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Emad E, Khaled E, Eshtyag B, Fatima AE, Ghada S. Role of Clinical Pharmacy anticoagulation service on Apixaban prescribing appropriateness in atrial fibrillation in Saudi Arabia. Curr Probl Cardiol 2024; 49:102517. [PMID: 38521288 DOI: 10.1016/j.cpcardiol.2024.102517] [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: 03/03/2024] [Accepted: 03/13/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Inappropriate DAOC dosing is precuarious and frequently encountered. Apixaban is the most reported DOAC to be inappropriately dosed. We examined the effect of adding a Clinical Pharmacist to the cardiology team rounds to the standard practice in Apixaban prescription patterns in a tertiary center in KSA. OBJECTIVE To determine the effect of clinical pharmacy services on Apixaban dose appropriateness upon discharge in Atrial Fibrillation patient pobulation. METHODS This is a single-center, retrospective cohort of patients with atrial fibrillation using a quasi-experiment of pre-post design to evaluate Apixaban dose appropriateness using clinical pharmacy services. Clinical pharmacist was added to the team to evaluate and change the regimen according to FDA dosing. Data were collected for 9 months for each, patients were followed up for efficacy and safety outcomes for 1 year. RESULTS A total of 550 patients were initially collected after follow-up, the number of patients was in the pre-phase cohort (NO CCP; n= 112) from July 2018 to the March 2019 and compared to post phase cohort (CCP, n=103) from July 2019 to March 2020. 215 Patients were included, For primary end point, CCP cohort had significantly appropriate prescriptions of apixaban compared to Non-CCP (90.2 % vs 71.5 %, p<0.001)., no differences in thromboembolic and hemorrhagic adverse events betewwn 2 cohorts. CONCLUSION A multidisciplinary team approach including clinical pharmacy services is effective in increasing the appropriate use of Apixaban upom discharge without apparent increased risk of bleeding or Adverse events.
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Affiliation(s)
- Elkholy Emad
- Pharmaceutical Service Department, King Abdullah Medical City, Makkah, KSA, Saudi Arabia.
| | - Elshammaa Khaled
- Pharmaceutical Service Department, King Abdullah Medical City, Makkah, KSA, Saudi Arabia
| | - Bajnaid Eshtyag
- Pharmaceutical Service Department, King Abdullah Medical City, Makkah, KSA, Saudi Arabia
| | - Aboul-Enein Fatima
- Cardiology Center, King Abdullah Medical City, Makkah, KSA, Saudi Arabia; Cardiology Department, Faculty of Medicine, Alexandria University, Egypt
| | - Shalaby Ghada
- Cardiology Center, King Abdullah Medical City, Makkah, KSA, Saudi Arabia; Cardiology Department, Faculty of Medicine, Zagazig University, Egypt
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De Vincentis A, Soraci L, Arena E, Sciacqua A, Armentaro G, Aucella F, Corsonello A, Aucella F, Antonelli Incalzi R. Appropriateness of direct oral anticoagulant prescribing in older subjects with atrial fibrillation discharged from acute medical wards. Br J Clin Pharmacol 2024; 90:1231-1239. [PMID: 38321367 DOI: 10.1111/bcp.16010] [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: 12/09/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Knowledge on the prescriptive practice of direct oral anticoagulants (DOACs) in older subjects with atrial fibrillation (AF) hospitalized in acute medical wards is limited. This study aimed to evaluate the prevalence and appropriateness of DOAC prescriptions in hospitalized older subjects with AF, discharged from acute medical wards. METHODS We analysed a cohort of 609 subjects with AF, aged ≥65 years (mean age 85 years) enrolled from 39 geriatric and nephrology wards in Italy. DOAC prescriptive appropriateness was evaluated according to the summary of product characteristics (smPC), 2019 Beers and STOPP criteria, and drug-drug interactions (DDIs). RESULTS At hospital discharge, 33% of patients with AF were prescribed with DOAC, 26% with vitamin-K antagonist, while 41% did not receive any anticoagulant. Among subjects on DOAC therapy, 31% presented a violation of the smPC criteria (mainly underdosage-17%), while 48% and 18% presented a Beers/STOPP inappropriate prescription, or a DDI, respectively. Older age, lower body mass index (BMI), cancer and higher estimated glomerular filtration rate (eGFR) were independently associated with DOAC underdosage or missed prescription (age: adjusted odds ratio [aOR] 1.06, 95% confidence interval [95% CI] 1.00-1.12 for underdosage; eGFR: aOR 1.04, 95% CI 1.02-1.07 for underdosage; BMI: aOR 0.95, 95% CI 0.91-0.99 for missed prescription; cancer: aOR 1.93, 95% CI 1.19-3.13 for missed prescription). CONCLUSIONS This study showed a suboptimal DOAC prescriptive practice in older in-patients, with frequent missed prescription and DOAC underdosage. Contrary to current recommendations, physicians appear overly concerned by bleeding risk in real-life older and frailer subjects. Strategies should be developed to promote appropriate DOAC prescription in the hospital setting.
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Affiliation(s)
- Antonio De Vincentis
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Internal Medicine, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Luca Soraci
- Unit of Geriatric Medicine, IRCCS INRCA, Cosenza, Italy
| | - Elena Arena
- Research Unit of Internal Medicine, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Angela Sciacqua
- Unit of Geriatric Medicine, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Italy
| | - Giuseppe Armentaro
- Unit of Geriatric Medicine, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Italy
| | - Francesco Aucella
- SC di Nefrologia e Dialisi, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | | | - Filippo Aucella
- SC di Nefrologia e Dialisi, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Raffaele Antonelli Incalzi
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Internal Medicine, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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3
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Simard C, Poirier-Blanchette L, Rizzolo A, Cafaro T, Kerzner R, Mantzanis H, Koolian M. Standardized direct oral anticoagulants prescription for treatment of acute venous thromboembolism in the emergency department: A quality improvement initiative. Thromb Res 2024; 236:68-73. [PMID: 38401355 DOI: 10.1016/j.thromres.2024.02.015] [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: 12/20/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) are commonly used for the treatment and prevention of venous thromboembolism (VTE). However, prescription errors with DOACs can lead to patient dissatisfaction and harm. This study aimed to evaluate the impact of a standardized prescription for DOACs for VTE on prescription appropriateness. MATERIALS AND METHODS The study included patients discharged from the Emergency Department (ED) with a DOAC prescription for an acute VTE. A standardized prescription tool was developed and implemented, and patients were divided into pre- and post-intervention groups. The appropriateness of prescriptions was assessed using the Medication Appropriateness Index (MAI). RESULTS A total of 161 patients with VTE were included in the study. The post-intervention group showed a significant increase in prescriptions with an MAI rating of "appropriate" and a decrease in ratings of "inappropriate." Improvements were observed in loading dose duration, maintenance dose frequency and duration, and inclusion of necessary drug coverage codes. CONCLUSION The implementation of a standardized prescription for DOACs in the management of VTE in the ED significantly improved medication appropriateness and reduced inappropriate prescriptions. Standardized prescriptions have the potential to enhance patient safety and optimize care by providing clear and uniform guidance to healthcare providers. Further research is needed to explore the effectiveness of medication prescription software systems in real-world clinical settings to improve prescribing practices.
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Affiliation(s)
- C Simard
- Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre of Excellence in Thrombosis and Anticoagulation, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
| | | | - A Rizzolo
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - T Cafaro
- Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - R Kerzner
- Department of Pharmacy, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - H Mantzanis
- Department of Pharmacy, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - M Koolian
- Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre of Excellence in Thrombosis and Anticoagulation, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Amrouch C, Vauterin D, Amrouch S, Grymonprez M, Dai L, Damiano C, Calderón-Larrañaga A, Lahousse L, De Bacquer D, Lip GYH, Vetrano DL, De Smedt D, Petrovic M. Potentially inappropriate prescribing in multimorbid and polymedicated older adults with AF: A Systematic Review and Meta-Analysis. Drugs Aging 2024; 41:13-30. [PMID: 37976015 PMCID: PMC10769941 DOI: 10.1007/s40266-023-01078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/19/2023]
Abstract
AIM Polypharmacy in multimorbid older patients with atrial fibrillation (AF) is a risk factor for potentially inappropriate prescribing (PIP). We aimed to systematically assess the evidence on the prevalence of PIP and its impact on adverse health outcomes in this patient group. METHODS A systematic search of the published peer-reviewed literature describing the prevalence of PIP and/or its association with adverse health outcomes in multimorbid (AF plus one comorbidity) and polymedicated (≥ 2 drugs) adults ≥ 65 years was done up to March 2023. A meta-analysis of the prevalence of PIP of (direct) oral anticoagulants ((D)OACs) was conducted using a random-effects model. Leave-one-out analysis was performed with R (version 4.2.2) and RStudio (version 2022.12.0+353). RESULTS Of the 12 studies included, only one reported on the prevalence of overall PIP (65%). The meta-analysis of 10 studies assessing PIP of (D)OACs produced a pooled prevalence [95% confidence interval (CI)] of 35% [30-40%], with significant heterogeneity between the included studies (I2 95%). No statistically significant association was reported in three studies between PIP of (D)OACs, cardiovascular (CV) and all-cause mortality, hospital readmission, CV hospitalisation and stroke. Reported associations between PIP and major bleeding differed, with one study demonstrating a significant association (odds ratio 2.17; 95% CI 1.14-4.12) and the other study not showing such association. CONCLUSION This systematic review highlights the scarce evidence regarding the prevalence of PIP and its association with adverse health outcomes in multimorbid older adults with AF. Large, prospective and better-designed studies are needed.
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Affiliation(s)
- Cheima Amrouch
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium.
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Delphine Vauterin
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ghent, Belgium
| | - Souad Amrouch
- Department of Medicine, Antwerp University, Antwerp, Belgium
| | - Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ghent, Belgium
| | - Lu Dai
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Cecilia Damiano
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Amaia Calderón-Larrañaga
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dirk De Bacquer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Gregory Y H Lip
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Davide L Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Delphine De Smedt
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
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5
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van der Horst SFB, van Rein N, van Mens TE, Huisman MV, Klok FA. Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: A narrative review. Thromb Res 2023; 231:135-140. [PMID: 37005194 DOI: 10.1016/j.thromres.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Direct oral anticoagulants (DOACs) have become the cornerstone for prevention of thromboembolic events in patients with atrial fibrillation and patients with a history of venous thromboembolism. However, studies show that DOAC prescriptions are commonly inconsistent with guideline recommendations. DOAC dosing in the acutely ill patient could impose an even greater challenge. In this review, we describe the prevalence of inappropriate inpatient prescribing of DOACs and the associated rationales, predictors and clinical consequences. With the aim of promoting appropriate prescriptions of DOACs to hospitalized patients, we further outline DOAC dose reduction criteria justified by various guidelines, illustrating the complexities of appropriate dosing, especially in acutely ill patients. Moreover, we will discuss the impact of anticoagulant stewardship programs and the vital role that pharmacists may play in optimizing inpatient DOAC treatment.
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Affiliation(s)
- S F B van der Horst
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands.
| | - N van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands; Amsterdam UMC, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, University of Amsterdam, Amsterdam, Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
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6
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Ko HTK, Pham J, Anpalahan M. Prevalence and predictors of inappropriate dosing of direct oral anticoagulants. Intern Med J 2023; 53:1790-1795. [PMID: 36448650 DOI: 10.1111/imj.15957] [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: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 10/21/2023]
Abstract
BACKGROUND Information on inappropriate dosing of direct oral anticoagulants (DOACs) is scarce in the Australian context. AIM To describe the prevalence and potential predictors of inappropriate dosing of DOACs. METHODS Patients who received DOACs during admission under a general medical unit over a 2-year period (from January 2017 to December 2018) were retrospectively studied. Appropriateness of the dosing regimen was verified against the recommendations of the Therapeutic Goods Administration of Australia. Data were obtained from medical records and analysed in univariate and multivariate logistic regression models. The variables associated with under- and overdosing were also determined. RESULTS A total of 203 (mean age 71.6 ± 14.5 years, females 52%) patients were studied. Inappropriate dosing occurred in 44 (22%) patients: underdosing 27 (13%) and overdosing 17 (8%). Age ≥75 years (P < 0.01), lower estimated creatinine clearance (CrCl) (P < 0.01), prescription of DOAC prior to index admission (P < 0.01) and higher Charlson Comorbidity Index (P < 0.01), HAS-BLED (P < 0.01) and CHA2 DS2 -VASc (P < 0.01) scores had a significant univariate association with inappropriate dosing. However, in the multivariate logistic regression only lower CrCl (odds ratio (OR) 1.04, 95% confidence interval (CI): 1.01-1.07, P < 0.01) and prescription of DOAC prior to index admission (OR 2.62, 95% CI: 1.01-6.75, P = 0.047) remained significantly associated with inappropriate dosing. Impaired renal function also had a significant association with underdosing (OR 1.04, 95% CI: 1.01-1.07, P = 0.01) and borderline significance with overdosing (OR 1.03, 95% CI: 1.00-1.07, P = 0.06). CONCLUSION Inappropriate dosing of DOACs, especially underdosing, is common in clinical practice. Clinicians should exercise due diligence when prescribing DOACs to patients with renal impairment and in outpatient settings.
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Affiliation(s)
- Hiu T K Ko
- Department of General Medicine, Eastern Health, Melbourne, Victoria, Australia
| | - Jonathan Pham
- Department of General Medicine, Eastern Health, Melbourne, Victoria, Australia
| | - Mahesan Anpalahan
- Department of General Medicine, Eastern Health, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
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7
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Tang J, Wang K, Yang K, Jiang D, Fang X, Su S, Lin Y, Chen S, Gu H, Li P, Yan S. A combination of Beers and STOPP criteria better detects potentially inappropriate medications use among older hospitalized patients with chronic diseases and polypharmacy: a multicenter cross-sectional study. BMC Geriatr 2023; 23:44. [PMID: 36694126 PMCID: PMC9875512 DOI: 10.1186/s12877-023-03743-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/10/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Research on potentially inappropriate medications (PIM) and medication-related problems (MRP) among the Chinese population with chronic diseases and polypharmacy is insufficient. OBJECTIVES This study aimed to investigate the prevalence of PIM and MRP among older Chinese hospitalized patients with chronic diseases and polypharmacy and analyze the associated factors. METHODS A retrospective cross-sectional study was conducted in five tertiary hospitals in Beijing. Patients aged ≥ 65 years with at least one chronic disease and taking at least five or more medications were included. Data were extracted from the hospitals' electronic medical record systems. PIM was evaluated according to the 2015 Beers criteria and the 2014 Screening Tool of Older Persons' Prescriptions (STOPP) criteria. MRPs were assessed and classified according to the Helper-Strand classification system. The prevalence of PIM and MRP and related factors were analyzed. RESULTS A total of 852 cases were included. The prevalence of PIM was 85.3% and 59.7% based on the Beers criteria and the STOPP criteria. A total of 456 MRPs occurred in 247 patients. The most prevalent MRP categories were dosages that were too low and unnecessary medication therapies. Hyperpolypharmacy (taking ≥ 10 drugs) (odds ratio OR 3.736, 95% confidence interval CI 1.541-9.058, P = 0.004) and suffering from coronary heart disease (OR 2.620, 95%CI 1.090-6.297, P = 0.031) were the influencing factors of inappropriate prescribing (the presence of either PIM or MRP in a patient). CONCLUSION PIM and MRP were prevalent in older patients with chronic disease and polypharmacy in Chinese hospitals. More interventions are urgently needed to reduce PIM use and improve the quality of drug therapies.
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Affiliation(s)
- Jing Tang
- grid.413259.80000 0004 0632 3337Department of Pharmacy, Xuanwu Hospital, the First Clinical Medical College of Capital Medical University, No. 45, Changchun Street, Xicheng District 100053 Beijing, China ,National Clinical Research Center for Geriatric Disorders, Beijing, 100053 China
| | - Ke Wang
- grid.413259.80000 0004 0632 3337Department of Pharmacy, Xuanwu Hospital, the First Clinical Medical College of Capital Medical University, No. 45, Changchun Street, Xicheng District 100053 Beijing, China ,National Clinical Research Center for Geriatric Disorders, Beijing, 100053 China
| | - Kun Yang
- grid.413259.80000 0004 0632 3337Department of Evidence-Based Medicine, Xuanwu Hospital, the First Clinical Medical College of Capital Medical University, Beijing, 100053 China
| | - Dechun Jiang
- grid.413259.80000 0004 0632 3337Department of Pharmacy, Xuanwu Hospital, the First Clinical Medical College of Capital Medical University, No. 45, Changchun Street, Xicheng District 100053 Beijing, China ,National Clinical Research Center for Geriatric Disorders, Beijing, 100053 China
| | - Xianghua Fang
- grid.413259.80000 0004 0632 3337Department of Evidence-Based Medicine, Xuanwu Hospital, the First Clinical Medical College of Capital Medical University, Beijing, 100053 China
| | - Su Su
- grid.413259.80000 0004 0632 3337Department of Pharmacy, Xuanwu Hospital, the First Clinical Medical College of Capital Medical University, No. 45, Changchun Street, Xicheng District 100053 Beijing, China ,National Clinical Research Center for Geriatric Disorders, Beijing, 100053 China
| | - Yang Lin
- grid.411606.40000 0004 1761 5917Department of Pharmacy, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, 100029 China
| | - Shicai Chen
- grid.478016.c0000 0004 7664 6350Department of Pharmacy, Beijing Luhe Hospital Affiliated to Capital Medical University, Beijing, 101149 China
| | - Hongyan Gu
- grid.414367.3Department of Pharmacy, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, 100038 China
| | - Pengmei Li
- grid.415954.80000 0004 1771 3349Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029 China
| | - Suying Yan
- grid.413259.80000 0004 0632 3337Department of Pharmacy, Xuanwu Hospital, the First Clinical Medical College of Capital Medical University, No. 45, Changchun Street, Xicheng District 100053 Beijing, China ,National Clinical Research Center for Geriatric Disorders, Beijing, 100053 China
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Retrospective analysis of gastrointestinal bleedings with direct oral anticoagulants reported to EudraVigilance. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:1143-1153. [PMID: 36656352 DOI: 10.1007/s00210-023-02388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
Direct oral anticoagulants (DOACs) are increasingly used and are an important cornerstone in antithrombotic therapy. Adverse drug reactions (ADRs) such as bleedings have only partially been investigated during clinical trials. The primary goal was to analyse pharmacovigilance data based on spontaneous reports of gastrointestinal (GI) bleedings with DOACs reported to EudraVigilance. A second goal was to compare GI safety profiles between DOACs based on these signals. All DOAC related GI bleedings mentioned in individual case safety reports (ICSRs) from 2012 till 2017 in the European Economic Area were classified in four GI categories based on the reported site of occurrence of the haemorrhage. Age group and gender of the patient, seriousness and ADR outcome, and the reporter's qualification were assessed per category and per DOAC. Disproportionality analyses were performed to evaluate whether or not the reported ADRs were more prevalent with a given DOAC. ICSRs were bleeding-related in about half of the cases (n = 28,992/53,471). Of these bleedings, >25% was GI-related. Most patients experiencing GI bleedings were between 65 and 85 years old, with no obvious differences between men and women. Stomach, ulcer-related duodenal, and rectal bleedings were the most reported GI bleedings with a fatal outcome in 5.8%, 7.5%, and 9.8% of the cases for rivaroxaban, apixaban, and dabigatran, respectively. The disproportionality data suggest that dabigatran is more frequently involved in GI bleeding events than the other DOACs. DOACs were significantly associated with GI bleedings. Although the data should be interpreted with caution, it seems that dabigatran was associated more often than other DOACs with GI bleedings based on the analysis of spontaneous pharmacovigilance reports.
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9
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Caso V, de Groot JR, Sanmartin Fernandez M, Segura T, Blomström-Lundqvist C, Hargroves D, Antoniou S, Williams H, Worsley A, Harris J, Caleyachetty A, Vardar B, Field P, Ruff CT. Outcomes and drivers of inappropriate dosing of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation: a systematic review and meta-analysis. Heart 2023; 109:178-185. [PMID: 36316100 PMCID: PMC9872251 DOI: 10.1136/heartjnl-2022-321114] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE There has been limited systematic evaluation of outcomes and drivers of inappropriate non-vitamin K antagonist oral anticoagulants (NOACs) dosing among patients with atrial fibrillation (AF). This review identified and systematically evaluated literature on clinical and economic outcomes of inappropriate NOAC dosing and associated patient characteristics. METHODS MEDLINE, Embase, Cochrane Library, International Pharmaceutical Abstracts, Econlit, PubMed and NHS EEDs databases were searched for English language observational studies from all geographies published between 2008 and 2020, examining outcomes of, or factors associated with, inappropriate NOAC dosing in adult patients with AF. RESULTS One hundred and six studies were included in the analysis. Meta-analysis showed that compared with recommended NOAC dosing, off-label underdosing was associated with a null effect on stroke outcomes (ischaemic stroke and stroke/transient ischaemic attack (TIA), stroke/systemic embolism (SE) and stroke/SE/TIA). Meta-analysis of 15 studies examining clinical outcomes of inappropriate NOAC dosing found a null effect of underdosing on bleeding outcomes (major bleeding HR=1.04, 95% CI 0.90 to 1.19; p=0.625) but an increased risk of all-cause mortality (HR=1.28, 95% CI 1.10 to 1.49; p=0.006). Overdosing was associated with an increased risk of major bleeding (HR=1.41, 95% CI 1.07 to 1.85; p=0.013). No studies were found examining economic outcomes of inappropriate NOAC dosing. Narrative synthesis of 12 studies examining drivers of inappropriate NOAC dosing found that increased age, history of minor bleeds, hypertension, congestive heart failure and low creatine clearance (CrCl) were associated with an increased risk of underdosing. There was insufficient evidence to assess drivers of overdosing. CONCLUSIONS Our analysis suggests that off-label underdosing of NOACs does not reduce bleeding outcomes. Patients prescribed off-label NOAC doses are at an increased risk of all-cause mortality. These data underscore the importance of prescriber adherence to NOAC dosing guidelines to achieve optimal clinical outcomes for patients with AF. PROSPERO REGISTRATION NUMBER CRD42020219844.
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Affiliation(s)
- Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Joris R de Groot
- Heart Center, Department of Cardiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | | | - Tomás Segura
- Deparment of Neurology, Hospital General Universitario de Albacete, Albacete, Spain
| | | | - David Hargroves
- Stroke Medicine, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | | | - Helen Williams
- South East London Integrated Card Systemt, and UCLPartners, London, UK
| | | | | | | | | | | | - Christian T Ruff
- Cardiovascular Division, Deparmtent of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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10
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Appropriateness of Non-vitamin K Antagonist Oral Anticoagulants Dosing According to Different Prescription Guides Used in Belgian Ambulatory Care. Clin Drug Investig 2022; 42:775-786. [PMID: 35986867 PMCID: PMC9392068 DOI: 10.1007/s40261-022-01190-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
Abstract
Background Non-vitamin K antagonist oral anticoagulants (NOACs) are the preferred choice of anticoagulants to prevent stroke in most patients with atrial fibrillation (AF). NOAC's dosing algorithms are defined in the respective Summary of Product Characteristics (SmPC) but the European Heart Rhythm Association (EHRA) Practical Guide can also be used as it considers more complex clinical scenarios. Nevertheless, suboptimal dosing of NOACs compromises the efficacy and safety of this commonly prescribed therapy in the AF population. Clearer objectification of inappropriate dosing and its influencing factors is needed to optimise management of AF patients. Objectives The primary aim of this study was to investigate whether there is a difference in the perceived appropriateness of NOAC dosing with respect to the SmPC or the 2018 EHRA Practical Guide in AF patients criteria and influencing factors. The secondary aim was to explore if there were differences in appropriateness of NOAC dosing between primary care and specialist care, and when using different renal function formulas. Methods This retrospective study included AF patients treated with a NOAC in primary or in ambulatory specialist care in Antwerp (Belgium). Appropriateness of the NOAC dose was assessed according to the SmPC and 2018 EHRA recommendations. Univariate/multivariate analyses were performed to explore influencing factors for under- and overdosing of NOACs. Results Of the included 294 AF patients, 19.4% and 15.6% received an inappropriate dose according to the SmPC and the 2018 EHRA Practical Guide respectively (p = 0.003). Perceived frailty and higher weight were associated with underdosing relative to the SmPC, while a higher body mass index and the use of drugs/alcohol were associated with underdosing relative to the EHRA 2018 recommendations. Lower renal function and treatment with other NOACs than apixaban were associated with relative overdosing compared to both standards. Conclusions Inappropriate NOAC dosing is present in almost twenty percent of AF patients according to the SmPC and requires further education of health care professionals and frequent reassessment of NOAC dosing. However, a significant lower prevalence of underdosing was present when judged by the 2018 EHRA criteria, likely reflecting decision making in complex AF patients. Perceived frailty, weight, renal function and type of NOAC are the main determinants of deviated dosing. Supplementary Information The online version contains supplementary material available at 10.1007/s40261-022-01190-2.
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11
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Zhang ZX, Schroeder-Tanka J, Stooker W, Wissen S, Khorsand N. Management of combined oral antithrombotic therapy by an Antithrombotic Stewardship Program: a prospective study. Br J Clin Pharmacol 2022; 88:4092-4099. [PMID: 35384015 DOI: 10.1111/bcp.15346] [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: 11/12/2021] [Revised: 03/27/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022] Open
Abstract
AIMS Antithrombotic management initiatives could prevent inappropriate prescribing and improve patient outcomes especially in patients on combined antithrombotic therapy. To investigate this, a multidisciplinary antithrombotic stewardship program (ASP) was implemented in our hospital. The primary aim of this study was to determine the efficacy of this ASP by assessing the number of patients on combined antithrombotic therapy for whom one or more interventions were needed. METHODS A prospective cohort study in a large teaching hospital was conducted. Hospitalized patients were included who received combined antithrombotic therapy in which an oral anticoagulant was combined with one (double therapy) or two (triple therapy) platelet aggregation inhibitors. The ASP proactively evaluated the appropriateness of this combined antithrombotic therapy. If needed, ASP improved the concerned therapy. Each improvement measurement recommended by the ASP was counted as one intervention. RESULTS A total of 460 patients were included over a period of 12 months. 251 (54.6%) patients required at least one intervention from the ASP. The most common interventions were: 1) to define and document the maximum duration of the combined antithrombotic therapy needed instead of lifetime use of the combination (65.5%), 2) to discontinue antithrombotic therapy as the proper indication was lacking (19.4%), and 3) to adjust the dosage (8.1%). CONCLUSION An intervention was needed in more than half of the patients on combined antithrombotic therapy. Implementation of an dedicated ASP evaluating combined antithrombotic therapy improves the use and safety of antithrombotic medication.
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Affiliation(s)
| | | | - Wim Stooker
- Department of Cardiothoracic Surgery, Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | - Sanne Wissen
- Department of Internal Medicine, OLVG, Amsterdam, The Netherlands
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12
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Khalil V. Evaluation of oral anticoagulant prescribing patterns and associated hospital acquired complications – a single centre Australian study. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Viviane Khalil
- Senior Pharmacist Peninsula Health Pharmacy Department Frankston Australia
- Assistant Deputy Director of Pharmacy Pharmacy Department Monash Health Clayton Australia
- Lecturer Monash University Melbourne Clayton Australia
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13
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Lin KJ, Schneeweiss S, Pawar A, Singer DE, Liu J, Gagne JJ. Using a Simple Prescription Gap to Determine Warfarin Discontinuation Can Lead to Substantial Misclassification. Thromb Haemost 2022; 122:386-393. [PMID: 33984866 DOI: 10.1055/a-1508-8187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Warfarin remains widely used and a key comparator in studies of other direct oral anticoagulants. As longer-than-needed warfarin prescriptions are often provided to allow for dosing adjustments according to international normalized ratios (INRs), the common practice of using a short allowable gap between dispensings to define warfarin discontinuation may lead to substantial misclassification of warfarin exposure. We aimed to quantify such misclassification and determine the optimal algorithm to define warfarin discontinuation. METHODS We linked Medicare claims data from 2007 to 2014 with a multicenter electronic health records system. The study cohort comprised patients ≥65 years with atrial fibrillation and venous thromboembolism initiating warfarin. We compared results when defining warfarin discontinuation by (1) different gaps (3, 7, 14, 30, and 60 days) between dispensings and (2) having a gap ≤60 days or bridging larger gaps if there was INR ordering at least every 42 days (60_INR). Discontinuation was considered misclassified if there was an INR ≥2 within 7 days after the discontinuation date. RESULTS Among 3,229 patients, a shorter gap resulted in a shorter mean follow-up time (82, 95, 117, 159, 196, and 259 days for gaps of 3, 7, 14, 30, 60, and 60_INR, respectively; p < 0.001). Incorporating INR (60_INR) can reduce misclassification of warfarin discontinuation from 68 to 4% (p < 0.001). The on-treatment risk estimation of clinical endpoints varied significantly by discontinuation definitions. CONCLUSION Using a short gap between warfarin dispensings to define discontinuation may lead to substantial misclassification, which can be improved by incorporating intervening INR codes.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Daniel E Singer
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
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14
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Al Rowily A, Jalal Z, Price MJ, Abutaleb MH, Almodiaemgh H, Al Ammari M, Paudyal V. Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis. Eur J Clin Pharmacol 2021; 78:623-645. [PMID: 34935068 PMCID: PMC8926953 DOI: 10.1007/s00228-021-03212-y] [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: 03/04/2021] [Accepted: 08/28/2021] [Indexed: 10/30/2022]
Abstract
PURPOSE This study aimed to estimate the prevalence, contributory factors, and severity of medication errors associated with direct acting oral anticoagulants (DOACs). METHODS A systematic review and meta-analysis were undertaken by searching 11 databases including Medline, Embase, and CINHAL between January 2008 and September 2020. The pooled prevalence of errors and predictive intervals were estimated using random-effects models using Stata software. Data related to error causation were synthesised according to Reason's accident causation model. RESULTS From the 5205 titles screened, 32 studies were included which were mostly based in hospitals and included DOAC treatment for thromboembolism and atrial fibrillation. The proportion of study population who experienced either prescription, administration, or dispensing error ranged from 5.3 to 37.3%. The pooled percentage of patients experiencing prescribing error was 20% (95% CI 15-25%; I2 = 96%; 95% PrI 4-43%). Prescribing error constituted the majority of all error types with a pooled estimate of 78% (95%CI 73-82%; I2 = 0) of all errors. The common reported causes were active failures including wrong drug, and dose for the indication. Mistakes such as non-consideration of renal function, and error-provoking conditions such as lack of knowledge were common contributing factors. Adverse events such as potentially fatal intracranial haemorrhage or patient deaths were linked to the errors but causality assessments were often missing. CONCLUSIONS Despite their favourable safety profile, DOAC medication errors are common. There is a need to promote multidisciplinary working, guideline-adherence, training, and education of healthcare professionals, and the use of theory-based and technology-facilitated interventions to minimise errors and maximise the benefits of DOACs usage in all settings. PROTOCOL A protocol developed as per PRISMA-P guideline is registered under PROSPERO ID = CRD42019122996.
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Affiliation(s)
- Abdulrhman Al Rowily
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK.,Pharmaceutical Care Department, King Fahad Military Medical Complex (KFMMC), Medical Department, Ministry of Defence, Dhahran, Saudi Arabia
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mohammed H Abutaleb
- Pharmaceutical Care Department, King Fahad Central Hospital, Jazan Health Affairs, Ministry of Health, Jazan, Saudi Arabia
| | - Hind Almodiaemgh
- Pharmaceutical Care Department, King Abdulaziz Medical City, King Abdullah International Medical Research Center/King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Al Ammari
- Pharmaceutical Care Department, King Abdulaziz Medical City, King Abdullah International Medical Research Center/King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK.
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15
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Aguilar F, Lo KB, Quintero EE, Torres RJ, Hung WA, Albano JC, Alviz I, Rodriguez C, Garcia MJ, Romero J, Slipczuk L. Off-label direct oral anticoagulants dosing in atrial fibrillation and venous thromboembolism is associated with higher mortality. Expert Rev Cardiovasc Ther 2021; 19:1119-1126. [PMID: 34879208 DOI: 10.1080/14779072.2021.2013816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) off-label use data is lacking. Our study aimed to assess the clinical outcomes in a racially mixed population treated for atrial fibrillation (AF) and venous thromboembolism (VTE). METHODS We retrospectively evaluated six months of DOAC prescriptions for AF or VTE treatment. Prescriptions were classified as off-label or appropriate following FDA labeling. The off-label group was sub-classified as under or overdosing. RESULTS Of the 1,087 DOAC prescriptions, 67% were for AF. African Americans and Caucasians were equally represented. There were 171 (16%) inappropriate prescriptions, with 106 (62%), being underdosed. The off-label group had a higher 30-day readmissions risk (OR = 1.69, 95% CI:1.11-2.54, p = 0.012) and 1-year all-cause mortality (OR = 1.90, 95% CI:1.02-3.37, p = 0.032). There was no difference in major bleeding (OR = 1.27, 95% CI:0.63-2.37, p = 0.480) or new thromboembolism (OR = 1.27, 95% CI:0.73-2.13, p = 0.369) between the groups. Underdosing carried a higher risk of new thromboembolism (OR = 3.15, 95% CI:1.09-9.15, p = 0.024). CONCLUSIONS One in every six patients received off-label DOACs dosing. Off-label use had increased 30-day readmissions and 1-year all-cause mortality. Underdosing was associated with a higher risk of new thromboembolism.
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Affiliation(s)
- Francisco Aguilar
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Kevin B Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | | | - Ricardo J Torres
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Wikien A Hung
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Jeri C Albano
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Isabella Alviz
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Carlos Rodriguez
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Mario J Garcia
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Jorge Romero
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
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16
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Qian Y, Zhang J, Li J, Weng Z. A retrospective study on the evaluation of the appropriateness of oral anticoagulant therapy for patients with atrial fibrillation. PLoS One 2021; 16:e0259199. [PMID: 34762667 PMCID: PMC8584758 DOI: 10.1371/journal.pone.0259199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The incidence of atrial fibrillation (AF) is increasing, and effective anticoagulation therapy can prevent adverse events. Selecting the appropriate OAC based on patient characteristics has become a challenge. Interventions are going to be a potential area of focus. OBJECTIVES To explore the discrepancies between clinician prescriptions and recommended guidelines of oral anticoagulants (OACs) for patients with atrial fibrillation (AF), and to provide direction for improving anticoagulation strategies for treating patients with AF. MATERIALS AND METHODS Data were collected from the electronic medical record system of Fuwai Yunnan Cardiovascular Hospital between July 2019 and January 2020. The suitability of prescribed OACs for patients with AF was assessed according to the Rules for Avoiding Prescription Inappropriateness, the prescribed medicine label, and any relevant antithrombotic guidelines for treating patients with AF. RESULTS A total of 460 patients met the inclusion criteria. Of these, 53.7% received an appropriate prescription and 46.3% received an inappropriate prescription. Of the patients who received inappropriate prescriptions, 15.4% were prescribed without the presenting appropriate indicators, 1.3% were prescribed inappropriate drug selection, and 29.6% were prescribed inappropriate drug doses. For patients prescribed without providing appropriate indicators, 2.2% had no indication for medication and 13.3% had an indication for medication, but not a specific OAC. For patients with inappropriate drug selection, 1, 5 patients were on rivaroxaban, dabigatran respectively. The distribution of NOAC doses was as follows: dabigatran standard dose (45.2%), the low dose (54.8%). Rivaroxaban standard dose (58.9%), low dose (36.8%), high dose (4.3%). A total of 44 patients (9.6%) experienced bleeding events, 12 patients (2.6%) experienced embolic events, and 7 patients experienced other adverse events after dosing. CONCLUSIONS In clinical practice, it is common for patients with AF to receive inappropriate prescriptions of OACs. Therefore there is a need to enhance anticoagulation management in patients with AF to improve the appropriate use of OACs.
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Affiliation(s)
- Yiyi Qian
- Dept. of Pharmacy, Fuwai Yunnan Cardiovascular Hospital, Kunming, Yunnan, China
- * E-mail: (ZW); (YQ)
| | - Jiajun Zhang
- School of Pharmaceutical Science, Yunnan Medical Health College, Kunming, Yunnan, China
| | - Jiangya Li
- School of Pharmaceutical Science, Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, Yunnan, China
| | - Zhiying Weng
- School of Pharmaceutical Science, Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, Yunnan, China
- * E-mail: (ZW); (YQ)
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17
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Willeford A, Leiman V, Noel ZR. Impact of a
pharmacist‐to‐dose
direct oral anticoagulant protocol on medication errors at an academic medical center. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Andrew Willeford
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
| | - Victoria Leiman
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
| | - Zachary R. Noel
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
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18
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Capiau A, Mehuys E, Dhondt E, De Backer T, Boussery K. Physicians' and pharmacists' views and experiences regarding use of direct oral anticoagulants in clinical practice. Br J Clin Pharmacol 2021; 88:1856-1865. [PMID: 34625983 DOI: 10.1111/bcp.15106] [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: 04/25/2021] [Revised: 09/16/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Direct oral anticoagulants (DOACs) are increasingly used compared to vitamin K antagonists (VKAs). Guidelines advocate a structured multidisciplinary approach in the management of patients treated with DOACs. The aim of this study was to assess the views and experiences of physicians and pharmacists regarding DOAC use in clinical practice. METHODS An online questionnaire was sent to both primary (general practitioners [GPs], community pharmacists) and secondary healthcare professionals (cardiologists, residents in internal medicine and hospital pharmacists) between March and July 2020. The questionnaire covered four topics: (i) current practice, (ii) prescribing behaviour (only for physicians), (iii) self-perceived knowledge about DOACs and (iv) views and opinions about DOACs versus VKAs. RESULTS In total, 110 physicians and 111 pharmacists completed the survey. Healthcare professionals in secondary care had more experience with DOACs and felt more confident with higher self-perceived knowledge about DOACs compared to their colleagues in primary care. Healthcare professionals' self-perceived knowledge was more or less complementary, for example physicians felt less confident in managing drug-drug interactions (DDIs) where pharmacists reported being more confident in this topic. Physicians reported uncertainties on the potential impact of risk factors - such as older age, lower body weight and DDIs - on appropriate DOAC dosing. CONCLUSION Complementarity in physicians' and pharmacists' self-perceived knowledge levels of DOACs may facilitate and necessitate future multidisciplinary collaboration initiatives for the management and follow-up of DOAC patients.
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Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Eline Dhondt
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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19
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Erküner Ö, van Eck M, Xhaet O, Verheij H, Neefs J, Duygun A, Nijmeijer R, Saïd SAM, Uiterwaal H, Hagens V, Bhagwandien R, Szili-Torok T, Bijsterveld N, Tjeerdsma G, Vijgen J, Friart A, Hoffer E, Evrard P, Srynger M, Meeder J, de Groot JR, van Opstal J, Gevers R, Lip GYH, Boriani G, Crijns HJGM, Luermans JGLM, Mairesse GH. Contemporary management of patients with atrial fibrillation in the Netherlands and Belgium: a report from the EORP-AF long-term general registry. Neth Heart J 2021; 29:584-594. [PMID: 34524620 PMCID: PMC8556427 DOI: 10.1007/s12471-021-01634-y] [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] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. METHODS We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1‑year follow-up data were gathered. RESULTS At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). CONCLUSIONS Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.
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Affiliation(s)
- Ö Erküner
- Department of Cardiology, Maastricht University Medical Center + (MUMC+), Maastricht, The Netherlands. .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - M van Eck
- Department of Cardiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - O Xhaet
- Department of Cardiology, CHU Namur, Yvoir, Belgium
| | - H Verheij
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J Neefs
- Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - A Duygun
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | - R Nijmeijer
- Department of Cardiology, Tjongerschans Hospital Heerenveen, Heerenveen, The Netherlands
| | - S A M Saïd
- Department of Cardiology, Ziekenhuis Groep Twente, Hengelo, The Netherlands
| | - H Uiterwaal
- Department of Cardiology, Flevo Hospital, Almere, The Netherlands
| | - V Hagens
- Department of Cardiology, Ommelander Hospital Group, Delfzijl, The Netherlands
| | - R Bhagwandien
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - T Szili-Torok
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - N Bijsterveld
- Department of Cardiology, Flevo Hospital, Almere, The Netherlands
| | - G Tjeerdsma
- Department of Cardiology, Tjongerschans Hospital Heerenveen, Heerenveen, The Netherlands
| | - J Vijgen
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - A Friart
- Department of Cardiology, CHU Tivoli, La Louvière, Belgium
| | - E Hoffer
- Department of Cardiology, CHR Citadelle, Liège, Belgium
| | - P Evrard
- Department of Cardiology, CHC St Joseph, Liège, Belgium
| | - M Srynger
- Department of Cardiology, CHU Liège, Liège, Belgium
| | - J Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | - J R de Groot
- Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - J van Opstal
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R Gevers
- Department of Cardiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - G Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - G Boriani
- Modena University Hospital, Department of Cardiology, University of Modena and Reggio Emilia, Modena, Italy
| | - H J G M Crijns
- Department of Cardiology, Maastricht University Medical Center + (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J G L M Luermans
- Department of Cardiology, Maastricht University Medical Center + (MUMC+), Maastricht, The Netherlands
| | - G H Mairesse
- Arlon and Clinique Ste Thérèse, Department of Cardiology, Cliniques du Sud-Luxembourg, Bastogne, Belgium
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20
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Moudallel S, Cornu P, Dupont A, Steurbaut S. Determinants for under- and overdosing of direct oral anticoagulants and physicians' implementation of clinical pharmacists' recommendations. Br J Clin Pharmacol 2021; 88:753-763. [PMID: 34331720 DOI: 10.1111/bcp.15017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/07/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS To analyse the appropriateness of direct oral anticoagulant (DOAC) dosing and determinants for under-and overdosing as well as acceptance and implementation rates of pharmacists' interventions. METHODS Cross-sectional study in a tertiary hospital in hospitalized patients with atrial fibrillation on DOACs in 2019 (n = 1688). Primary outcome was the proportion of patients with inappropriate DOAC prescribing with identification of determinants for under-and overdosing. Secondary outcomes included acceptance and implementation rates of pharmacists' recommendations and determination of reasons for nonacceptance/nonimplementation. RESULTS Inappropriate prescribing was observed in 16.9% of patients (n = 286) with underdosing (9.7%) being more prevalent than overdosing (6.9%). For all DOACs considered together, body weight<60 kg (odds ratio [OR] 0.46 [0.27-0.77]), edoxaban use (OR 0.42 [0.24-0.74]), undergoing surgery (OR 0.57 [0.37-0.87]) and being DOAC naïve (OR 0.45 [0.29-0.71]) were associated with significantly lower odds of underdosing. Bleeding history (OR 1.86 [1.24-2.80]) and narcotic use (OR 1.67 [1.13-2.46]) were associated with significantly higher odds for underdosing. Determinants with a significantly higher odds of overdosing were renal impairment (OR 11.29 [6.23-20.45]) and body weight<60 kg (OR 2.34 [1.42-3.85]), whereas dabigatran use (OR 0.24 [0.08-0.71]) and apixaban (OR 0.18 [0.10-0.32]) were associated with a significantly lower odds of overdosing compared to rivaroxaban. Physicians accepted the pharmacists' advice in 179 cases (79.2%) consisting of 92 (51.4%) recommendations for underdosing, 82 (45.8%) for overdosing and 5 (2.8%) for contraindications. CONCLUSION Inappropriate DOAC prescribing remains common, although there is a slight improvement compared to our study of 2016. Clinical services led by pharmacists help physicians to reduce the number of inadequate prescriptions for high-risk medications such as DOACs.
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Affiliation(s)
- Souad Moudallel
- Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Pieter Cornu
- Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Alain Dupont
- Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Stephane Steurbaut
- Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
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21
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Li RJ, Caughey GE, Shakib S. Appropriateness of inpatient dosing of direct oral anticoagulants for atrial fibrillation. J Thromb Thrombolysis 2021; 53:425-435. [PMID: 34302286 DOI: 10.1007/s11239-021-02528-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 12/22/2022]
Abstract
Direct oral anticoagulant (DOAC) use for stroke prevention in atrial fibrillation (AF) has dose reduction criteria including age, weight, serum creatinine, and creatinine clearance. There is a paucity of data for rates of inappropriate inpatient DOAC dosing in Australia. The objective was to determine the rates of inappropriate inpatient DOAC dosing in AF and identifying its associated underlying factors. We conducted a retrospective cross-sectional study from December 2013 to November 2019 across six South Australian public hospitals utilising a centralised electronic health record. Multivariate analysis was used to identify factors associated with underdosing of patients prescribed apixaban. Of 1882 inpatients, 544 (28.9 %) were inappropriately dosed. Underdosing was the most common form of inappropriate dosing with rates of 22.9 % (n = 295), 7.1 % (n = 7), and 25.1 % (n = 124) for apixaban, dabigatran, and rivaroxaban, respectively. Independent factors predictive of apixaban underdosing included higher age (adjusted odds ratio (aOR) 1.63 [95 % Confidence Interval (CI): 1.47-1.81]), higher serum creatinine (aOR 1.13 [95 % CI: 1.08-1.19]), higher total number of drugs on discharge (aOR 1.08 [95 % CI: 1.04-1.11]), and being already prescribed a DOAC on admission (aOR 1.63 [95 % CI: 1.12-2.38]). Nearly one quarter of all apixaban prescribing was inappropriately underdosed. Older patients with multimorbidity, frailty and polypharmacy present a challenge for clinicians in balancing risks of thromboembolism and bleeding. It is likely prescribers are more conservative in their apixaban dosing in this population. Clinicians should consider alternative drug regimens to avoid DOAC use at inappropriate doses at unknown safety and efficacy.
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Affiliation(s)
- Ray J Li
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, 5000, Australia.
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, 5000, Adelaide, Australia.
| | - Gillian E Caughey
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, 5000, Australia
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, 5000, Adelaide, Australia
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, 5000, Australia
- Division of Health Sciences, University of South Australia, 5000, Adelaide, Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, 5000, Australia
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, 5000, Adelaide, Australia
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22
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de Vries TAC, Hemels MEW, Cools F, Crijns HJGM, Yperzeele L, Vanacker P, Blankoff I, Lancellotti P, Mairesse GH, de Veer A, Casado Arroyo R, Catez E, de Pauw M, Vanassche T, de Asmundis C, Kirchhof P, De Caterina R, de Groot JR. Characteristics of patients with atrial fibrillation prescribed edoxaban in Belgium and The Netherlands: insights from the ETNA-AF-Europe study. Acta Cardiol 2021; 76:431-439. [PMID: 33406996 DOI: 10.1080/00015385.2020.1746095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Studies on the use of non-vitamin K antagonist oral anticoagulants in unselected patients with atrial fibrillation (AF) show that clinical characteristics and dosing practices differ per region, but lack data on edoxaban. METHODS With data from Edoxaban Treatment in routiNe clinical prActice for patients with AF in Europe (ETNA-AF-Europe), a large prospective observational study, we compared clinical characteristics (including the dose reduction criteria for edoxaban: creatinine clearance 15-50 mL/min, weight ≤60 kg, and/or use of strong p-glycoprotein inhibitors) of patients from Belgium and the Netherlands (BeNe) with those from other European countries (OEC). RESULTS Of all 13,639 patients in ETNA-AF-Europe, 2579 were from BeNe. BeNe patients were younger than OEC patients (mean age: 72.3 vs 73.9 years), and had lower CHA2DS2-VASc (mean: 2.8 vs 3.2) and HAS-BLED scores (mean: 2.4 vs 2.6). Patients from BeNe less often had hypertension (61.6% vs 80.4%), and/or diabetes mellitus (17.3% vs 23.1%) than patients from OEC. Moreover, relatively fewer patients in BeNe were prescribed the reduced dose of 30 mg edoxaban (14.8%) than in OEC (25.4%). Overall, edoxaban was dosed according to label in 83.1% of patients. Yet, 30 mg edoxaban was prescribed in the absence of any dose reduction criteria in 36.9% of 30 mg users (5.5% of all patients) in BeNe compared with 35.5% (9.0% of all patients) in OEC. CONCLUSION There were several notable differences between BeNe and OEC regarding clinical characteristics and dosing practices in patients prescribed edoxaban, which are relevant for the local implementation of dose evaluation and optimisation. TRIAL REGISTRATION NCT02944019; Date of registration: October 24, 2016.
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Affiliation(s)
- Tim A C de Vries
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Amsterdam Medical Centres/University of Amsterdam, Amsterdam, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frank Cools
- Department of Cardiology, General Hospital Klinieken Noord-Antwerpen, Brasschaat, Belgium
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Laetitia Yperzeele
- Department of Neurosurgery, University Hospital Antwerp, Antwerp, Belgium
| | - Peter Vanacker
- Department of Neurosurgery, University Hospital Antwerp, Antwerp, Belgium
- Department of Neurology, General Hospital Groeninge, Kortrijk, Belgium
| | - Ivan Blankoff
- Department of Cardiology, Civil Hospital Marie Curie, Charleroi, Belgium
| | | | | | - Anne de Veer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Emmanuel Catez
- Department of Cardiology, Brugmann University Hospital, Brussels, Belgium
| | - Michel de Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Thomas Vanassche
- Department of Cardiology, Leuven University Hospital, Leuven, Belgium
| | - Carlo de Asmundis
- Department of Cardiology, University Hospital Brussels, Brussels, Belgium
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- The Atrial Fibrillation NETwork (AFNET), Münster, Germany
| | | | - Joris R de Groot
- Department of Cardiology, Amsterdam Medical Centres/University of Amsterdam, Amsterdam, The Netherlands
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23
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Raccah PharmD PhD BH, Erlichman Y, Pollak A, Matok I, Muszkat M. Prescribing Errors With Direct Oral Anticoagulants and Their Impact on the Risk of Bleeding in Patients With Atrial Fibrillation. J Cardiovasc Pharmacol Ther 2021; 26:601-610. [PMID: 34060932 PMCID: PMC8547237 DOI: 10.1177/10742484211019657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Anticoagulants are associated with significant harm when used in error, but there are limited data on potential harm of inappropriate treatment with direct oral anticoagulants (DOACs). We conducted a matched case-control study among atrial fibrillation (AF) patients admitting the hospital with a chronic treatment with DOACs, in order to assess factors associated with the risk of major bleeding. METHODS Patient data were documented using hospital's computerized provider order entry system. Patients identified with major bleeding were defined as cases and were matched with controls based on the duration of treatment with DOACs and number of chronic medications. Appropriateness of prescribing was assessed based on the relevant clinical guidelines. Conditional logistic regression was used to evaluate the potential impact of safety-relevant prescribing errors with DOACs on major bleeding. RESULTS A total number of 509 eligible admissions were detected during the study period, including 64 cases of major bleeding and 445 controls. The prevalence of prescribing errors with DOACs was 33%. Most prevalent prescribing errors with DOACs were "drug dose too low" (16%) and "non-recommended combination of drugs" (11%). Safety-relevant prescribing errors with DOACs were associated with major bleeding [adjusted odds ratio (aOR) 2.17, 95% confidence interval (CI) 1.14-4.12]. CONCLUSION Prescribers should be aware of the potential negative impact of prescribing errors with DOACs and understand the importance of proper prescribing and regular follow-up.
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Affiliation(s)
- Bruria Hirsh Raccah PharmD PhD
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Cardiology, Hadassah University Hospital, Jerusalem, Israel
| | - Yevgeni Erlichman
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Arthur Pollak
- Department of Cardiology, Hadassah University Hospital, Jerusalem, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah University Hospital, Mt. Scopus, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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24
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Trends and patterns in EU(7)-PIM prescribing to elderly patients in Germany. Eur J Clin Pharmacol 2021; 77:1553-1561. [PMID: 33938975 DOI: 10.1007/s00228-021-03148-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/20/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this study was to explore patterns and long-term development in prescribing potentially inappropriate medication (PIM) according to the EU(7)-PIM list to elderly patients in Germany. METHODS We analysed anonymized German claims data. The study population comprised 6.0 million insured individuals at least 65 years old, including all their prescriptions reimbursed in 2019. For the analysis of long-term development, we used data for the years 2009-2019. Factors associated with PIM prescribing were considered from two perspectives: patient-oriented analysis was performed with logistic regression and prescriber-oriented analysis was performed with multiple linear regression. RESULTS EU(7)-PIM prevalence was reduced from 56.9% in 2009 to 45.1% in 2019. Average annual volume (DDDs/insured) decreased from 145 in 2009 to 121 in 2019. These figures are substantially greater than those for the older PRISCUS list. The majority of investigated ATC level 2 groups with the highest EU(7)-PIM DDD volume exhibited substantial decreases; moderate increases were found for antihypertensive and urological drugs. Antithrombotics increased strongly with the introduction of direct oral anticoagulants. The most prevalent EU(7)-PIM medication was diclofenac; however, in the age group 85+ years, apixaban was twice as prevalent as diclofenac. Polypharmacy, female sex, age < 90 years, need for nursing care and living in Eastern regions were identified as risk factors. Prescriber specialty was the most marked factor in the prescriber-oriented analysis. CONCLUSION Although the use of EU(7)-PIMs has been declining, regional differences indicate considerable room for improvement. The comparison with PRISCUS highlights the necessity of regular updates of PIM lists.
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25
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Katel A, Aryal M, Neupane A, Gosain R, Pathak R, Bhandari Y, Kouides P. Efficacy and Safety of Direct Oral Anticoagulants in Venous Thromboembolism Compared to Traditional Anticoagulants in Morbidly Obese Patients: A Systematic Review and Meta-Analysis. Cureus 2021; 13:e14572. [PMID: 34026385 PMCID: PMC8135070 DOI: 10.7759/cureus.14572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Randomized clinical trials comparing the efficacy and safety of direct oral anticoagulants (DOAC) with vitamin K antagonist (VKA) or low molecular weight heparin (LMWH) for the treatment of venous thromboembolism (VTE) generally exclude patients who are morbidly obese (body mass index ≥ 40 kg/m2 or weight ≥ 120 kg). Recently, smaller studies have compared DOACs with warfarin or low molecular weight heparin (LMWH) in morbidly obese patients with VTE. We aim to systematically review and do a meta-analysis of the studies that directly compared DOACs with VKAs or LMWH in morbidly obese patients. Methods Studies comparing DOAC with warfarin or LMWH in patients with acute VTE were identified through electronic literature searches of MEDLINE, EMBASE, Scopus, clinicaltrials.gov, and the Cochrane Library up to March 2020. The primary efficacy outcome was recurrent VTE and the primary safety outcome was major bleeding as defined by the International Society on Thrombosis and Haemostasis (ISTH) guidelines. Study-specific odds ratios (OR) were calculated and combined using a random-effects model meta-analysis. Result Five studies were identified. Recurrent VTE occurred in 95 of 3207 (2.96%) patients in the DOAC group and 81 of 3181 (2.54%) patients in the VKA and LMWH group (OR: 1.17; 95% CI 0.87 to 1.59, p=.30). Major bleeding occurred in 63 of 3316 (1.89%) patients in the DOAC group, and 83 of 3259(2.54%) patients in the VKA or LMWH group (OR: 0.74; 95% CI: 0.53 to 1.03, p=.08). Sensitivity analysis comparing factor Xa inhibitors apixaban and rivaroxaban to warfarin also yielded consistent findings. Conclusion DOACs showed similar efficacy and safety in the prevention of recurrent VTE risk and major bleeding events in morbidly obese patients when compared to warfarin/LMWH. Our study underscores the need for further modifications of therapy to reduce the high VTE recurrence rate irrespective of whether the patient is on a DOAC or VKA. This might be possible through a very large multi-institutional randomized clinical trial.
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Affiliation(s)
- Anjan Katel
- Department of Internal Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, NPL
| | - Madan Aryal
- Department of Medicine, Enloe Medical Center, Enloe Regional Cancer Center, California, USA
| | - Arun Neupane
- Department of Nursing and Critical Care, Alta Bates Summit Medical Center, California, USA
| | - Rohit Gosain
- Department of Medicine, Roswell Park Comprehensive Cancer Institute, New York, USA
| | - Ranjan Pathak
- Department of Oncology, Nepal Medical College Pvt. Ltd., Kathmandu, NPL
| | | | - Peter Kouides
- Department of Hematology/Oncology, Rochester General Hospital, Rochester, USA
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26
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Fernández MS, Marín F, Rafols C, Arribas F, Barrios V, Cosín-Sales J, Sánchez MA. Thromboembolic and bleeding events with rivaroxaban in clinical practice in Spain: impact of inappropriate doses (the EMIR study). J Comp Eff Res 2021; 10:583-593. [PMID: 33787316 DOI: 10.2217/cer-2020-0286] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aim: To analyze the frequency and variables related to inappropriate rivaroxaban dosage in clinical practice and its impact on outcomes after 2 years. Materials & methods: Postauthorization, observational, multicenter study, in which atrial fibrillation patients, treated with rivaroxaban ≥6 months were included. Results: A total of 1421 patients (74.2 ± 9.7 years, CHA2DS2-VASc 3.5 ± 1.6) were included. Overall, 22.9% received rivaroxaban 15 mg. The proper dose of rivaroxaban was taken by 83.3% (9.7% underdosed, 7.0% overdosed). Older age and renal insufficiency were associated with inadequate rivaroxaban dosage. There was a trend toward higher all-cause mortality among underdosed patients (adjusted hazard ratio 1.39; 95% CI 0.75-2.58), and more bleedings in overdosed patients (2.29 vs 0.80 events/100 patient-years; p = 0.14). Conclusion: In clinical practice, rivaroxaban is properly dosed in most patients.
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Affiliation(s)
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Carles Rafols
- Department of Medical Affairs, Bayer Hispania, Barcelona, Spain
| | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre; Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM); Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12); CIBERCV, Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, Hospital Ramón y Cajal; Alcalá University, Madrid, Spain
| | - Juan Cosín-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Universitario Reina Sofia, IMIBIC, University of Córdoba, Córdoba, Spain
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27
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Ting C, Rhoten M, Dempsey J, Nichols H, Fanikos J, Ruff CT. Evaluation of Direct Oral Anticoagulant Prescribing in Patients With Moderate to Severe Renal Impairment. Clin Appl Thromb Hemost 2021; 27:1076029620987900. [PMID: 33517715 PMCID: PMC7863154 DOI: 10.1177/1076029620987900] [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] [Indexed: 01/23/2023] Open
Abstract
Patients with renal impairment require dose adjustments for direct oral anticoagulants (DOACs), though there is uncertainty regarding their use in severe chronic kidney disease. Inappropriately dosed DOACs may increase risk of ischemic events when under-dosed, or risk of bleeding when over-dosed. The purpose of this study was to describe DOAC selection, dosing strategies, and associated clinical outcomes in patients with moderate to severe renal impairment at our institution. This was a single-center retrospective analysis of adult outpatients with moderate to severe renal impairment (estimated creatinine clearance <50 mL/min, including need for hemodialysis) who were prescribed a DOAC by a cardiologist between June 1, 2015 and December 1, 2018. Outcomes evaluated included the percentage of patients who received appropriate and inappropriate DOAC dosing, prescriber reasons for inappropriate DOAC dosing if documented, and incidence of thrombotic and bleeding events. A total of 207 patients were included. Overall, 61 (29.5%) patients received inappropriate dosing, with 43 (70.5%) being under-dosed and 18 (29.5%) being over-dosed as compared to FDA-labeled dosing recommendations for atrial fibrillation or venous thromboembolism (VTE). By a median follow-up duration of 20 months, stroke occurred in 6 (3.3%) patients receiving DOACs for atrial fibrillation, and VTE occurred in 1 (4.3%) patient receiving a DOAC for VTE. International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding occurred in 25 (12.1%) patients. Direct oral anticoagulants were frequently prescribed at off-label doses in patients with moderate to severe renal impairment, with a tendency toward under-dosing.
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Affiliation(s)
- Clara Ting
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA, USA
- Clara Ting, Department of Pharmacy, Brigham and Women’s Hospital, Pharmacy Administration; L2, 75 Francis Street, Boston, MA 02215, USA.
| | - Megan Rhoten
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jillian Dempsey
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA, USA
| | - Hunter Nichols
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA, USA
| | - Christian T. Ruff
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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28
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Gross PL, Chan NC. Thromboembolism in Older Adults. Front Med (Lausanne) 2021; 7:470016. [PMID: 33585495 PMCID: PMC7873530 DOI: 10.3389/fmed.2020.470016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 12/21/2020] [Indexed: 01/01/2023] Open
Abstract
Arterial and venous thromboembolism are both more common in older adults. The use of anticoagulants, the mainstay to prevent thromboembolism, requires consideration of the balance between risk and benefit. Such consideration is even more important in the very elderly in whom the risk of anticoagulant-related bleeding and thrombosis are higher. This review will focus on the challenges of implementing and managing anticoagulant therapy in older patients in an era when the options for anticoagulants include not only vitamin K antagonists (VKAs), but also direct-acting oral anticoagulants (DOACs).
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Affiliation(s)
- Peter L Gross
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Noel C Chan
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
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29
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de Vries TAC, Hemels MEW, Cools F, Crijns HJGM, Yperzeele L, Vanacker P, Blankoff I, Lancellotti P, Mairesse GH, de Veer A, Casado Arroyo R, Catez E, de Pauw M, Vanassche T, de Asmundis C, Kirchhof P, De Caterina R, de Groot JR. Characteristics of patients with atrial fibrillation prescribed edoxaban in Belgium and the Netherlands: insights from the ETNA-AF-Europe study. Neth Heart J 2021; 29:158-167. [PMID: 33411231 PMCID: PMC7904979 DOI: 10.1007/s12471-020-01518-7] [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] [Accepted: 10/21/2020] [Indexed: 11/09/2022] Open
Abstract
Background Studies on the use of non-vitamin K antagonist oral anticoagulants in unselected patients with atrial fibrillation (AF) show that clinical characteristics and dosing practices differ per region, but lack data on edoxaban. Methods With data from Edoxaban Treatment in routiNe clinical prActice for patients with AF in Europe (ETNA-AF-Europe), a large prospective observational study, we compared clinical characteristics (including the dose reduction criteria for edoxaban: creatinine clearance 15–50 ml/min, weight ≤60 kg, and/or use of strong p‑glycoprotein inhibitors) of patients from Belgium and the Netherlands (BeNe) with those from other European countries (OEC). Results Of all 13,639 patients in ETNA-AF-Europe, 2579 were from BeNe. BeNe patients were younger than OEC patients (mean age: 72.3 vs 73.9 years), and had lower CHA2DS2-VASc (mean: 2.8 vs 3.2) and HAS-BLED scores (mean: 2.4 vs 2.6). Patients from BeNe less often had hypertension (61.6% vs 80.4%), and/or diabetes mellitus (17.3% vs 23.1%) than patients from OEC. Moreover, relatively fewer patients in BeNe were prescribed the reduced dose of 30 mg edoxaban (14.8%) than in OEC (25.4%). Overall, edoxaban was dosed according to label in 83.1% of patients. Yet, 30 mg edoxaban was prescribed in the absence of any dose reduction criteria in 36.9% of 30 mg users (5.5% of all patients) in BeNe compared with 35.5% (9.0% of all patients) in OEC. Conclusion There were several notable differences between BeNe and OEC regarding clinical characteristics and dosing practices in patients prescribed edoxaban, which are relevant for the local implementation of dose evaluation and optimisation. Trial registration NCT02944019; Date of registration 24 October 2016 Electronic supplementary material The online version of this article (10.1007/s12471-020-01518-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- T A C de Vries
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands. .,Department of Cardiology, Amsterdam Medical Centres/University of Amsterdam, Amsterdam, The Netherlands.
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - F Cools
- Department of Cardiology, General Hospital Klinieken Noord-Antwerpen, Brasschaat, Belgium
| | - H J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - L Yperzeele
- Department of Neurosurgery, University Hospital Antwerp, Antwerp, Belgium
| | - P Vanacker
- Department of Neurosurgery, University Hospital Antwerp, Antwerp, Belgium.,Department of Neurology, General Hospital Groeninge, Kortrijk, Belgium
| | - I Blankoff
- Department of Cardiology, Civil Hospital Marie Curie, Charleroi, Belgium
| | - P Lancellotti
- Department of Cardiology, University Hospital of Liège, Liège, Belgium
| | - G H Mairesse
- Department of Cardiology, Cliniques du Sud-Luxembourg, Arlon, Belgium
| | - A de Veer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R Casado Arroyo
- Department of Cardiology, Hospital Erasme, Anderlecht, Belgium
| | - E Catez
- Department of Cardiology, Brugmann University Hospital, Brussels, Belgium
| | - M de Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - T Vanassche
- Department of Cardiology, Leuven University Hospital, Leuven, Belgium
| | - C de Asmundis
- Department of Cardiology, University Hospital Brussels, Brussels, Belgium
| | - P Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,The Atrial Fibrillation NETwork (AFNET), Münster, Germany
| | - R De Caterina
- Department of Cardiology, University of Pisa, Pisa, Italy
| | - J R de Groot
- Department of Cardiology, Amsterdam Medical Centres/University of Amsterdam, Amsterdam, The Netherlands
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Adverse outcomes associated with inappropriate direct oral anticoagulant starter pack prescription among patients with atrial fibrillation: a retrospective claims-based study. J Thromb Thrombolysis 2021; 51:1144-1149. [PMID: 33389520 DOI: 10.1007/s11239-020-02358-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
Direct oral anticoagulant (DOAC) starter packs are designed for unique treatment dosing for acute venous thromboembolism (VTE). Inappropriate use of 30-day DOAC starter packs in patients with atrial fibrillation (AF) may increase the risk for bleeding events given higher dosing in the first 1-3 weeks of treatment. A retrospective analysis of medical and outpatient pharmacy claims data from 2015 to 2018 in Optum's De-identified Clinformatics® Data Mart was performed. Patients greater than 18 years of age with AF and a new prescription of apixaban or rivaroxaban were included. Patients with an acute VTE were excluded. The main outcome of interest was adverse events (emergency department [ED] visits, hospitalizations, and deaths within 90 days after prescription fill date) associated with inappropriate DOAC starter pack prescription. A total of 90,950 DOAC-treated patients with AF were identified. The mean age was 74.5 years (SD 10.0) and 42,717 (47.0%) were female. Inappropriate starter packs were used by 117 (0.1%) patients, who were younger than non-starter pack patients (71.3 years vs. 74.5 years). Patients who received an inappropriate DOAC prescription were more likely to identify as Black (12.0% vs. 8.8%). Rates of ED visits, hospitalizations, and deaths overall were numerically lower in patients with starter pack compared to non-starter pack DOAC prescriptions. In contrast, rates of ED visits and hospitalizations related to significant bleeding were numerically higher in patients with starter pack compared to non-starter pack DOAC prescriptions. Among patients with AF but no VTE, those who received an inappropriate DOAC starter pack had numerically higher rates of severe bleeding leading to ED visits and hospitalizations compared to those prescribed an appropriate non-starter pack DOAC anticoagulant.
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Cohen AT, Hoffmann U, Hainaut P, Gaine S, Ay C, Coppens M, Schindewolf M, Jimenez D, Brüggenjürgen B, Levy P, Laeis P, Fronk EM, Zierhut W, Malzer T, Manu MC, Reimitz PE, Bramlage P, Agnelli G. ETNA VTE Europe: A contemporary snapshot of patients treated with edoxaban in clinical practice across eight European countries. Eur J Intern Med 2020; 82:48-55. [PMID: 32826158 DOI: 10.1016/j.ejim.2020.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Edoxaban has proven its efficacy and safety in the ENGAGE AF-TIMI 48 and HOKUSAI-VTE clinical trials. Clinical practice patients, however, may differ from those enolled in clinical trials. We aimed to compare patients from the HOKUSAI-VTE clinical trial with those treated in clinical practice. MATERIALS AND METHODS ETNA-VTE-Europe is a prospective, non-interventional post-authorisation safety study conducted in eight European countries. RESULTS A total of 2,879 patients presenting with acute symptomatic venous thromboembolism (VTE) were enrolled at 339 sites. Of the 2,680 patients with complete data, 23.6% reported prior VTE and 2.8% had a history of bleeding. Patients in ETNA-VTE were older (65vs.57 years), more likely to be female (46.5vs.39.8%) and had a higher prevalence of chronic venous insufficiency (11.1vs.1.6%) than those in the European cohort of the HOKUSAI-VTE trial (n=1,512). Bodyweight and creatinine clearance were substantially lower in clinical practice. Edoxaban dosing was adherent to label in 90% of patients, with higher (60 mg) and lower than recommended doses (30 mg) used in 6.6% and 3.3% of the patients, respectively. Heparin lead-in was used in 84.7% of the patients overall, and was more frequently used in patients with PE than patients with DVT only (91.3% vs. 80.1%; p<0.0001). CONCLUSIONS These data reinforce the largely appropriate use of edoxaban in routine clinical practice, where the study population differs from those in prior randomised controlled trials. CLINICALTRIALS. GOV IDENTIFIER NCT02943993.
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Affiliation(s)
- Alexander T Cohen
- Guy's and St Thomas' NHS Foundation Trust, King's College London, UK.
| | - Ulrich Hoffmann
- Division of Angiology, Medical Clinic IV, University Hospital, Ludwig-Maximilians-University, Munich, Germany.
| | - Philippe Hainaut
- Department of General Internal Medicine, Cliniques Universitaires Saint Luc, UCL, Bruxelles, Belgium.
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
| | - Marc Schindewolf
- Swiss Cardiovascular Center, Division of Vascular Medicine, University Hospital Bern, Switzerland.
| | - David Jimenez
- Respiratory Department, Ramón y Cajal Hospital, Madrid, Spain.
| | | | - Pierre Levy
- LEDa-LEGOS, Université Paris-Dauphine, PSL University, Paris, France.
| | - Petra Laeis
- Daiichi Sankyo Europe GmbH, Munich, Germany.
| | | | | | | | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Berlin, Germany.
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy.
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Gueta I, Schacham YN, Markovits N, Halkin H, Loebstein R. Uninterrupted direct oral anticoagulant treatment during acute illness: Impact on clinical outcomes. Thromb Res 2020; 196:457-462. [PMID: 33065411 DOI: 10.1016/j.thromres.2020.09.034] [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: 04/19/2020] [Revised: 09/08/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Uninterrupted drug therapy during acute illness is often associated with pharmacokinetic and pharmacodynamic variations. Among warfarin treated patients, these changes are reflected in the INR. However, in the case of direct oral anticoagulants (DOACs), given that routine laboratory monitoring is not recommended, these changes may result in unforeseen thromboembolic or bleeding events. OBJECTIVES To determine the rate of thromboembolic (TEE) and bleeding events associated with uninterrupted DOAC compared to warfarin treatment during acute illness. METHODS A retrospective cohort study of patients treated with DOACs or warfarin, both at steady state, who were hospitalized for acute illness. Primary outcome was any TEE or major bleeding requiring re-hospitalization within one month from discharge. Secondary outcome was a composite of major bleeding and clinically relevant non-major bleeding (CRNMB) events. RESULTS A total of 410 patients continued oral anticoagulant treatment during their hospitalization, of whom 191 (46.6%) were on DOACs and 219 (53.4%) on warfarin, with a total of 18 (4.4%) events. Rates of TEE and major bleeding events did not differ between DOACs and warfarin treated patients (0.9% vs. 0.5% and 0.5% vs. 1%, respectively). Similarly, rate of secondary outcome was comparable between DOACs (4.7%) and warfarin (2.7%, p = 0.29). Sub-analyses demonstrated significantly higher rates among rivaroxaban (10.4%) treated patients compared to warfarin (p = 0.03). CONCLUSION Uninterrupted treatment with DOACs during acute illness is not associated with increased risk for re-hospitalizations due to bleeding or thromboembolic events compared to warfarin. Our results suggest a higher bleeding rate among rivaroxaban treated patients at high bleeding risk.
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Affiliation(s)
- Itai Gueta
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Department of Medicine A, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yehoshua Nadav Schacham
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel
| | - Noa Markovits
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hillel Halkin
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Loebstein
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective. Heart Rhythm 2020; 17:1804-1832. [DOI: 10.1016/j.hrthm.2020.04.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
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Jakowenko N, Nguyen S, Ruegger M, Dinh A, Salazar E, Donahue KR. Apixaban and rivaroxaban anti-Xa level utilization and associated bleeding events within an academic health system. Thromb Res 2020; 196:276-282. [PMID: 32947066 PMCID: PMC7474843 DOI: 10.1016/j.thromres.2020.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/30/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022]
Abstract
Background Oral factor Xa inhibitors (FXaI) can be administered in fixed doses without the need for routine laboratory monitoring. Anti-Xa assays can estimate anticoagulant effect for specific FXaI's. The aim of this study was to characterize anti-Xa levels in patients taking apixaban or rivaroxaban with major bleeding events. Methods Apixaban and rivaroxaban anti-Xa assays ordered within our hospital system from May 2016 to September 2019 were evaluated. The primary outcome was major bleeding events defined by International Society of Thrombosis and Haemostasis criteria. Median anti-Xa levels for each FXaI were calculated for those with and without major bleeding, as well as those who did and did not receive reversal agents. Results A total of 606 anti-Xa levels were analyzed. There were 146 major bleeding events documented, with the most common site being intracranial (63%). Median anti-Xa levels in patients with and without major bleeding were similar, whereas those on apixaban therapy who received reversal agents typically had higher anti-Xa levels (73 ng/mL vs. 153 ng/mL, p = 0.0019). Factors significantly associated with increased odds of bleeding were an age > 80 years, inappropriately high dosing regimens, and modest anti-Xa levels (100–300 ng/mL) for rivaroxaban specifically. Conclusions Older age and inappropriately high dosing regimens were associated with major bleeding in patients taking apixaban and rivaroxaban. Further investigation into the utility of anti-Xa levels for FXaI is warranted. Quantification and assessment of anticoagulation can be accomplished with factor Xa inhibitor (FXaI) specific anti-Xa levels Elderly patients and those on inappropriately high dosing regimens may be at an elevated risk for major bleeding It is unclear if elevated anti-Xa levels confer a direct increased risk for bleeding in the absence of other factors Anti-Xa levels are useful for confirmed or suspected bleeding, clearance for parenteral anticoagulation, and prior to an emergent procedure
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Affiliation(s)
- Nicholas Jakowenko
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America.
| | - Steffany Nguyen
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Melanie Ruegger
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Ashley Dinh
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States of America
| | - Eric Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
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Bo M, Corsini A, Brunetti E, Isaia G, Gibello M, Ferri N, Poli D, Marchionni N, De Ferrari GM. Off-label use of reduced dose direct oral factor Xa inhibitors in subjects with atrial fibrillation: a review of clinical evidence. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:334-345. [PMID: 32853346 DOI: 10.1093/ehjcvp/pvaa103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/31/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
In real-world clinical practice, underdosing, i.e. off-label use of reduced doses (RDs), of oral factor Xa inhibitors (oFXaIs) is quite common in stroke prevention in non-valvular atrial fibrillation, possibly reflecting the hope to increase safety without reducing efficacy in selected patients. To assess whether this strategy is associated with some clinical benefit, we used a physician-centred approach to evaluate whether current evidence supports the hypothesis that a substantial proportion of underdosing may be voluntary rather than casual, whether and to what extent oFXaIs' dose rather than patients' characteristics are associated with bleeding events, and which are the safety and efficacy clinical implications of oFXaIs' underdosing. Our review found consistent evidence that underdosing is often an intentional strategy; however, available studies do not demonstrate a sizeable net clinical benefit of using off-label RD oFXaIs.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics, Department of Medical Sciences, Università di Torino, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126 Turin, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via Giuseppe Balzaretti 9, 20133 Milan, Italy.,IRCCS Multimedica Hospital, Via Gaudenzio Fantoli 16/15, 20138 Milan, Italy
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, Università di Torino, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126 Turin, Italy
| | - Gianluca Isaia
- Section of Geriatrics, Department of Medical Sciences, Università di Torino, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126 Turin, Italy
| | - Maddalena Gibello
- Section of Geriatrics, Department of Medical Sciences, Università di Torino, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126 Turin, Italy
| | - Nicola Ferri
- Department of Pharmaceutical and Pharmacological Sciences, Università degli Studi di Padova, Via Marzolo 5, 35131 Padua, Italy
| | - Daniela Poli
- Centro Trombosi, Cardiothoracovascular Department, A.O.U. Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Niccolò Marchionni
- Division of General Cardiology, Cardiothoracovascular Department, Department of Clinical and Experimental Medicine, A.O.U. Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, Università di Torino, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126 Turin, Italy
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Zhang ZX, van de Garde EMW, Söhne M, Harmsze AM, van den Broek MPH. Quality of clinical direct oral anticoagulant prescribing and identification of risk factors for inappropriate prescriptions. Br J Clin Pharmacol 2020; 86:1567-1574. [PMID: 32090369 PMCID: PMC7373716 DOI: 10.1111/bcp.14264] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/31/2020] [Accepted: 02/10/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS Even though the use of direct oral anticoagulants (DOACs) is safe based on clinical outcomes, drug safety also depends on appropriateness of drug prescription, which is challenging for DOACs since many patient factors need to be considered. The aim of this study was to assess the appropriateness of DOAC prescriptions and to identify risk factors of determinants for inappropriate DOAC prescriptions. METHODS A retrospective study in a nonuniversity teaching hospital was performed of hospitalized patients (≥18 years) who received an initial DOAC prescription between February and August 2018. Appropriateness of prescribing was evaluated on 8 criteria by using a modified version of the medication appropriateness index. RESULTS A total of 770 initial DOAC prescriptions of inpatients were evaluated: 267 patients (34.6%) had at least met 1 inappropriate criterion for a DOAC prescription. The most frequent inappropriate criterion was dosage (17.4%). Of the 4 DOACs, dabigatran (21.6%) and apixaban (21.2%) were mostly inappropriate dosed. In a multivariable analysis, reduced renal function (estimated glomerular filtration rate <50 mL/min; odds ratio [OR] = 2.35; P < .001), a diagnosis of atrial fibrillation (OR = 1.87; P = .004), and 'prescribed by surgeons' (OR = 1.9; P = .013) were independently associated with inappropriateness of prescribing. CONCLUSION This study has highlighted a high degree of inappropriate prescribing of DOACs. These results underline the need for targeted interventions to improve DOAC prescribing.
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Affiliation(s)
- Zhu Xian Zhang
- Department of Clinical PharmacySt Antonius HospitalUtrecht/NieuwegeinThe Netherlands
| | - Ewoudt M. W. van de Garde
- Department of Clinical PharmacySt Antonius HospitalUtrecht/NieuwegeinThe Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical SciencesUtrecht UniversityUtrechtThe Netherlands
| | - Maaike Söhne
- Department of Internal MedicineSt Antonius HospitalUtrecht/NieuwegeinThe Netherlands
| | - Ankie M. Harmsze
- Department of Clinical PharmacySt Antonius HospitalUtrecht/NieuwegeinThe Netherlands
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Systematic review and meta-analysis of the efficacy and safety of apixaban compared to rivaroxaban in acute VTE in the real world. Blood Adv 2020; 3:2381-2387. [PMID: 31405948 DOI: 10.1182/bloodadvances.2019000572] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022] Open
Abstract
Both apixaban and rivaroxaban have been approved for use in acute venous thromboembolism (VTE). Although indirect comparison through network meta-analyses of randomized trials have been performed to compare the efficacy and safety of these agents, further comparison between these agents was lacking until recently. We sought to systematically review and carry out a meta-analysis of studies to further compare apixaban with rivaroxaban from multiple studies done in the real-world settings. Studies comparing rivaroxaban with apixaban in patients with acute VTE were identified through electronic literature searches of MEDLINE, EMBASE, Scopus, and the Cochrane library up to May 2019. Study-specific risk ratios (RRs) were calculated and combined using a random-effects model meta-analysis. In an analysis involving 24 041 patients, recurrent VTE within 6 months occurred in 56 of 4897 patients (1.14%) in the apixaban group and 258 of 19 144 patients (1.35%) in the rivaroxaban group (RR, 0.89; 95% confidence interval [CI], 0.67-1.19; P = .45). Clinically relevant major bleeding occurred in 85 of 11 559 patients (0.74%) in the apixaban group and 350 of 33 909 patients (1.03%) in the rivaroxaban group (RR, 0.73; 95% CI, 0.58-0.93; P = .01). Clinically relevant nonmajor bleeding occurred in 169 of 3417 patients (4.95%) in the apixaban group and 1094 of 12 475 patients (8.77%) in the rivaroxaban group (RR, 0.59; 95% CI, 0.50-0.70; P < .01). Apixaban shows equivalent efficacy in prevention of recurrent VTE but decreased risk of major and minor bleeding events compared with rivaroxaban.
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De Simone V, Mugnolo A, Zanotto G, Morando G. Direct oral anticoagulants for patients aged over 80 years in nonvalvular atrial fibrillation: the impact of frailty. J Cardiovasc Med (Hagerstown) 2020; 21:562-569. [PMID: 32520853 DOI: 10.2459/jcm.0000000000000986] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In patients aged at least 80 years, atrial fibrillation is responsible for significant morbidity and mortality, with a high incidence of stroke. Four new direct oral anticoagulants (DOACs) have been introduced in Italy for the prevention of thromboembolism. Their safety and efficacy in the elderly have already been confirmed. Frailty is frequently associated with aging, but only a few studies have paid attention to interactions between frailty and anticoagulation therapy. METHODS We retrospectively evaluated the effectiveness and safety of DOACs in a population aged at least 80 years. Frailty was appraised using an adaptation of the Reported Edmonton Frail Scale, considering a value at least 8 (on a scale from 0 to 18). RESULTS The majority (644/731) of patients remained on DOACs for more than 1 year. A total of 19 patients experienced a thrombotic event while on anticoagulation (1.11 events per 100 person-years) and 26 patients a major bleeding episode (1.52 events per 100 person-years). The probability of interrupting therapy increased significantly with frailty [hazard ratio 2.91 with confidence interval (CI) 2.15-3.92 at univariate analysis, hazard ratio 2.80 with CI 2.03-3.86 at multivariate]; frailty showed a significant impact also on major bleeding (hazard ratio 3.28 with CI 1.45-7.37 at univariate analysis, hazard ratio 3.56 with CI 1.58-8.01 at multivariate). CONCLUSION Our study highlights how DOACs are a safe and effective option for anticoagulation, even in frail elderly people; the introduction of these drugs is leading to an increased use of anticoagulation therapy in this population. Prospective trials will be needed to reinforce these results and to consider new variables in the thrombotic and hemorrhagic risk scores underlying the prescription of DOACs.
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Affiliation(s)
- Vincenzo De Simone
- Department of Cardiology, Mater Salutis Hospital, Legnago, Verona, Italy
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Tchen S, Ryba N, Patel V, Cavanaugh J, Sullivan JB. Validation of Bleeding Risk Prediction Scores for Patients With Major Bleeding on Direct Oral Anticoagulants. Ann Pharmacother 2020; 54:1175-1184. [DOI: 10.1177/1060028020933186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Direct oral anticoagulants (DOACs) offer many benefits over vitamin K antagonists (VKAs) but still carry a significant risk of major bleeding. Bleeding risk prediction scores such as the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, and Drugs/Alcohol (HAS-BLED), Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk, and Stroke (HEMORR2HAGES), Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), Registro Informatizado Enfermedad TromboEmbólica (RIETE), and CHEST scores were validated or evaluated for use with VKAs and parenteral anticoagulants, but evidence for use with DOACs is lacking. Objective: This study aims to evaluate bleeding risk prediction scores for DOAC patients presenting with major bleeding. Methods: A retrospective analysis of patients presenting from 2015 to 2018 was performed. Patients were separated into bleed and nonbleed groups. The primary objective was to assess the diagnostic accuracy of the bleeding risk prediction scores utilizing the receiver operating characteristic (ROC) curve. Results: A total of 126 patients were included in the analyses. The areas under the curve (AUC) for the ROC curves of the HAS-BLED, HEMORR2HAGES, ATRIA, RIETE, and CHEST scores were 0.645, 0.675, 0.580, 0.638, and 0.667, respectively. Conclusion and Relevance: The HAS-BLED, HEMORR2HAGES, RIETE, and CHEST scores were found to have sufficient diagnostic accuracy for predicting risk of major bleeding in our study population; however, no score was identified as having an AUC greater than 0.7. Caution may be considered when utilizing these scores for patients on DOACs.
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Affiliation(s)
| | - Nicole Ryba
- Fairleigh Dickinson University School of Pharmacy & Health Sciences, Florham Park, NJ, USA
| | | | | | - Jesse B. Sullivan
- Fairleigh Dickinson University School of Pharmacy & Health Sciences, Florham Park, NJ, USA
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Alves da Costa F, Rydant S, Antoniou S. The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT). J Eval Clin Pract 2020; 26:670-681. [PMID: 31994273 DOI: 10.1111/jep.13316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 07/17/2019] [Accepted: 10/21/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration. METHODS It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide. RESULTS Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self-management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals. CONCLUSION On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care.
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Affiliation(s)
- Filipa Alves da Costa
- Centre for Interdisciplinary Research Egas Moniz (CiiEM), University Institute Egas Moniz, Campus Universitário, Caparica, Portugal.,Research Institute for Medicines (iMED.ULisboa), Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Silas Rydant
- Meduca, Royal Pharmacist Association of Antwerp (KAVA), Antwerp, Belgium
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Health NHS Trust, UCL Partners, London, UK
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Burden of Inappropriate Prescription of Direct Oral Anticoagulants at Hospital Admission and Discharge in the Elderly: A Prospective Observational Multicenter Study. Drugs Aging 2020; 36:1047-1055. [PMID: 31486994 DOI: 10.1007/s40266-019-00710-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) were developed to overcome some of the limitations associated with vitamin K antagonists (VKAs), such as interindividual variability or the need for therapeutic drug monitoring. However, the complexity of DOAC dose regimens can still lead to dosing errors and potential bleeding-related or thromboembolic adverse events, especially in the elderly. OBJECTIVE Our objective was to evaluate the rate of inappropriate preadmission DOAC prescriptions at hospital and to evaluate the ability of hospitals to correct them. METHODS An observational prospective study was conducted in elderly patients (aged ≥ 65 years) hospitalized in six acute units of three Parisian university hospitals between February and July 2018. DOAC prescriptions prior to admission and at discharge were analyzed according to the guidelines in the summaries of product characteristics. RESULTS A total of 157 patients were included in the study, with a median age of 84 years (interquartile range [IQR] 77-89). The median glomerular filtration rate, determined with the Cockcroft-Gault equation, was 48 mL/min (IQR 35-61). Apixaban was the most frequently prescribed drug, mainly for atrial fibrillation. Overall, 48 (30.6%) and 34 (22.4%) prescriptions were inappropriate prior to admission and at discharge, respectively, showing a significant decrease (p < 0.001). Hospitals significantly corrected more inappropriate prescriptions (37.5%) than they generated (4.6%) (p < 0.05). The nature of the inappropriate prescribing was underdosing (68.8% and 76.5% prior to admission and at discharge, respectively), followed by overdosing (stable rate at almost 20%) and indication errors. No risk factors for inappropriate use were identified by our analysis. CONCLUSION One-third of DOAC preadmission prescriptions for elderly patients were inappropriate, indicating that a need remains to strengthen DOAC prescribing guidelines in ambulatory clinical practice. However, the rate of inappropriate prescriptions decreased at patient discharge. Future studies are needed to test actions to promote the proper use of DOACs.
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Miyazaki M, Matsuo K, Uchiyama M, Nakamura Y, Sakamoto Y, Misaki M, Tokura K, Jimi S, Okamura K, Adachi S, Yamamoto T, Shirai K, Urata H, Imakyure O. Inappropriate direct oral anticoagulant dosing in atrial fibrillation patients is associated with prescriptions for outpatients rather than inpatients: a single-center retrospective cohort study. J Pharm Health Care Sci 2020; 6:2. [PMID: 32071730 PMCID: PMC7014592 DOI: 10.1186/s40780-020-0157-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/20/2020] [Indexed: 02/05/2023] Open
Abstract
Background Inappropriate dosing of direct oral anticoagulants (DOACs) has been associated with clinical safety and efficacy; however, little is known about clinical data associated with an inappropriate DOAC dosing in Japan. In addition, there is no report in which the appropriateness of DOAC dosing between prescription for inpatients and for outpatients was examined. In this study, we aimed to investigate the prevalence and factors associated in the inappropriate dosing of DOACs in patients with atrial fibrillation (AF). Methods The retrospective cohort study was conducted at a single Japanese university hospital. Both inpatients and outpatients, who were diagnosed with AF and for whom treatment with either dabigatran, rivaroxaban, apixaban, or edoxaban was initiated between April 1, 2014 and March 31, 2018, were enrolled in the study. Appropriateness of DOAC dosing was assessed according to the manufacturer’s labeling recommendations (dose reduction criteria) of each DOAC. Inappropriate reduced dose, namely, underdosing, was defined as prescription of a reduced dose of DOAC despite the patient not meeting the dose reduction criteria. Inappropriate standard dose, namely, overdosing, was defined as prescription of a standard dose of DOAC despite the patient meeting the dose reduction criteria. Inappropriate DOAC dosing was defined as a deviation of the recommended dose (both underdosing and overdosing). Results A total of 316 patients (dabigatran, 28; rivaroxaban, 107; apixaban, 116; and edoxaban, 65) were included, with a median (interquartile range) age of 75 (66–81) years and 62.3% male. DOACs were prescribed at an appropriate standard dose in 39.2% of patients, an appropriate reduced dose in 36.7%, an inappropriate standard dose in 2.5%, and an inappropriate reduced dose in 19.3%. Multivariate analysis revealed that the inappropriate dosing of DOACs was significantly associated with prescriptions for outpatients (vs. inpatients; odds ratio [OR] 2.87, 95% confidence interval [CI] 1.53–5.62, p < 0.001) and those with higher HAS-BLED scores (OR 1.87, 95% CI 1.42–2.51, p < 0.001). Conclusions Our results demonstrated that the inappropriate dosing of DOACs occurred in approximately 20% of AF patients, and was more frequent in outpatients (vs. inpatients) and in those with a higher risk of bleeding. It is recommended that pharmacists play a greater role in assisting in the prescription process to help physicians make better decisions.
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Affiliation(s)
- Motoyasu Miyazaki
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Koichi Matsuo
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Masanobu Uchiyama
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Yoshihiko Nakamura
- 2Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan; 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180 Japan
| | - Yuya Sakamoto
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Momoko Misaki
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Kaoko Tokura
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Shiro Jimi
- 3Central Laboratory for Pathology and Morphology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan; 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180 Japan
| | - Keisuke Okamura
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Sen Adachi
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Tomohiko Yamamoto
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Kazuyuki Shirai
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Hidenori Urata
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Osamu Imakyure
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
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Prevalence and predictors of inappropriate apixaban dosing in patients with non-valvular atrial fibrillation at a large tertiary academic medical institution. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00696-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Frazer A, Rowland J, Mudge A, Barras M, Martin J, Donovan P. Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients. Eur J Clin Pharmacol 2019; 75:1645-1657. [PMID: 31511939 DOI: 10.1007/s00228-019-02752-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Anticoagulation-associated adverse drug events are common in hospitalised patients and result in morbidity, mortality, increased length of hospital stay and higher costs of care. Many are preventable. We reviewed the literature to identify and assess interventions intended to improve safety or quality anticoagulant prescribing. METHODS A systematic search of EMBASE, MEDLINE, the Cochrane Library, Pretty Darn Quick-Evidence and Health Systems Evidence was undertaken to identify controlled studies assessing system-level interventions to improve prescribing of oral or parenteral therapeutic anticoagulation for any indication in hospitalised adults. Data were extracted for safety and quality outcomes, with studies grouped by intervention type for meta-analysis and narrative review. RESULTS Of 10,640 records screened, 19 trials evaluating 12,742 participants were included for analysis. No study specifically evaluated prescribing of low molecular weight heparins (LMWHs) or direct acting oral anticoagulants (DOACs). Our findings suggest that physician-led anticoagulation consultation services may reduce bleeding rates in high-risk patients. On meta-analysis, decision supported warfarin dosing resulted in higher proportion of time with international normalised ratio in therapeutic range (p = 0.0007). Studies of other clinical decision support systems and heparin monitoring systems did not demonstrate improved safety, and quality findings were inconsistent. Systematic education and feedback programs were not efficacious. CONCLUSIONS There is currently insufficient high-quality evidence to recommend any reviewed intervention, though several warrant closer evaluation. Adequately powered controlled trials assessing safety outcomes and evidence-based quality markers in high-risk patient groups and studies of interventions to improve safety of LMWH and DOAC prescribing are needed.
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Affiliation(s)
- Andrew Frazer
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia.
| | - James Rowland
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Alison Mudge
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Michael Barras
- University of Queensland School of Pharmacy, 20 Cornwall Street, Woolloongabba, QLD, 4102, Australia
| | - Jennifer Martin
- Chair of Clinical Pharmacology, University of Newcastle School of Medicine and Public Health, University Drive, Callaghan, NSW, 2308, Australia
| | - Peter Donovan
- Director of Clinical Pharmacology, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
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Akbashev M, Adhyaru B, Allen A. Can apixaban prevent venous thromboembolism better than rivaroxaban? Lancet Haematol 2019; 6:e180. [PMID: 30926079 DOI: 10.1016/s2352-3026(19)30053-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Mikhail Akbashev
- Emory University Department of Medicine, Atlanta, GA 30303, USA.
| | - Bhavin Adhyaru
- Emory University Department of Medicine, Atlanta, GA 30303, USA
| | - Arthur Allen
- Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
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