Appropriateness of Dabigatran and Rivaroxaban Prescribing for Hospital Inpatients

Appropriateness of Prescribing Rivaroxaban at King Khalid University Hospital Riyadh

Background and aim

Warfarin is recognized as a first-line treatment for different coagulopathy conditions; however, guidelines also encourage the use of rivaroxaban as an alternative option. The recent approval of the novel oral anticoagulants (NOACs) has led to swift changes in anticoagulant prescribing practices. This study aimed to review rivaroxaban prescribing patterns in adult patients in a large tertiary care setting in the Kingdom of Saudi Arabia (KSA).

Materials and methods

A retrospective cross-sectional study was conducted from January 2019 to September 2020 at King Khalid University Hospital, Riyadh, KSA. Data was collected from the patient's medical record. Data analysis was performed with the Statistical Package for the Social Sciences (SPSS) IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.

Results

A total of 309 patients were included in this study. Rivaroxaban use for non-valvular atrial fibrillation (NVAF) was relatively higher than deep venous thrombosis/pulmonary embolism (DVT/PE). 45% of the patients had NVAF, followed by DVT/PE (26%), and DVT/PE prophylaxis (25%). Fifty-six patients, (18%) received an inappropriate dose of rivaroxaban for NVAF.

Conclusion

This study found a relatively high percentage of inappropriate rivaroxaban prescribing, predominantly because of inappropriate dosing, which can potentially increase medication-related events. The use of rivaroxaban should be monitored to increase the appropriateness of therapy and improve patient safety.

Impact of direct oral anticoagulant off-label doses on clinical outcomes of atrial fibrillation patients: A systematic review

AIMS

Worldwide observational studies are evidencing discordance between guidelines and real-world practice regarding direct oral anticoagulant drug (DOAC) doses. This systematic review summarizes and evaluate DOACs use in real-world practice.

METHODS

This review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines searching PubMed (MEDLINE) and Medscape databases.

RESULTS

Data from 75 studies showed that most of the patients treated with DOACs for stroke prevention in atrial fibrillation received doses in accordance to the guidelines. However, a significant number of patients received off-label doses (25-50% in most of the studies evaluated). DOAC overdosing was associated with increased all-cause mortality and worse bleeding events while underdosing was associated with increased cardiovascular hospitalization and, particularly for apixaban, with a nearly 5-fold increased risk of stroke.

CONCLUSION

Patients prescribed with off-label DOAC doses did not receive the full benefit of anticoagulation and presented an increased risk of stroke, bleeding and/or adverse effects.

Rivaroxaban prescribing in a Saudi tertiary care teaching hospital

Purpose

This drug utilization review (DUR) aimed to describe the use of rivaroxaban in a tertiary care teaching hospital and to audit the hospital physicians’ prescribing practice.

Methods

This study reviewed rivaroxaban prescriptions for patients admitted to a tertiary care teaching hospital in Riyadh, Saudi Arabia, between October 1, 2016 and January 15, 2017. It included all in-patients who received at least one dose of rivaroxaban, using data from the hospital’s health information system (HIS). Appropriateness of prescribing was evaluated based on documented indication, dosing according to the patient’s renal function for each approved indication, and restriction policy as per hospital department.

Results

During the study period, a total of 343 rivaroxaban prescriptions for 322 patients were identified. Overall, more than 56% of rivaroxaban prescriptions met at least one inappropriate criterion. Inappropriate dosing per patient’s creatinine clearance (CrCl) was recognized in 42% of rivaroxaban prescriptions with the majority of these prescriptions issued for lower doses in 82.9% of prescriptions and non-approved indications identified in 14% of rivaroxaban prescriptions.

Conclusions

The introduction of oral rivaroxaban represents a paradigm shift in anticoagulation management. Future longer, larger multi-center research is needed to identify the most effective interventions to enhance rivaroxaban knowledge translation and reduce the likelihood of inappropriate rivaroxaban prescribing and associated economic and side effects sequelae.

Impact of Pharmacists' audit on improving the quality of prescription of dabigatran etexilate methanesulfonate: a retrospective study

Background

Appropriate prescription of dabigatran etexilate methanesulfonate (JAN) is more complicated than assumed, because there are totally 10 items of contraindications and instructions for dosage reduction depending on patients’ characteristics. We aimed to study whether the routine audit of first-time prescriptions of dabigatran performed by pharmacists is effective in improving the quality of prescription.

Methods

A retrospective re-audit was performed on all the prescriptions of dabigatran issued at Kitahara International Hospital, Tokyo between March 2011 and February 2014, by evaluating the prescriptions rigorously against the approved prescribing information of the drug. The original routine audit of the prescriptions for inpatients was performed by hospital pharmacists using electronic medical records (EMR), whereas the audit for ambulant patients receiving external prescriptions was performed by community pharmacists using information obtained mainly by questioning patients. The frequencies of inappropriate prescriptions detected by the re-audit in the two groups were compared.

Results

Two hundred and twenty-eight patients (131 ambulant patients and 97 inpatients) were prescribed dabigatran for the first time during the study period. All patients met the approved indications. While 33% of the prescriptions for ambulant patients showed at least one violation of the approved usage, only 11% of the prescriptions for inpatients showed violations (p < 0.001). Two ambulant patients with creatinine clearance < 30 mL/min were dispensed dabigatran, whereas no such case was found among inpatients. A significantly greater proportion of ambulant patients aged ≥70 years showed violation of the instruction for dosage reduction compared to inpatients of the same age group (18 and 4%, respectively).

Conclusion

The present study suggests that pharmacists may achieve better performance in auditing prescriptions of dabigatran when medical records are fully available than when information is available mainly by questioning patients. Further large-scale studies are required to clarify whether the audit of dabigatran prescriptions improves ultimate therapeutic outcomes or complications.