban users had significantly higher MH risk compared with dabigatran users in the medium and high comorbidity groups (HR, 1.24; 95% CI, 1.04-1.48; P = .02 and HR, 1.28; 95% CI, 1.05-1.56; P = .01, respectively). Dabigatran and rivaroxaban users had lower rates of death compared with warfarin users (HR ranged from 0.52-0.84), across comorbidity levels. CONCLUSIONS AND RELEVANCE Oral anticoagulants are similarly effective in stroke prevention among patients with AF with MCC. However, dabigatran and rivaroxaban use may be associated with lower rates of mortality in patients with MCC.
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Affiliation(s)
- Amgad Mentias
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Ghanshyam Shantha
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Pulkit Chaudhury
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Mary S Vaughan Sarrazin
- Department of Internal Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa, Iowa City
- Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center, Iowa City
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