scholarly journals New Oral Anaticoagulant Prescribing Decisions amongst General Practitioners: Handle with Care

10.36469/9798 ◽  
2017 ◽  
Vol 5 (1) ◽  
pp. 55-64 ◽  
Author(s):  
Ann Kirby ◽  
Aileen Murphy ◽  
Colin Bradley
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Renal Impairment ◽  
Drug Interactions ◽  
General Practitioners ◽  
Hepatic Impairment ◽  
Oral Anticoagulants ◽  
Multivariate Probit ◽  
Primary Data ◽  
Effective Manner

Background: Prescribing oral anticoagulants for atrial fibrillation patients is becoming more challenging as more alternatives enter the market. While warfarin has dominated the market it is a challenging medicine to use owing to its narrow therapeutic range, increased bleeding risk and requirement for continuous monitoring. The introduction of new oral anticoagulants (NOACs) offers a wider choice but they are more costly and their use also brings additional pharmacological considerations. Objective: This paper investigates if the identified risk factors (renal impairment, hepatic impairment, other co-morbidities & drug interactions) influence GPs’ NOAC prescribing decisions, using a multivariate probit model, while controlling for other GP characteristics. Methods: Employing primary data, collected using a dedicated survey of Irish GPs in November 2015, a multivariate probit is employed. This measures the joint decision making process of prescribing a NOAC based on four risk factors - renal impairment, hepatic impairment, other comorbidities and drug interactions. Results: Younger GPs are more likely to consider ‘other co-morbidities’ and ‘renal impairment’ as important when making NOAC prescribing decisions. Male GPs are more likely to consider ‘other co-morbidities’ and ‘drug interactions’ as important when prescribing NOACs compared to female GPs. Prescribers who have initiated NOACs are more likely to consider ‘renal impairment’ as important compared with non-initiators. Conclusions: Our study highlights the importance for general practitioners prescribing NOACs and caring for patients on oral anticoagulants, of adequate education, of appropriate patient selection and of appropriate monitoring of such patients. While warfarin prescribing remains predominant, NOAC prescribing is increasing. Incorporating the risk factors into prescribing decisions signals responsible prescribing for atrial fibrillation patients. Existing prescribing guidelines/toolkits need to be used in an effective manner.

scholarly journals Contemporary utilization of antithrombotic therapy for stroke prevention in patients with atrial fibrillation: an audit in an Australian hospital setting

2017 ◽  
Vol 9 (2) ◽  
pp. 97-111 ◽  
Author(s):  
Ekta Yogeshkumar Pandya ◽  
Elizabeth Anderson ◽  
Clara Chow ◽  
Yishen Wang ◽  
Beata Bajorek
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Renal Impairment ◽  
Oral Anticoagulants ◽  
Hospital Setting ◽  
Medication History ◽  
Nonvalvular Atrial Fibrillation ◽  
Retrospective Audit ◽  
To Receive ◽  
Australian Hospital

Background: To document antithrombotic utilization in patients with nonvalvular atrial fibrillation (NVAF), particularly, recently approved NOACs (nonvitamin K antagonist oral anticoagulants) and warfarin; and identify factors predicting the use of NOACs versus warfarin. Methods: A retrospective audit was conducted in an Australian hospital. Data pertaining to inpatients diagnosed with atrial fibrillation (AF) admitted between January and December 2014 were extracted. This included patient demographics, risk factors (stroke, bleeding), social history, medical conditions, medication history, medication safety issues, medication adherence, and antithrombotic prescribed at admission and discharge. Results: Among 199 patients reviewed, 84.0% were discharged on antithrombotics. Anticoagulants (± antiplatelets) were most frequently (52.0%) prescribed (two-thirds were prescribed warfarin, the remainder NOACs), followed by antiplatelets (33.0%). Among 41 patients receiving NOACs, 59.0% were prescribed rivaroxaban, 24.0% dabigatran, and 17.0% apixaban. Among patients aged 75 years and over, antiplatelets were most frequently used (37.0%), followed by warfarin (33.0%), then NOACs (14.0%). Compared with their younger counterparts, patients aged 75 years and over were significantly less likely to receive NOACs (14.0% versus 28.0%, p = 0.01). Among the ‘most eligible’ patients (Congestive Cardiac Failure, Hypertension (, Age ⩾ 75 years, Age= 65-74 years, Diabetes Mellitus, Stroke/ Transient Ischaemic Attack/ Thromboembolism, Vascular disease, Sex female[CHA2DS2-VASc] score ⩾2 and no bleeding risk factors), 46.0% were not anticoagulated on discharge. Patients with anaemia (68.0% versus 86.0%, p = 0.04) or a history of bleeding (65.0% versus 87.0%, p = 0.01) were less likely to receive antithrombotics compared with those without these risk factors. Warfarin therapy was less frequently prescribed among patients with cognitive impairment compared with patients with no cognitive issues (12.0% versus 23.0%, p = 0.01). Multivariate logistic regression modelling identified that patients with renal impairment were 3.6 times more likely to receive warfarin compared with NOACs (odds ratio = 3.6, 95% confidence interval = 0.08–0.90, p = 0.03, 60.0% correctly predicted; Cox and Snell R2 = 0.51, Nagelkerke R2 = 0.69). Conclusion: Despite the availability of NOACs, warfarin remains a preferred treatment option, particularly among patients with renal impairment. The high proportion of eligible patients still being prescribed antiplatelet therapy or ‘no therapy’ needs to be addressed.

scholarly journals Evaluation of Direct Oral Anticoagulant Prescribing in Patients With Moderate to Severe Renal Impairment

2021 ◽  
Vol 27 ◽  
pp. 107602962098790
Author(s):  
Clara Ting ◽  
Megan Rhoten ◽  
Jillian Dempsey ◽  
Hunter Nichols ◽  
John Fanikos ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Renal Impairment ◽  
Severe Renal Impairment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Events ◽  
Increase Risk ◽  
Severe Chronic Kidney Disease ◽  
Dosing Strategies ◽  
Require Dose

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.

scholarly journals Clinical profile and cardiovascular risk factors of patients treated with novel oral anticoagulants in atrial fibrillation - patterns of use in the European PREFER in AF registry

2013 ◽  
Vol 34 (suppl 1) ◽  
pp. P5138-P5138
Author(s):  
L. M. Rincon ◽  
B. Ammentorp ◽  
H. Darius ◽  
R. De Caterina ◽  
P. Kirchhof ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Cardiovascular Risk ◽  
Cardiovascular Risk Factors ◽  
Oral Anticoagulants ◽  
Clinical Profile ◽  
Novel Oral Anticoagulants ◽  
Patterns Of Use

Advances in Atrial Fibrillation-related Stroke Prevention

2015 ◽  
Vol 9 (2) ◽  
pp. 122
Author(s):  
Pierre Amarenco ◽  
Werner Hacke ◽  
Bo Norrving ◽  
Natalia Rost ◽  
◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Anticoagulant Therapy ◽  
Stroke Prevention ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Factor Xa ◽  
Haemorrhagic Stroke ◽  
Bleeding Events ◽  
Patients At Risk

In patients with atrial fibrillation (AF) the risk of stroke is substantially increased, especially in those who are elderly (over 75 years) or have risk factors such as previous stroke, heart failure or hypertension. Stroke outcomes are also generally much worse in those with AF. Current guidelines indicate that any patient with AF and risk factors for stroke should receive anticoagulant therapy to limit their stroke risk. Despite these established recommendations, only 50 % of patients at risk receive anticoagulation with a vitamin K antagonist (VKA) and only 50 % of those are within the therapeutic range, indicating lack of adherence to the guidelines. Withholding anticoagulant therapy is mainly left to an individual physician’s choice, as shown in the ongoing GARFIELD registry of AF stroke prevention practice. Many physicians fear the risk of intracranial haemorrhage (ICH) for which outcomes remain poor. Recent clinical studies have shown that the non-VKA oral anticoagulants (NOACs) (apixaban, rivaroxaban, dabigatran and edoxaban) significantly reduce the risk of ICH and other bleeding events, while having non-inferior stroke prevention to warfarin. Use of these drugs, limiting exposure to aspirin and alcohol and controlling blood pressure have been shown to minimise ICH risk in large clinical trials and meta-analyses. Recent data from the Effective aNticoaGulation with factor xA next GEneration in Atrial Fibrillation (ENGAGE AF)-TIMI 48 study showed that the factor Xa inhibitor edoxaban was non-inferior to well-managed warfarin for reducing all stroke risk, and significantly reduced haemorrhagic stroke, major bleeding, ICH and death. These findings further support the case for using NOAC therapy for stroke prevention in patients with AF and risk factors for stroke.

scholarly journals Reasons for Switching from Warfarin to a Direct Oral Anticoagulant: A Retrospective Study

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5060-5060
Author(s):  
Siavash Piran ◽  
Marlene Robinson ◽  
Erjona Kruja ◽  
Sam Schulman
Keyword(s):  
Atrial Fibrillation ◽  
Cardiac Surgery ◽  
Drug Interactions ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Retrospective Chart Review ◽  
Mechanical Valve ◽  
Adherence Rate ◽  
Valve Prosthesis ◽  
Significant Difference

Abstract Background: Direct oral anticoagulants (DOACs) are slowly replacing warfarin for the prevention of stroke in atrial fibrillation and treatment and secondary prevention of venous thromboembolism. Patients with poor time in therapeutic range (TTR) are often switched to a DOAC. Poor TTR can be due to drug interactions but if the reason is poor compliance, outcomes could be worse using a DOAC without monitoring. Methods: To understand the compliance patterns we performed a retrospective chart review in patients from the anticoagulation clinic at Hamilton General Hospital that were switched from warfarin to a DOAC from April 2013 to April 2018. Patients who were taking warfarin for ≥ 2 months for any indication, except for mechanical valve prosthesis, and who were switched to a DOAC were included. We excluded patients who had a DOAC-to-DOAC switch, patients who had no reported TTR available, and those who were temporarily on warfarin after cardiac surgery. The documented reasons for a switch from warfarin to a DOAC were compared between patients with TTR ≤ 60% and >60%. Non-adherence to international normalized ratio (INR) monitoring was considered if >20% of tests were not done or delayed for more than 2 days. Results: A total of 643 eligible patients were initially screened and 288 patients were excluded: 179 had no available TTR, 93 were temporarily on warfarin after cardiac surgery, 11 were not actually switched from warfarin to a DOAC, and 5 had a DOAC-to-DOAC switch. The remaining 355 patients were included in the analysis: 223 had a TTR ≤ 60% and 132 patients had a TTR >60%. There were no differences in the median age or gender distribution. The most common indication for anticoagulation was atrial fibrillation in both groups. The median TTR was 43% in the TTR ≤ 60% group and 71% in the TTR >60% group. The median duration on anticoagulation with warfarin was significantly longer for the TTR >60% group compared with the TTR ≤ 60% group (42 months versus 19 months; P <0.001). Apixaban was the most common DOAC of choice for the switch in both groups. The most common documented reasons for a switch in the group with a TTR >60% were: switch by another physician for unknown reason (n=36), bleeding (n=30), and patient preference (n=20). The most common reasons for a switch in those with a TTR ≤ 60% were: unstable INR readings (n=42), drug interactions (n=33), and bleeding (n=30). There was no significant difference in the rate of non-adherence with the scheduled INR monitoring (42% in the group with a TTR >60% versus 49% in those with a TTR ≤ 60%). Conclusion: We found that about half of the patients on chronic anticoagulation with warfarin and switched to a DOAC were non-adherent with the scheduled INR monitoring. This, in combination with low TTR, should alert the physician of possible non-compliance with taking DOACs. Further prospective studies are needed to examine the DOAC adherence rate and clinical outcomes in this specific population. Disclosures Schulman: Boehringer-Ingelheim: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria; Sanofi: Honoraria; Bayer: Honoraria.

scholarly journals The role of edoxaban in preventing thromboembolic complications in patients with atrial fibrillation

2020 ◽  
pp. 28-43
Author(s):  
O. O. Shakhmatova
Keyword(s):  
Atrial Fibrillation ◽  
Drug Interactions ◽  
Dose Reduction ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Extensive Study ◽  
Thromboembolic Complications ◽  
Nonvalvular Atrial Fibrillation ◽  
Life Threatening

Edoxaban is a selective direct factor Xa inhibitor. Edoxaban in a dose of 60 mg per day is an effective and safe option in the prevention of thromboembolic complications in patients with nonvalvular atrial fibrillation, including in combination therapy in patients after percutaneous coronary interventions. ENGAGE AF-TIMI 48 is currently the most extensive study comparing direct oral anticoagulants and warfarin in patients with atrial fibrillation, both in terms of number of participants and duration of observation. For edoxaban, an adequate approach to dose reduction has been developed in patients with alikely increase in plasma concentration due to renal impairment, low body weight or inter-drug interactions. Such dose reduction does notlead to an increase in the frequency of ischemic complications.Edoxaban is characterized by an optimal safety profile in patients with chronic moderate kidney disease, a small number of drug interactions and a convenient mode of administration. In patients with atrial fibrillation and concomitant ischemic heart disease, the use of Edoxaban is associated with a decrease in the frequency of myocardial infarctions, as well as strokes and episodes of systemic thromboembolism in comparison with warfarin. The drug can be successfully used as anticoagulant support for cardioversion and catheter ablation for atrial fibrillation.Edoxaban intake does not require routinelaboratory control. In case of unexpected situations (life-threatening bleeding, urgent surgical intervention) in patients receiving edoxaban, to assess the degree of anticoagulation should use the determination of anti-Xa activity. Clinical studies of a specific antidote of edoxaban - andexanet alfa are ongoing. Before approval of the specific antidote in severe andlife-threatening bleedings against the background of edoxaban administration, the use of prothrombin complex concentrate should be considered. Data on the effective and safe use of edoxaban in routine clinical practice have been accumulated.

Systemic Thromboemboli In Mitral Starr-Edwards Prosthesis: A Long-Term Followup (10-19 Years)

1981 ◽  
Author(s):  
V Fuster ◽  
J H Chesebro
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Mitral Valve ◽  
Predictive Factors ◽  
Oral Anticoagulants ◽  
Functional Class ◽  
Class Iii ◽  
Platelet Inhibitor ◽  
Mitral Incompetence

The study comprised 170 consecutive patients (pts) seen at Mayo Clinic between 1962 and 1970 who underwent mitral valve replacement with Starr-Edwards prosthesis (model 6000 in 35% of pts, model 6120 in 65% of pts) because of significant chronic mitral incompetence (functional Class III-IV). All patients were on oral anticoagulants and were followed until January 1980 with a followup of 10 to 19 years (yrs) (median 15 yrs). We analyzed (1) the cumulative incidence of systemic emboli, their location and whether or not they left residual deficit; and (2) possible risk factors that might have been predictive, including in the analysis: age, sex, functional class, presence or absence of atrial fibrillation, degree of cardiomegaly, type of prosthesis and degree of anticoagulation.At 12 yrs of followup, 48% of pts had at least one episode of emboli (among these pts, 12% had two episodes); the rate of emboli was maximal within 1 yr postoperatively but persisted over the total followup at a rate of about 3% per yr. Of all emboli, 94% occurred in the cerebral circulation and 66% left neurological deficit. Regarding predictive factors, the incidence of emboli was slightly higher in pts with the prosthesis model 6000 (p<0.05) and in pts considered to be poorly anticoagulated (p<0.05).This unique long-term followup study on pts with mitral Starr-Edwards prosthesis reveals that systemic emboli is a persistent and significant problem. Preliminary data indicates that the addition of a platelet inhibitor to the oral anticoagulant may be beneficial.

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