Patient Preferences for Oral Anticoagulation Therapy in Atrial Fibrillation: A Systematic Literature Review

Abstract

Objectives Since the introduction of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs), an additional treatment option, apart from VKAs, has become available for stroke prevention in patients with atrial fibrillation (AF). For various reasons, it is important to consider patients' preferences regarding type of medication, particularly in view of the established relationship between preferences towards treatment, associated burden of treatment, and treatment adherence. This review aimed to systematically analyse the scientific literature assessing the preferences of AF patients with regard to long-term oral anticoagulant (OAC) treatment. Methods We searched the MEDLINE, Scopus and EMBASE databases (from 1980 to 2015), added records from reference lists of publications found, and conducted a systematic review based on all identified publications. Outcomes of interest included any quantitative information regarding the opinions or preferences of AF patients towards OAC treatment, ideally specified according to different clinical or convenience attributes describing different OAC treatment options. Results Overall, 27 publications describing the results of studies conducted in 12 different countries were included in our review. Among these, 16 studies analysed patient preferences towards OACs in general. These studies predominantly assessed which benefits (mainly lower stroke risk) AF patients would require to tolerate harms (mainly higher bleeding risk) associated with an OAC. Most studies showed that patients were willing to accept higher bleeding risks if a certain threshold in stroke risk reduction could be reached. Nevertheless, most of the publications also showed that the preferences of AF patients towards OACs may differ from the perspective of clinical guidelines or the perspective of physicians. The remaining 11 studies included in our review assessed the preferences of AF patients towards specific OAC medication options, namely NOACs versus VKAs. Our review showed that AF patients prefer easy-to-administer treatments, such as treatments that are applied once daily without any food/drug interactions and without the need for bridging and frequent blood controls. Conclusion Stroke risk reduction and a moderate increase in the risk of bleeding are the most important attributes for an AF patient when deciding whether they are for or against OAC treatment. If different anticoagulation options have similar clinical characteristics, convenience attributes matter to patients. In this review, AF patients favour attribute levels that describe NOAC treatment.

Methods to perform systematic reviews of patient preferences: a literature survey

“…2013Umar [35]2012Elicitation & use of patients’ preferencesin the treatment of psoriasis: a systematic review“To critically review the scientific evidence regarding the elicitation & use of patients’ preferences in psoriasis treatment.”Nov. 2009Van Brunt [10]2011Preferences related to attention-deficit/hyperactivity disorder & its treatment“To identify & summarize published research on preferences related ADHD & its treatment, while suggesting directions for future research.”UnclearVon Arx [36]2014The patient perspective of diabetes care:a systematic review of stated preference research“To examine how stated preference methods are applied in diabetes care, & to evaluate the value of this information in developing the patient perspective in clinical & policy decisions.”May 2013Wilke [37]2016Patient preferences for oral anti-coagulation therapy in atrial fibrillation:a systematic literature review“To systematically analyse the scientific literature assessing the preferences of AF patients with regard to long-term oral anticoagulant treatment.”2015Wortley [38]2014Assessing stated preferences for colorectal cancer screening: a critical systematic review of discrete choice experiments“To undertake a systematic review of discrete choice experiments of CRC screening.”April 2013 ADHD Attention-deficit/hyperactivity disorder, AF Atrial fibrillation, BPH Benign prostatic hyperplasia, BWS Best-worst scaling, COPD Chronic obstructive pulmonary disease, CRC Colorectal cancer, DCE Discrete choice experiment, NSCLC Non-small-cell lung cancer, SGI Standard gamble interview, TTO Time trade-off …”

Fibrilación auricular: enfoque para el médico no cardiólogo

“…Estudios postmercadeo recientes confirman la seguridad y eficacia de dabigatran y rivaroxaban en pacientes con FA no valvular (36,38), aun sin contar con estudios postmercadeo para apixaban y edoxaban que reporten datos de seguridad y eficacia en mundo real. Existen múltiples registros que describen el uso de los anticoagulantes directos fuera de los ensayos clínicos controlados, donde se ha evidenciado una tendencia de uso de los anticoagulantes directos cada vez mayor, prefiriendo estos frente a warfarina en pacientes de edad avanzada, con riesgo alto de sangrado, riesgo alto de eventos embólicos y mayor tasa de comorbilidades (26,(42)(43)(44)79); excepto para dabigatran, que tiende a prescribirse más en pacientes jóvenes, con riesgo de sangrado menor y menos tasa de comorbilidades que se cree está relacionada con la mayor tasa de sangrado observada en los datos del estudio RE-LY y en los diferentes metanálisis y estudios de registro (26,(42)(43)(44)79). Una de las preocupaciones existentes respecto a la seguridad de estos nuevos agentes era la ausencia de terapias para la reversión de su efecto ante un evento de sobreanticoagulación o sangrado mayor (12, 16-18, 26, 27, 39, 40, 42, 43, 80), que se ha superado parcialmente tras contarse actualmente con antídoto contra los inhibidores directos de trombina (idarucizumab) (1, 5, 80-82) e inhibidores del factor Xa (adexanet alfa) (1,5,80,83) que han sido seguros y eficaces en estudios fase II (81, 83) con aprobación para idarucizumab por la FDA y EMA tras la publicación preliminar de seguridad y eficacia del estudio fase III (82), teniendo en cuenta que ninguno de ellos esta aun disponible en el medio.…”

“…Este puntaje predice la falla a terapia con warfarina en pacientes con un puntaje ≥ 2 puntos (84, 85, 87) y aunque es una herramienta de fácil uso que brinda información importante para ayudar a seleccionar a los candidatos ideales para el uso de anticoagulantes orales directos, no fue incluida en las recomendaciones de las guías de práctica clínica recientemente actualizadas, dado que cada vez hay más evidencia fuerte a favor de usar anticoagulantes orales directos como primera línea de tratamiento, reservándose la warfarina para casos donde estén contraindicados estos medicamentos (disfunción renal severa, presencia de valvular mecánicas o estenosis valvular mitral significativa). Sin embargo el costo de estos anticoagulantes es mucho mayor que el de warfarina (12,19,20,25,27,31,32,40,71,72,74,79), por lo cual su uso debe ser respaldado con costoefectividad a la hora de emitir recomendaciones para su uso en países de medianos ingresos como Colombia (73). En la actualidad existen 3 publicaciones que evalúan la costoefectividad de estos medicamentos en Colombia (31,41,54,71), las cuales han mostrado resultados conflictivos, en su mayoría a favor de warfarina como la estrategia más costoefectiva y a favor de dabigatran como el anticoagulante directo de mejor relación de costoefectividad, con la salvedad que es el medicamento asociado a mayor tasa de sangrado digestivo en los diferentes estudios clínicos y registros de vida real (31,41,54,71).…”

Association between subjective risk perception and objective risk estimation in patients with atrial fibrillation: a cross-sectional study

“…It has been shown that the extent of information perceived influenced patients' preferences towards or against OAC treatment the most. 9 Clinicians use algorithms like CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, sex category) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile INR, elderly, drugs or alcohol) scores [10][11][12] to predict the balance of future risk for stroke and embolic events versus bleeding in an individual patient. A recent survey of the European Heart Rhythm Association proved that a considerable amount of time and resources are needed in daily clinical practice to communicate risk/benefit ratios to patients suffering from AF: several centres have established special OAC clinics and initial visits mostly lasted 21-30 min.…”