Older people, are underrepresented in randomised controlled trials of direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation (AF). The aim of this study was to combine data from observational studies to provide evidence for the treatment of people aged ≥75 years. Medline, Embase, Scopus and Web of Science were searched. The primary effectiveness outcome was ischaemic stroke. Safety outcomes were major bleeding, intracranial haemorrhage, gastrointestinal bleeding, myocardial infarction, and mortality. Twenty-two studies were eligible for inclusion. Two studies related specifically to people ≥75 years but were excluded from meta-analysis due to low quality; all data in the meta-analyses were from subgroups. The pooled risk estimate of ischaemic stroke was slightly lower for DOACs. There was no significant difference in major bleeding, mortality, or myocardial infarction. Risk of intracranial haemorrhage was 44% lower with DOACs, but risk of GI bleeding was 46% higher. Our results suggest that DOACs may be preferable for the majority of older patients with AF, provided they are not at significant risk of a GI bleed. However, these results are based entirely on data from subgroup analyses so should be interpreted cautiously. There is a need for adequately powered research in this patient group.

Background Anticoagulation for stroke prevention in atrial fibrillation (AF) has, historically, been under-used in older people. The aim of this study was to investigate prescribing of oral anticoagulants (OACs) for people aged ≥ 75 years in the UK before and after direct oral anticoagulants (DOACs) became available. Methods A cohort of patients aged ≥ 75 years with a diagnosis of AF was derived from the Clinical Practice Research Datalink (CPRD) between January 1, 2003, and December 27, 2017. Patients were grouped as no OAC, incident OAC (OAC newly prescribed) or prevalent OAC (entered study on OAC). Incidence and point prevalence of OAC prescribing were calculated yearly. The risk of being prescribed an OAC if a co-morbidity was present was calculated; the risk difference (RD) was reported. Kaplan-Meier curves were used to explore persistence with anticoagulation. A Cox regression was used to model persistence with warfarin and DOACs over time. Results The cohort comprised 165,596 patients (66,859 no OAC; 47,916 incident OAC; 50,821 prevalent OAC). Incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017. Older patients (≥ 90 years) were 40% less likely to receive an OAC (RD −0.40, 95% CI −0.41 to −0.39) than younger individuals (75–84 years). The likelihood of being prescribed an OAC was lower with a history of dementia (RD −0.34, 95% CI −0.35 to −0.33), falls (RD −0.17, 95% CI −0.18 to −0.16), major bleeds (RD −0.17, 95% CI −0.19 to −0.15) and fractures (RD −0.13, 95% CI −0.14 to −0.12). Persistence with warfarin was higher than DOACs in the first year (0–1 year: HR 1.25, 95% CI 1.17–1.33), but this trend reversed by the third year of therapy (HR 0.75, 95% CI 0.63–0.89). Conclusions OAC prescribing for older people with AF has increased; however, substantial disparities persist with age and co-morbidities. Whilst OACs should not be withheld solely due to the risk of falls, these results do not reflect this national guidance. Furthermore, the under-prescribing of OACs for patients with dementia or advancing age may be due to decisions around risk-benefit management. Trial registration EUPAS29923. First registered on: 27/06/2019.

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IntroductionWarfarin has frequently been underused in older people for stroke prevention in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) entered the UK market from 2008 and have been recommended as an alternative to warfarin. This study aimed to describe any changes in the prescribing of oral anticoagulants (OACs) to people aged ≥75 years in UK general practice before and after the introduction of DOACs, to examine differences in patient characteristics which may influence prescribers’ decisions regarding anticoagulation, to evaluate the time people stay on OACs and switching between OACs.Methods and analysisA retrospective cohort study design will be used. Patients with a diagnosis of AF will be identified from the Clinical Practice Research Datalink (CPRD). The study period will run from 1 January 2003 to 27 December 2017. Patients enter the cohort at the latest date of the start of the study period, first AF diagnosis, 75th birthday or a year from when they started to contribute research standard data. Follow-up continues until they leave the practice, death, the date the practice stops contributing research standard data or the end of the study period (27 December 2017). Exposure to OACs will be defined as ≥1 prescription issued for an OAC of interest during the study period. Patients issued an OAC in the year preceding study entry will be defined as ‘prevalent users’. Patients starting on an OAC during the study period will be defined as ‘incident users’. Incidence and prevalence of OAC prescribing, patient demographics and characteristics will be described during three time periods: 2003–2007, 2008–2012 and 2013–2017. Persistence (defined as the time from initiation to discontinuation of medication) with and switching between different OACs will be described.Ethics and disseminationThe protocol for this study was approved by the CPRD Independent Scientific Advisory Committee. The results will be disseminated in a peer-reviewed journal and at conferences.Trial registration numberEUPAS29923.

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of the following research output: 76 Developing a protocol for a systematic review and meta-analysis of observational studies comparing direct oral anticoagulants with vitamin K antagonists for stroke prevention in people aged over 75 with atrial fibrillation.

Purpose The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications. Methods Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing. Results Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes. Conclusions Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms—principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.

Introduction The ED in our tertiary referral Hospital was working at capacity and invited pharmacy to send a team for a period to assess the impact they might have on workflow and doctor time, by carrying out detailed (level 2) medicine reconciliations and resolving medicine related issues at the outset. Aim To assess the impact that allocating an experienced pharmacist (Independent prescriber) together with a pharmacy technician might have on workflow and patient safety in ED. Methods The pharmacy team were directed to managing patients’ medicines carrying out the more comprehensive level 2 (1) medicines reconciliation (MR). This is a more thorough level of MR than that usually carried out on admission by a doctor (Level 1 MR). The time taken to conduct each MR was recorded. Interventions made were categorised by the clinical pharmacist using the MERP index. Five doctors were surveyed and asked how long they usually took to conduct a level 1 MR. Results 132 MRs were carried out over 5 days. The pharmacist conducted 65 MRs mean time per MR 13.8 minutes SD 6.84 CI 90% (+/- 0.11) and the technician conducted 67 MRs mean time 23.73 minutes SD 11.07 CI 90% (+/- 0.17). The doctor group took 15 minutes (estimated) to conduct a level 1 MR SD 34.85 CI 90% (+/- 0.81). 1013 interventions were made, 15 were judged to be significant in terms of harm or potential harm and a further 128 related to non-prescribing of critical items (see table). A 90% Confidence interval was used reflecting the significant variance in time that a medicine reconciliation can take. Conclusion This project had limitations; it was brief, and the number of doctors surveyed few. However, it was adjudged to be a success in terms of doctor time saved (33 hours) and patient safety identifying 14 harm or potential harm occurrences and 128 critical medicines omissions at the outset of the patient journey. Following the project, the trust recognised the impact the team had and has subsequently funded an ED pharmacy team. References (1) Improving the Quality of Meds Reconciliation: A Best Practice Resource and Toolkit: V1.1 June 17 Specialist Pharmacy Service. Accessed Oct 2021 Medicines_Reconciliation_Best_Practice_Standards_Toolkit_Vs1.1_June-15-links-updated-Aug-17.pdf (sps.nhs.uk) (2) Types of Medication Errors | NCC MERP, accessed 7/10/2021. https://www.nccmerp.org/types-medication-errors