Guideline-discordant dosing of direct-acting oral anticoagulants in the veterans health administration

Rose, Adam J.; Lee, Jong Soo; Berlowitz, Dan R.; Liu, Weisong; Mitra, Avijit; Yu, Hong

doi:10.1186/s12913-021-07397-x

Cited by 3 publications

(2 citation statements)

References 14 publications

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“…16 Consistent with prior, smaller studies, we found that several patient characteristics are more common in those treated with an off-label dose, including older age, weight, and dialysis dependence. 6,17 The DOACs studied (apixaban, rivaroxaban and dabigatran) account for the majority of DOAC use in the United States. 18,19 Broadly, these data provide opportunities to address this quality gap, focusing on patient profiles at-risk for off-label DOACs dose, risk of over or underdosing based on type of DOAC utilized.…”

Section: Discussionmentioning

confidence: 99%

Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients with Atrial Fibrillation

Sandhu

Kaltenbach

Chiswell

et al. 2023

Preprint

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Introduction: Among patients hospitalized for atrial fibrillation (AF), the frequency of off-label direct oral anticoagulant (DOAC) dosing, associated factors, hospital-level variation, and temporal trends in contemporary clinical practice are unknown. Methods: Using the Get With The Guidelines ® Atrial Fibrillation (GWTG-AF) registry, patients admitted from January 1st, 2014 to March 31st, 2020, and discharged on DOAC therapy were stratified according to receipt of underdosing, overdosing, or recommended dosing. Factors associated with off-label dosing were identified using logistic regression. Hospital-level variation and temporal trends were assessed. Results: Of 22,470 patients prescribed a DOAC at discharge from hospitalization for AF (66% apixaban, 29% rivaroxaban, 5% dabigatran), underdosing occurred among 2006 (8.9%), overdosing among 511 (2.3%), and recommended dosing among 19953 (88.8%). Patient-related factors associated with off-label DOAC use included age (underdosing: OR 1.06 per 1-year increase [95% CI 1.06-1.07] and overdosing: OR 1.07 per 1-year increase [1.06-1.09]), dialysis dependence (underdosing: OR 5.50 [3.76-8.05] and overdosing: OR 5.47 [2.74-10.88]), female sex (overdosing: OR 0.79 [0.63-0.99]) and weight (overdosing: OR 0.96 per 1-Kg increase [0.95-1.00]). Across hospitals, the adjusted median odds ratio for off-label DOAC use was 1.45 [95% CI 1.34-1.65] (underdosing: 1.52 [1.39-1.76] and overdosing: 1.32 [1.20-1.84]), indicating significant hospital-level variation. Hospital characteristics associated with underdosing included West vs. Northeast location (OR: 1.55 [1.04-2.31]), rural vs. urban setting (OR: 0.48 [0.28-0.83]), and number of beds (<200 vs. 500+, OR: 1.95 [1.29-2.95]). Recommended dosing significantly increased over time (81.9% in 2014 to 90.9% in 2020, p<0.0001 for trend) with a corresponding decline in underdosing (14.4% in 2014 to 6.6% in 2020, p<0.0001 for trend) and overdosing (3.8% in 2014 to 2.5% in 2020, p=0.001 for trend). Conclusion: One of 10 patients hospitalized for atrial fibrillation is discharged on off-label dosing of DOAC with significant variation across hospitals. While the proportion of patients receiving recommended dosing has significantly improved over time, opportunities to improve DOAC dosing persist.

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Section: Discussionmentioning

confidence: 99%

Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients with Atrial Fibrillation

Sandhu

Kaltenbach

Chiswell

et al. 2023

Preprint

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show abstract

“…16 Consistent with prior, smaller studies, we found that several patient characteristics are more common in those treated with an off-label dose, including older age, weight, and dialysis dependence. 6,17 The DOACs studied (apixaban, rivaroxaban, and dabigatran) account for the majority of DOAC use in the United States. 18,19 Broadly, these data provide opportunities to address this quality gap, focusing on patient profiles at risk for off-label DOAC dose, risk of overdosing or underdosing based on the type of DOAC utilized.…”

Section: Discussionmentioning

confidence: 99%

Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients With Atrial Fibrillation in the United States

Sandhu,

Kaltenbach,

Chiswell

et al. 2023

Circ: Cardiovascular Quality and Outcomes

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BACKGROUND: Among patients hospitalized for atrial fibrillation, the frequency of off-label direct oral anticoagulant (DOAC) dosing, associated factors, hospital-level variation, and temporal trends in contemporary practice are unknown. METHODS: Using the Get With The Guidelines–Atrial Fibrillation registry, patients admitted from January 1, 2014, to March 31, 2020, and discharged on DOACs were stratified according to receipt of underdosing, overdosing, or recommended dosing. Factors associated with off-label dosing (defined as underdosing or overdosing) were identified using logistic regression. Median odds ratio (OR) and time-series analyses were used to assess hospital-level variation and temporal trends, respectively. RESULTS: Of 22 470 patients (70.1±12.1 years, 48.1% female, 82.5% White) prescribed a DOAC at discharge from hospitalization for atrial fibrillation (66% apixaban, 29% rivaroxaban, and 5% dabigatran), underdosing occurred among 2006 (8.9%), overdosing among 511 (2.3%), and recommended dosing among 19 953 (88.8%). The overall rate of off-label dosing was 11.2%. Patient-related factors associated with off-label dose included age (underdosing: OR, 1.06 per 1-year increase [95% CI, 1.06–1.07]; overdosing: OR, 1.07 per 1-year increase [95% CI, 1.06–1.09]), dialysis dependence (underdosing: OR, 5.50 [95% CI, 3.76–8.05]; overdosing: OR, 5.47 [95% CI, 2.74–10.88]), female sex (overdosing: OR, 0.79 [95% CI, 0.63–0.99]), and weight (overdosing: OR, 0.96 per 1-kg increase [95% CI, 0.95–1.00]). Across hospitals, the adjusted median OR for off-label DOAC dose was 1.45 (95% CI, 1.34–1.65; underdosing: OR, 1.52 [95% CI, 1.39–1.76]; overdosing: OR, 1.32 [95% CI, 1.20–1.84]), indicating significant hospital-level variation. Over the study period, recommended dosing significantly increased over time (81.9%–90.9%; P <0.0001 for trend) with a corresponding decline in underdosing (14.4%–6.6%; P <0.0001 for trend) and overdosing (3.8%–2.5%; P =0.001 for trend). CONCLUSIONS: Over 1 in 10 patients hospitalized for atrial fibrillation are discharged on an off-label DOAC dose with significant variation across hospitals. While the proportion of patients receiving recommended dosing has significantly improved over time, opportunities to improve DOAC dosing persist.

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Effectiveness and safety of Dabigatran 110 mg versus 150 mg for Stroke Prevention in Patients with Atrial Fibrillation at High Bleeding Risk

Cheetham

Luong

et al. 2023

Clinical Therapeutics

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Guideline-discordant dosing of direct-acting oral anticoagulants in the veterans health administration

Cited by 3 publications

References 14 publications

Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients with Atrial Fibrillation

Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients with Atrial Fibrillation

Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients With Atrial Fibrillation in the United States

Effectiveness and safety of Dabigatran 110 mg versus 150 mg for Stroke Prevention in Patients with Atrial Fibrillation at High Bleeding Risk

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