Anticoagulant Preferences and Concerns among Venous Thromboembolism Patients

Abstract

Background: Warfarin and direct oral anticoagulants (DOACs) are used for the initial treatment and secondary prevention of venous thromboembolism (VTE), and have similar efficacy. Patient concerns and preferences are important considerations when selecting an anticoagulant, yet are not well studied. Methods: VTE patients (n = 519) were surveyed from online sources [clotconnect.org, stoptheclot.org and National Blood Clot Alliance Facebook followers (n = 495)], and a hematology clinic in Vermont (n = 24). Results: Patients were 83% female and on average (±SD) 45.7 ± 13.1 years; 65% self-reported warfarin as their initial VTE treatment and 35% a DOAC. Proportions reporting being extremely concerned about the following outcomes were as follows: recurrent VTE 33%, major bleeding 21%, moderate bleeding 16%, all-cause death 29%. When asked about oral anticoagulant characteristics, patients strongly preferred anticoagulants that are reversible (53%), and for which blood drug levels can be monitored (30%). Lower proportions agreed with statements that regular blood testing is inconvenient (18%), that they are comfortable using the newest drug versus an established drug (15%), and that it is difficult to change their diet to accommodate their anticoagulant (17%). In multivariable-adjusted models, patients tended to have had as their initial treatment, and to currently be taking, the oral anticoagulant option they personally preferred. Discussion: Patients held the greatest concern for recurrent VTE and mortality, regardless of which treatment they were prescribed. Potential weaknesses of warfarin (e.g. dietary restrictions, regular monitoring) were generally not considered onerous, while warfarin’s advantages (e.g. ability to monitor) were viewed favorably.

Patient values and preferences regarding VTE disease: a systematic review to inform American Society of Hematology guidelines

“…The same was true for patients treated for VTE, who held greater concerns for recurrent VTE risk (519 participants from 1 study; moderate certainty). 52 Studies also suggested that, although the majority of patients treated for VTE would like to avoid adverse events, only 21% to 25% are afraid of hemorrhagic events. Moreover, 87% of patients who had experienced a negative episode reported being "not afraid of" negative consequences (1019 participants from 4 studies; moderate certainty) 29,35,42,52 ( Table 3).…”

“…52 Studies also suggested that, although the majority of patients treated for VTE would like to avoid adverse events, only 21% to 25% are afraid of hemorrhagic events. Moreover, 87% of patients who had experienced a negative episode reported being "not afraid of" negative consequences (1019 participants from 4 studies; moderate certainty) 29,35,42,52 ( Table 3). Similarly, studies including cancer patients and patients with cancer-related thrombosis suggest "the interference with cancer treatment" is the most important attribute influencing their preferences for the medication, followed by "efficacy of the VTE treatment" and "the risk of major bleeding" (509 participants from 2 conjoint analyses; moderate certainty) 46,54 (Table 3).…”

“…24,32,39,40,[43][44][45][46][47][51][52][53][54]60,65,80 One study, including patients taking long-term anticoagulation, reported that only some (12%) patients using direct oral anticoagulants (DOACs) may switch to VKAs because of complications and fear of adverse effects, as well as for not being reimbursed (subgroup of 19 participants from 1 study including 1001 total participants; low certainty) 65 (Table 4). With regard to the use of oral VKAs in general, although routine monitoring does not seem to represent a limitation for patients accepting it, many (58-64%) would switch to another anticoagulant if it were equally effective and required less monitoring or dietary restrictions (2070 participants from 5 studies; low certainty) 40,45,47,52,65 (Table 4). Two studies in cancer patients receiving LMWH treatment also showed lower RIOs for attributes such as monitoring through blood tests, frequency of administration, mistakes, and costs (509 participants from 2 studies; moderate certainty) 46,54 ( Table 4).…”

“…Patients held the greatest concern for recurrent VTE (33% of them being extremely concerned) and mortality (29%), regardless of which treatment they were prescribed ⊕⊕⊕○ Moderate certainty due to RoB* 519 participants from 1 cross-sectional study Adverse events (Barcellona et al, 42 Keita et al, 29 Lutsey et al, 52 O'Meara et al 35 ) Patients considered adverse events burdensome, and the majority would like to avoid them. Some patients are fearful of hemorrhagic events (21%-25%), although most patients (87%) who have had a negative episode are "not afraid of" negative consequences.…”

Short-term versus extended anticoagulant treatment for unprovoked venous thromboembolism: A survey on guideline adherence and physicians' considerations

“…Moreover, patient's preference is among key determinants to decide on extended treatment. Since patients are generally more concerned about recurrent VTE than bleeding, this may stimulate prescribing extended treatment [19].…”