Factors Associated With the Choice of Oral Anticoagulant Class in the Older Patients: An Observational Study

Abstract

Aim: Oral anticoagulants are the first-line drugs for treating thrombotic disorders related to nonvalvular atrial fibrillation and for treating deep vein thrombosis, diseases that increase in prevalence with age. Older patients have a greater risk of thrombotic and hemorrhagic events and are more prone to drug interactions. Given this backdrop, we wanted to determine the factors associated with the prescription of direct oral anticoagulants and vitamin K antagonists in older patients. Methods: We performed a cross-sectional observational study using a hospital prescription database. The study population consists of 405 older patients who were given oral anticoagulants. The 2 variables of interest were the prescription of 1 of the 2 classes of oral anticoagulants (direct oral anticoagulants vs vitamin K antagonists) and appropriateness of oral anticoagulant prescribing according to Summary of Product Characteristics (potentially inappropriate vs appropriate). Results: The factors associated with direct oral anticoagulant prescribing were the female gender (odds ratio [OR]: 1.87, 95% confidence interval [CI]: 1.22-2.88) and initiation during hospital stay (OR: 2.56, 95% CI: [1.52-4.32]). Stage 4 and 5 chronic kidney diseases (OR: 0.39, 95% CI: [0.19-0.79] and OR: 0.07, 95% CI: [0.01-0.53]) were factors favoring vitamin K antagonist prescription. Being 90 years of age or more (OR: 2.05, 95% CI: [1.06-3.98]) was a factor for potentially inappropriate anticoagulant prescribing. The gastroenterology department (OR: 2.91, 95% CI: [1.05-8.11]) was associated with potentially inappropriate anticoagulant prescribing. Conclusions: Direct oral anticoagulants are the drugs of choice for anticoagulant treatment, including in older adults. The female gender and the initiation during hospital stay increased the chances of being prescribed a direct oral anticoagulant in older adults. Stage 4 and 5 chronic kidney disease increased the likelihood of having a vitamin K antagonist prescribed. Our study also revealed a persistence of potentially inappropriate oral anticoagulant prescriptions in older patients.

Direct oral anticoagulants vs vitamin K antagonist on dementia risk in atrial fibrillation: systematic review with meta-analysis

“…It is important to highlight that DOAC’s true beneficial effect on dementia risk might have been hindered due to DOAC’s tendency to be more often prescribed when treatment is initiated during hospitalization [ 41 ], thus including patients with more uncontrolled comorbidities and consequently more susceptible to neurocognitive impairment. Consequently, its effect may be higher than the results presented in this review.…”

Assessment of exposure to direct oral anticoagulants in elderly hospitalised patients

“…As well as improving patient safety, well‐being and experience of this already valuable anticoagulant treatment, increasing these indications to promote the more widespread introduction of a therapeutic monitoring system, including older patients, could bring benefits to health care systems in terms of improved delivery of care and reduction of costs associated with DOAC‐related hospital admissions. Scheduled monitoring of DOAC therapy could be used as an opportunity to assess and promote adherence, adverse effects and reassess the most appropriate anticoagulant drug and dosage based on the individual patient’s characteristics 39 . In consequence, the support of the EMA for an exploration of the benefits of modification of dosing recommendations is to be welcomed.…”

“…Scheduled monitoring of DOAC therapy could be used as an opportunity to assess and promote adherence, adverse effects and reassess the most appropriate anticoagulant drug and dosage based on the individual patient's characteristics. 39 In consequence, the support of the EMA for an exploration of the benefits of modification of dosing recommendations is to be welcomed.…”

Correct dosing, adherence and persistence of DOACs in atrial fibrillation and chronic kidney disease: a systematic review and meta-analysis

“…We also excluded systematic reviews, clinical trials, conference abstracts, letters and case reports. Following this, 147 were excluded, leaving 19 eligible studies [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47] for systematic literature review. After assessing studies that used the same data sources, and therefore, with overlapping populations, we included seven studies [28][29][30][31][32][33][34] in the meta-analysis, of which two dealt with medication adherence 33 34 and five [28][29][30][31][32] dealt with fidelity of prescribing to recommended doses (figure 1).…”

“…Of the 19 studies, [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46] all were observational (table 2).…”