Appropriateness of inpatient dosing of direct oral anticoagulants for atrial fibrillation

Li, Ray J.; Caughey, Gillian E.; Shakib, Sepehr

doi:10.1007/s11239-021-02528-x

Cited by 5 publications

(17 citation statements)

References 30 publications

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“…The association between impaired renal function and inappropriate dosing, both underdosing and overdosing, has been a consistent finding in the literature 9,22,24,29,30 . This was confirmed by the present study as well, although the association with overdosing demonstrated only a trend favouring impaired renal function, probably because the study was underpowered.…”

Section: Discussionsupporting

confidence: 90%

“…Furthermore, the majority of patients received apixaban as per the South Australian Medicines Formulary that recommends apixaban as the first-line DOAC and rivaroxaban and dabigatran as second-and third-line DOACs respectively. 24 The finding that underdosing is more frequent than overdosing is consistent with the current literature. Sanghai et al found that 78% of inappropriate dosing was underdosing in a registry-based study in a geriatric population who received DOACs for stroke prevention.…”

Section: Discussionsupporting

confidence: 89%

“…In another Australian study, Li et al . reported 28.9% inappropriate dosing in a larger sample of 1882 patients 24 . The varying rates of prevalence are probably explained by the methodological differences between studies.…”

Section: Discussionmentioning

confidence: 95%

“…Their sample consisted of only patients who received DOACs for stroke prevention in atrial fibrillation. Furthermore, the majority of patients received apixaban as per the South Australian Medicines Formulary that recommends apixaban as the first‐line DOAC and rivaroxaban and dabigatran as second‐ and third‐line DOACs respectively 24 …”

Section: Discussionmentioning

confidence: 99%

“…10 In another Australian study, Li et al reported 28.9% inappropriate dosing in a larger sample of 1882 patients. 24 The varying rates of prevalence are probably explained by the methodological differences between studies. For example, although Pattullo et al, similarly to the present study, used product information to determine the appropriateness of dosing for dabigatran and rivaroxaban, they used a local state-based guideline that used a higher CrCl cut-off of 30 mL/min for apixaban.…”

Section: Discussionmentioning

confidence: 99%

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Prevalence and predictors of inappropriate dosing of direct oral anticoagulants

Pham

Anpalahan

2022

Internal Medicine Journal

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BackgroundInformation on inappropriate dosing of direct oral anticoagulants (DOACs) is scarce in the Australian context.AimTo describe the prevalence and potential predictors of inappropriate dosing of DOACs.MethodsPatients who received DOACs during admission under a general medical unit over a 2‐year period (from January 2017 to December 2018) were retrospectively studied. Appropriateness of the dosing regimen was verified against the recommendations of the Therapeutic Goods Administration of Australia. Data were obtained from medical records and analysed in univariate and multivariate logistic regression models. The variables associated with under‐ and overdosing were also determined.ResultsA total of 203 (mean age 71.6 ± 14.5 years, females 52%) patients were studied. Inappropriate dosing occurred in 44 (22%) patients: underdosing 27 (13%) and overdosing 17 (8%). Age ≥75 years (P < 0.01), lower estimated creatinine clearance (CrCl) (P < 0.01), prescription of DOAC prior to index admission (P < 0.01) and higher Charlson Comorbidity Index (P < 0.01), HAS‐BLED (P < 0.01) and CHA2DS2‐VASc (P < 0.01) scores had a significant univariate association with inappropriate dosing. However, in the multivariate logistic regression only lower CrCl (odds ratio (OR) 1.04, 95% confidence interval (CI): 1.01–1.07, P < 0.01) and prescription of DOAC prior to index admission (OR 2.62, 95% CI: 1.01–6.75, P = 0.047) remained significantly associated with inappropriate dosing. Impaired renal function also had a significant association with underdosing (OR 1.04, 95% CI: 1.01–1.07, P = 0.01) and borderline significance with overdosing (OR 1.03, 95% CI: 1.00–1.07, P = 0.06).ConclusionInappropriate dosing of DOACs, especially underdosing, is common in clinical practice. Clinicians should exercise due diligence when prescribing DOACs to patients with renal impairment and in outpatient settings.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Prevalence and predictors of inappropriate dosing of direct oral anticoagulants

Pham

Anpalahan

2022

Internal Medicine Journal

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Potentially inappropriate prescribing in multimorbid and polymedicated older adults with AF: A Systematic Review and Meta-Analysis

Amrouch,

Vauterin,

Amrouch

et al. 2023

Drugs Aging

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Aim Polypharmacy in multimorbid older patients with atrial fibrillation (AF) is a risk factor for potentially inappropriate prescribing (PIP). We aimed to systematically assess the evidence on the prevalence of PIP and its impact on adverse health outcomes in this patient group. Methods A systematic search of the published peer-reviewed literature describing the prevalence of PIP and/or its association with adverse health outcomes in multimorbid (AF plus one comorbidity) and polymedicated (≥ 2 drugs) adults ≥ 65 years was done up to March 2023. A meta-analysis of the prevalence of PIP of (direct) oral anticoagulants ((D)OACs) was conducted using a random-effects model. Leave-one-out analysis was performed with R (version 4.2.2) and RStudio (version 2022.12.0+353). Results Of the 12 studies included, only one reported on the prevalence of overall PIP (65%). The meta-analysis of 10 studies assessing PIP of (D)OACs produced a pooled prevalence [95% confidence interval (CI)] of 35% [30–40%], with significant heterogeneity between the included studies (I 2 95%). No statistically significant association was reported in three studies between PIP of (D)OACs, cardiovascular (CV) and all-cause mortality, hospital readmission, CV hospitalisation and stroke. Reported associations between PIP and major bleeding differed, with one study demonstrating a significant association (odds ratio 2.17; 95% CI 1.14–4.12) and the other study not showing such association. Conclusion This systematic review highlights the scarce evidence regarding the prevalence of PIP and its association with adverse health outcomes in multimorbid older adults with AF. Large, prospective and better-designed studies are needed. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-023-01078-6.

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