Long-Term Adherence to Direct Oral Anticoagulants in Patients with Atrial Fibrillation: A Comparative Cross-Sectional Study

Abstract

Background: Long-term treatment with direct oral anticoagulants (DOAC) is required for the majority of patients with non-valvular atrial fibrillation (AF) to prevent ischemic stroke and systemic embolism. Adherence to therapy may impact clinical outcomes. Therefore, the purpose of this study was to assess the potential impact of structured follow-up on long-term adherence to DOAC therapy compared to standard care. Methods: This is a cross sectional study on the implementation phase of medication adherence to DOACs, comparing patients with AF following completion of structured follow-up of minimally 1 year with those who received standard care. All patients used DOACs for more than two years and completed a questionnaire on adherence. Adherence was measured with the MMAS-8 score and assessed via an online webportal. Results: A total of 212 patients were included. The mean MMAS-8 score was 7.55(SD 0.93) after structured follow-up and 7.25(SD 1.01) for standard care; p=0.045. Following structured follow-up 64.1% of patients had a high adherence (MMAS score of 8) compared to 50% receiving standard care; p=0.05. Patients following structured follow-up on a once daily DOAC regime had higher MMAS-8 scores compared to those on a twice daily regime; 7.74(SD 0.74) vs. 7.00(SD 1.22); p<0.001. The rates of minor bleedings were 10.6% versus 21.4% respectively, p=0.038. Conclusion: In patients on long-term DOAC treatment, adherence to therapy was significantly increased after receiving an initial period of structured follow-up compared to standard care. Additionally, adherence to DOAC therapy was higher with once-daily treatment regimen. Significant more minor bleedings were reported in the standard care group. . These results indicate that implementation of structured follow-up of patients with AF using DOACs merits further evaluation.

Association between oral anticoagulant adherence and serious clinical outcomes in patients with atrial fibrillation: A long-term retrospective cohort study

“…We conducted some exploratory analyses (e.g., examining only GI bleeding, concurrent NSAID, antiplatelet, or gastroprotective drug therapy, HAS-BLED stratum-specific analyses) to identify potential confounders, but this deserves further study. Other studies have also observed this inverted association between exposure (adherence) and outcome (major bleeding) 51–53 or lack of association. 54–56 A plausible explanation is that it is mediated by patient understanding (e.g., via education) about their condition and OAC bleeding risk reduction, factors which also increase OAC adherence and which are variables not available in administrative datasets.…”

Direct oral anticoagulants: patient reported adherence and minor bleedings

“…An attribute that might mark the inequality in adherence among the three studied DOACs could be dose regimen as rivaroxaban has once daily dosing in contrast to dabigatran and apixaban which have twice daily dosing. In DOAC treated patients medication persistence to a once daily intake regimen is significantly higher compared to a twice daily regimen [ 12 ], recently Gulpen et al confirmed this using MMAS-8 with significantly better adherence to once daily dosing in rivaroxaban or endoxaban [ 13 ]. Previously Rossi et al (mean CHA 2 DS 2 -VASc score 4.33 p) using the Morisky scale showed that twice daily dosage of DOACs being a main predictor of inadequate adherence 103 elderly subjects [ 14 ].…”

“…Minor bleedings constitute an important issue in DOAC treated patients as the effect on adherence and the subsequent possible increment of stroke risk has barely been studied. Gulpen et al recently proposed a one-year structured follow-up plan for DOAC treated patients which significantly improved the ratio of highly adherent patients compared to standard care [ 13 ]. This proposition seems valid as most of the DOAC discontinuation due to bleeding complications occur during the first year [ 20 ].…”