Patient Adherence to Novel Oral Anticoagulants (NOACs) for the Treatment of Atrial Fibrillation and Occurrence of Associated Bleeding Events: A Systematic Review and Meta-analysis

Shehab, Abdulla; Bhagavathula, Akshaya Srikanth; Abebe, Tamrat; Abegaz, Tadessa M.; Elnour, Asim Ahmed; Sabbour, Hani; Uzzafer, Masood; Hersi, Ahmad; Hamad, Adel Khalifa Sultan

doi:10.2174/1570161116666180123111949

Cited by 17 publications

(15 citation statements)

References 44 publications

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“…The I 2 statistics obtained in this study ranged from 93.8 to 99.5%. These values are consistent with those noted in other published meta-analyses of medication adherence across indications [ 19 , 70 – 73 ].…”

Section: Discussionsupporting

confidence: 92%

Real-world adherence to, and persistence with, once- and twice-daily oral disease-modifying drugs in patients with multiple sclerosis: a systematic review and meta-analysis

Nicholas

Edwards²,

Edwards³

et al. 2020

BMC Neurol

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Background Nonadherence to disease-modifying drugs (DMDs) for multiple sclerosis (MS) is associated with poorer clinical outcomes, including higher rates of relapse and disease progression, and higher medical resource use. A systematic review and quantification of adherence and persistence with oral DMDs would help clarify the extent of nonadherence and nonpersistence in patients with MS to help prescribers make informed treatment plans and optimize patient care. The objectives were to: 1) conduct a systematic literature review to assess the availability and variability of oral DMD adherence and/or persistence rates across ‘real-world’ data sources; and 2) conduct meta-analyses of the rates of adherence and persistence for once- and twice-daily oral DMDs in patients with MS using real-world data. Methods A systematic review of studies published between January 2010 and April 2018 in the PubMed database was performed. Only studies assessing once- and twice-daily oral DMDs were available for inclusion in the analysis. Study quality was evaluated using a modified version of the Newcastle-Ottawa Scale, a tool for assessing quality of observational studies. The random effects model evaluated pooled summary estimates of nonadherence. Results From 510 abstracts, 31 studies comprising 16,398 patients with MS treated with daily oral DMDs were included. Overall 1-year mean medication possession ratio (MPR; n = 4 studies) was 83.3% (95% confidence interval [CI] 74.5–92.1%) and proportion of days covered (PDC; n = 4 studies) was 76.5% (95% CI 72.0–81.1%). Pooled 1-year MPR ≥80% adherence ( n = 6) was 78.5% (95% CI 63.5–88.5%) and PDC ≥80% ( n = 5 studies) was 71.8% (95% CI 59.1–81.9%). Pooled 1-year discontinuation ( n = 20) was 25.4% (95% CI 21.6–29.7%). Conclusions Approximately one in five patients with MS do not adhere to, and one in four discontinue, daily oral DMDs before 1 year. Opportunities to improve adherence and ultimately patient outcomes, such as patient education, medication support/reminders, simplified dosing regimens, and reducing administration or monitoring requirements, remain. Implementation of efforts to improve adherence are essential to improving care of patients with MS.

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Section: Discussionsupporting

confidence: 92%

Real-world adherence to, and persistence with, once- and twice-daily oral disease-modifying drugs in patients with multiple sclerosis: a systematic review and meta-analysis

Nicholas

Edwards²,

Edwards³

et al. 2020

BMC Neurol

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“…It is notable, however, that DOAC is being increasingly used in the clinical practice both in Saudi Arabia and the Middle East [18]. Even though the general adherence to DOAC, irrespective to Ramadan, is reported as suboptimal worldwide [12], the current study showed a remarkably low adherence in terms of approval-conform intake even before the beginning of Ramadan. Many DOAC users (particularly those treated with dabigatran) were prescribed their anticoagulant inappropriately, resulting in under-dosing.…”

Section: Discussioncontrasting

confidence: 55%

“…What is known from a real world systematic review comprising 1.6 million patients with atrial fibrillation is that overall adherence to DOAC (irrespective of Ramadan) is relatively low. Moreover, the study highlighted suboptimal adherence to DOAC as a risk factor affecting clinical outcomes, with higher rate of non-adherent patients having bleeding events [12].…”

Section: Introductionmentioning

confidence: 96%

Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study

Batarfi

Alenezi

Alshehri

et al. 2020

J Thromb Thrombolysis

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Fasting Ramadan is known to influence patients' medication adherence. Data on patients' behavior to oral anticoagulant (OAC) drug intake during Ramadan is missing. We aimed to determine patient-guided modifications of OAC medication regimen during Ramadan and to evaluate its consequences. A multicenter cross-sectional study conducted in Saudi Arabia. Data were collected shortly after Ramadan 2019. Participants were patients who fasted Ramadan and who were on long-term anticoagulation. Patient-guided medication changes during Ramadan in comparison to the regular intake schedule before Ramadan were recorded. Modification behavior was compared between twice daily (BID) and once daily (QD) treatment regimens. Rates of hospital admission during Ramadan were determined. We included 808 patients. During Ramadan, 53.1% modified their intake schedule (31.1% adjusted intake time, 13.2% skipped intakes, 2.2% took double dosing). A higher frequency of patient-guided modification was observed in patients on BID regimen compared to QD regimen. During Ramadan, 11.3% of patients were admitted to hospital. Patient-guided modification was a strong predictor for hospital admission. Patient-guided modification of OAC intake during Ramadan is common, particularly in patients on BID regimen. It increases the risk of hospital admission during Ramadan. Planning of OAC intake during Ramadan and patient education on the risk of low adherence are advisable.

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“…These reviews, however, focus on discontinuation of therapy (not implementation or execution of dosing), or when looking at implementation, only focus on DOACs, summarise evidence from randomised controlled trials (which do not Open access reflect the day to day behaviours of patients) and provide a narrative summary of results with no meta-analysis. [19][20][21] Further, no studies have summarised the evidence on determinants of adherence in this patient population and the association between adherence and outcomes (clinical or economical). The objective of this systematic review and meta-analysis was to summarise the evidence from observational studies on the extent, determinants and impacts of adherence to all OACs among patients with AF.…”

Section: Introductionmentioning

confidence: 99%

Adherence to oral anticoagulants among patients with atrial fibrillation: a systematic review and meta-analysis of observational studies

et al. 2020

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IntroductionMedications cannot exert their effect if not taken as prescribed by patients. Our objective was to summarise the observational evidence on adherence to oral anticoagulants (OACs) among patients with atrial fibrillation (AF).MethodsIn March 2019, we systematically searched PubMed/Medline, Embase, CINAHL and PsycINFO (from inception) for observational studies measuring adherence, its determinants and impacts in patients with AF. Mean adherence measures and corresponding proportions of adherent patients were pooled using random effects models. Factors shown to be independently associated with adherence were extracted as well as the clinical and economic outcomes of adherence.ResultsWe included 30 studies. Pooled mean adherence scores of over half a million patients with AF 6 months and 1 year after therapy initiation were 77 (95% CI: 74–79) and 74 (68–79) out of 100, respectively. Drug-specific pooled mean adherence score at 6 months and 1 year were as follows: rivaroxaban: 78 (73–84) and 77 (69–86); apixaban: 77 (75–79) and 82 (74–89); dabigatran: 74 (69–79) and 75 (68–82), respectively. There was inadequate information on warfarin for inclusion in meta-analysis.Factors associated with increased adherence included: older age, higher stroke risk, once-daily regimen, history of hypertension, diabetes or stroke, concomitant cardiovascular medications, living in rural areas and being an experienced OAC user. Non-adherent patients were more likely to experience stroke and death, and incurred higher medical costs compared with patients with poor adherence.ConclusionsOur findings show that up to 30% of patients with AF are non-adherent, suggesting an important therapeutic challenge in this patient population.

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Patient Adherence to Novel Oral Anticoagulants (NOACs) for the Treatment of Atrial Fibrillation and Occurrence of Associated Bleeding Events: A Systematic Review and Meta-analysis

Cited by 17 publications

References 44 publications

Real-world adherence to, and persistence with, once- and twice-daily oral disease-modifying drugs in patients with multiple sclerosis: a systematic review and meta-analysis

Real-world adherence to, and persistence with, once- and twice-daily oral disease-modifying drugs in patients with multiple sclerosis: a systematic review and meta-analysis

Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study

Adherence to oral anticoagulants among patients with atrial fibrillation: a systematic review and meta-analysis of observational studies

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