Impact of the COVID-19 lockdown on the adherence of stroke patients to direct oral anticoagulants: a secondary analysis from the MAAESTRO study

Abstract Background The negative impact of the COVID-19 outbreak on stroke care has been reported, but no data exist on the influence of the lockdown on medication adherence to antithrombotic treatment for stroke prevention. We present a comparison of electronic adherence data of stroke patients treated with direct oral anticoagulants (DOAC) prior to and during the COVID-19 lockdown in spring 2020 in Switzerland. Methods This is a secondary analysis using data from the ongoing MAAESTRO study, in which stroke patients with atrial fibrillation electronically monitor their adherence to DOAC treatment. Eligible patients for this analysis had at least four weeks of adherence data prior to and during the COVID-19 lockdown. Three adherence metrics (taking adherence, timing adherence, drug holidays) were calculated and compared descriptively. Results The analysis included eight patients (median age 81.5 years, IQR 74.8–84.5). Five patients had a pre-lockdown taking adherence over 90% (mean 96.8% ± 2.9), with no change during lockdown, high timing adherence in both periods and no drug holidays. The remaining three patients had pre-lockdown taking and timing adherence below 90%. Of those, two patients showed a moderate decline either in taking or timing adherence compared to pre-lockdown. One showed a substantial increase in taking and timing adherence during lockdown (both + 25.8%). Conclusion Our data suggest that a major disruption of social life (i.e., the imposed COVID-19 lockdown) is unlikely to relevantly affect the medication intake behaviour of patients with high pre-established adherence, but might have an impact in patients with previously suboptimal adherence. Trial registration number MAAESTRO: electronic Monitoring and improvement of Adherence to direct oral Anticoagulant treatment—a randomized crossover study of an Educational and reminder-based intervention in ischaemic STROke patients under polypharmacy, NCT03344146.

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PROTOCOL FOR MAAESTRO: ELECTRONIC MONITORING OF ADHERENCE TO DIRECT ORAL ANTICOAGULANTS AND EDUCATIONAL, REMINDER-BASED INTERVENTION – A RANDOMISED CROSSOVER STUDY IN POLYMEDICATED ISCHEMIC STROKE PATIENTS

10.26226/morressier.5aeac941521e300021138007 ◽

2018 ◽

Author(s):

Alexandros Polymeris

Keyword(s):

Ischemic Stroke ◽

Crossover Study ◽

Electronic Monitoring ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Stroke Patients

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New Perspectives in Stroke Management: Old Issues and New Pathways

Brain Sciences ◽

10.3390/brainsci11060767 ◽

2021 ◽

Vol 11 (6) ◽

pp. 767

Author(s):

Fabio Pilato ◽

Rosalinda Calandrelli ◽

Fioravante Capone ◽

Michele Alessiani ◽

Mario Ferrante ◽

...

Keyword(s):

Time Window ◽

Enhanced Recovery ◽

Current Knowledge ◽

Oral Anticoagulants ◽

Chronic Phase ◽

Stroke Care ◽

New Drugs ◽

Stroke Patients ◽

Social Burden ◽

Novel Approaches

Stroke is a leading cause of disability and death worldwide and social burden is huge in terms of disabilities, mortality and healthcare costs. Recently, in an acute stroke setting, renewed interest in disease-modifying therapies and novel approaches has led to enhanced recovery and the reduction of long-term disabilities of patients who suffered a stroke. In the last few years, the basic principle “time is brain” was overcome and better results came through the implementation of novel neuroimaging tools in acute clinical practice, allowing one to extend acute treatments to patients who were previously excluded on the basis of only a temporal selection. Recent studies about thrombectomy have allowed the time window to be extended up to 24 h after symptoms onset using advanced neuroradiological tools, such as computer tomography perfusion (CTP) and magnetic resonance imaging (MRI) to select stroke patients. Moreover, a more effective acute management of stroke patients in dedicated wards (stroke units) and the use of new drugs for stroke prevention, such as novel oral anticoagulants (NOACs) for atrial fibrillation, have allowed for significant clinical improvements. In this editorial paper, we summarize the current knowledge about the main stroke-related advances and perspectives and their relevance in stroke care, highlighting recent developments in the definition, management, treatment, and prevention of acute and chronic complications of stroke. Then, we present some papers published in the Special Issue “Clinical Research on Ischemic Stroke: Novel Approaches in Acute and Chronic Phase”.

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Prescribing Errors With Direct Oral Anticoagulants and Their Impact on the Risk of Bleeding in Patients With Atrial Fibrillation

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/10742484211019657 ◽

2021 ◽

pp. 107424842110196

Author(s):

Bruria Hirsh Raccah, PharmD, PhD ◽

Yevgeni Erlichman ◽

Arthur Pollak ◽

Ilan Matok ◽

Mordechai Muszkat

Keyword(s):

Atrial Fibrillation ◽

Major Bleeding ◽

Negative Impact ◽

Conditional Logistic Regression ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Drug Dose ◽

Prescribing Errors ◽

Duration Of Treatment ◽

Inappropriate Treatment

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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Resolution of warfarin-induced alopecia with conversion to apixaban

BMJ Case Reports ◽

10.1136/bcr-2020-240579 ◽

2021 ◽

Vol 14 (3) ◽

pp. e240579

Author(s):

Katherine Leigh Hull ◽

Richard Gooding ◽

James O Burton

Keyword(s):

Hair Loss ◽

Warfarin Therapy ◽

Negative Impact ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Hair Follicles ◽

Dialysis Access ◽

Close Monitoring ◽

Patient Reported

Warfarin is frequently prescribed as a long-term anticoagulant in patients with end-stage kidney disease as direct oral anticoagulants undergo renal excretion. Anticoagulation is a rare cause of alopecia in adults and is thought to be due to the promotion of the ‘resting phase’ of hair follicles. In this case report, a prevalent haemodialysis female patient required long-term anticoagulation following a complex pulmonary embolus and dialysis access complications. After commencing warfarin therapy, the patient reported generalised loss and thinning of her hair. All other potential causes were excluded. Cessation of warfarin therapy and conversion to apixaban with close monitoring alleviated the hair loss. Warfarin therapy is a rare cause of alopecia but should be considered in patients on long-term anticoagulation when other diagnoses have been excluded. Hair loss has a profoundly negative impact on patient quality of life and should prompt investigation to determine the underlying cause.

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Abstract WMP85: Clinical Effectiveness of Direct Oral Anticoagulants (DOACs) vs. Warfarin in Older Ischemic Stroke Patients With Atrial Fibrillation: Findings From Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study

Stroke ◽

10.1161/str.50.suppl_1.wmp85 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Ying Xian ◽

Haolin Xu ◽

Emily C O’Brien ◽

Shreyansh Shah ◽

Laine Thomas ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Clinical Effectiveness ◽

Effectiveness Research ◽

Stroke Patients ◽

Patient Centered

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Venous Thromboembolism: A Survey of Oral Anticoagulant Preferences in the Treatment of Challenging Patient Populations

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029618804080 ◽

2018 ◽

Vol 24 (9_suppl) ◽

pp. 209S-216S ◽

Cited By ~ 2

Author(s):

Genevieve Claire Moyer ◽

Bethany Samuelson Bannow ◽

Courtney Thornburg ◽

Rachel Rosovsky ◽

Tzu-Fei Wang ◽

...

Keyword(s):

Venous Thromboembolism ◽

Oral Anticoagulant ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Treatment Options ◽

Antiphospholipid Antibody ◽

Antiphospholipid Antibody Syndrome ◽

Oral Anticoagulant Treatment ◽

Increased Risk ◽

Altered Metabolism

Venous thromboembolism (VTE) is a highly morbid condition with several available oral anticoagulant treatment options. Numerous studies have been published comparing warfarin to direct oral anticoagulants; however, several populations remain underrepresented in these reports. We surveyed members of The Venous ThromboEmbolism Network U.S. working group regarding their oral anticoagulant preferences for the treatment of VTE in different and challenging populations. In individuals with VTE and no other medical comorbidities, respondents preferred either rivaroxaban (48.7%) or apixaban (48.7%). Apixaban (53.3%) was preferred in elderly individuals with an increased risk of bleeding. Warfarin was preferred in individuals with liver or kidney dysfunction (42% and 47%), altered metabolism (>55%), and antiphospholipid antibody syndrome (84.2%). Low-molecular-weight heparin was preferred in individuals with malignancy (56.6%), followed by edoxaban (23.7%). These findings may help guide clinicians when choosing an anticoagulant in these challenging situations and demonstrate the urgent need for additional study in these groups.

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