Effect of New Oral Anticoagulants on Prescribing Practices for Atrial Fibrillation in Older Adults

Abstract

BACKGROUND Warfarin is effective in preventing stroke and systemic embolism in atrial fibrillation (AF) but has several limitations. The new oral anticoagulants (NOACs) address many of these limitations but their impact on prescribing practices in older adults with AF is unknown. DESIGN Retrospective observational cohort study SETTING Academic medical center in St. Louis, MO, USA PARTICIPANTS Patients age ≥75 with AF admitted from October 2010 through September 2015 (N=6568, 50% female, 15% non-white). MEASUREMENTS NOACs and warfarin prescribed at discharge were obtained from hospital discharge summaries. Linear regression was used to examine quarterly trends in use of these agents. Multivariable logistic regression was used to assess independent predictors of anticoagulant use. RESULTS NOAC use increased over time (correlation coefficient [r]=0.87, p<0.001), warfarin use did not change (r=−0.16, p=0.500), and overall anticoagulant use (NOACs and warfarin) increased (r=0.68, p=0.001). NOAC use increased over time in all age groups (ages 75–79, 80–84, 85–89) except age ≥90, but the rate of NOAC uptake was attenuated by increasing age. There was no consistent relationship between age and warfarin or overall anticoagulant use, except patients age ≥90 had consistently lower use. Overall, <45% of patients were prescribed an anticoagulant. In multivariable analysis, younger age, white race, female gender, higher hemoglobin, higher creatinine clearance, being on a medical service, hypertension, stroke/TIA, no history of intracranial hemorrhage and modified HAS-BLED score <3 increased the likelihood of receiving NOACs. CONCLUSION Prescription of anticoagulants for AF increased in older adults primarily due to an increase in the use of NOACs. Nonetheless, less than 45% of patients were prescribed an anticoagulant. Additional research is needed to optimize prescribing practices for older adults with AF.

Determinants of anticoagulant therapy in atrial fibrillation at discharge from a geriatric ward: cross sectional study

“…The increase in oral anticoagulant therapy in our study was mainly due to an increase in the NOAC prescription (from 11.8 to 33.3%; p < 0.001). The prescription of NOACs has increased, and use of VKAs has dropped significantly in many countries [21][22][23], and a progressive increase in the proportion of patients newly diagnosed with AF receiving guideline-recommended therapy, potentially driven by the availability of NOACs, was also observed [24][25][26][27]. But in the period that was covered by our study (and it is also the case now) all NOACs in Poland were [28].…”

Predictors of Oral Anticoagulants Utilization in Patients with Atrial Fibrillation

“…28,33,47 It reflects that clinicians are aware of NOACs and had a better understanding of indications for their use along with their use on antiplatelet therapy. 31,32 In contrast, antiplatelet use, paroxysmal AF, history of bleeding, history of falls, dementia, psychosis, liver disease, and use of antiplatelet were pointed as the potential reasons for OAC non-prescription by two of the studies. 29,35 Similarly, patients at higher risk of stroke who are at high risk of bleeding were found less likely to receive OAC.…”

“…This review describes the predictors of warfarin and NOAC utilization in patients with atrial fibrillation. From this review, it is revealed that NOACs were more likely to be prescribed in younger patients, [31][32][33][34]38 while warfarin was mostly used in older patients (≥75 years), except in patients ≥85 years. 27,30,32,36 In older patients, extra precautions should be followed while administering the drug, and they might have a higher incidence of contraindications with increasing age.…”

“…39 Other two studies by Fohtung et al and AbuDagga et al pointed out that NOACs were more prescribed in women than men. 31,38 This might be due to women being on lower risk of AF-associated stroke. 44 The difference might also be associated with a physician prescribing habit and belief that the benefits of warfarin use in men are higher than those in women, as men are at higher risk of stroke than women.…”

“…Therefore, a history of stroke and low stroke risk (CHADS2 score 0 or 1) were found to be the predictors of NOACs use. [31][32][33][34]38 Warfarin, being a narrow therapeutic index drug, requires close monitoring with frequent blood tests and counseling about drug and dietary interactions, which might have contributed to poor anticoagulation control and low utilization rates. 39,40,46 It was also found that patients with comorbid conditions like hypertension, coronary artery disease (CAD), peripheral artery disease (PAD), diabetes, and heart failure were more likely to be prescribed warfarin than NOACs.…”