Patterns of long‐term use of non‐vitamin K antagonist oral anticoagulants for non‐valvular atrial fibrillation: Quebec observational study

Douros, Antonios; Renoux, Christel; Coulombe, Janie; Suissa, Samy

doi:10.1002/pds.4333

Cited by 20 publications

(36 citation statements)

References 33 publications

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“…The high non‐persistence rates of DOAC use amongst patient with atrial fibrillation found in our study (34% for DOACs, 26% for apixaban, 27% for dabigatran and 42% for rivaroxaban, all at 1 year) were comparable to the non‐persistence found in other observational studies of patients using either VKA or DOACs after 1 year in which close patient monitoring was lacking. Neither Germany or France have specialized anticoagulant clinics to monitor VKA users.…”

Section: Discussionsupporting

confidence: 74%

Persistence of oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study

Zielinski

Rein

Teichert

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. AbstractBackground: In contrast to vitamin K antagonists (VKA), direct oral anticoagulants (DOAC's) are not strictly monitored and dose titrated by anticoagulation clinics in the Netherlands. This may affect drug persistence of atrial fibrillation (AF) patients, whom often require lifelong treatment.Objectives: To assess persistence of DOACs and of VKAs in patients with AF.

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Section: Discussionsupporting

confidence: 74%

Persistence of oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study

Zielinski

Rein

Teichert

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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“…These biases are particularly likely for hospitalized renal outcomes; according to their respective summary of product characteristics, DOAC dose reduction may be necessary in patients with moderate-to-severe renal impairment. As the extent of anticoagulation by DOAC therapy cannot be monitored, it is likely that this factor led prescribers to preferentially prescribe a VKA to patients with a recent history of renal outcomes rather than a DOAC, as reported elsewhere [ 41 ]. This selection in clinical practice, combined with the use of hospitalization data to define renal outcomes, may explain the strong spurious protective association observed in VKA new users, and, reciprocally, the strong and positive association observed with DOAC therapy.…”

Section: Discussionmentioning

confidence: 99%

Non-bleeding Adverse Events with the Use of Direct Oral Anticoagulants: A Sequence Symmetry Analysis

et al. 2018

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IntroductionPostmarketing pharmacovigilance reports have raised concerns about non-bleeding adverse events associated with direct oral anticoagulants (DOACs), but only limited results are available from large claims databases.ObjectiveThe aim of this study was to assess the potential association between DOAC initiation and the onset of four types of non-bleeding adverse events by sequence symmetry analysis (SSA).MethodsSSA was performed using nationwide data from the French National Healthcare databases (Régime Général, 50 million beneficiaries) to assess a cohort of 386,081 DOAC new users for the first occurrence of four types of non-bleeding outcomes: renal, hepatic, skin outcomes identified by using hospitalization discharge diagnoses, and gastrointestinal outcomes by using medication reimbursement. Asymmetry in the distribution of each investigated outcome occurring before and after initiation of DOAC therapy was used to test the association between DOAC therapy and these outcomes. SSA inherently controls for time-constant confounders, and adjusted sequence ratios were computed after correcting for temporal trends. Negative (glaucoma) and positive (bleeding, depressive disorders) control outcomes were used and analyses were replicated on a cohort of 310,195 patients initiating a vitamin K antagonist (VKA).ResultsThis study demonstrated the expected positive association between either DOAC or VKA therapy and hospitalised bleeding and initiation of antidepressant therapy, while no association was observed between either DOAC or VKA therapy and initiation of antiglaucoma medications. For DOAC therapy, signals were the associations with hepatic outcomes, including acute liver injury [for the 3-month time window, aSR3 = 2.71, 95% confidence interval (CI) 1.79–4.52]; gastrointestinal outcomes, including initiation of drugs for constipation and antiemetic drugs (aSR3 = 1.31, 95% CI 1.27–1.36; and 1.17, 95% CI 1.12–1.22, respectively); and kidney diseases (aSR3 = 1.33, 95% CI 1.29–1.37).ConclusionResults of this nationwide study suggest that DOACs are associated with rare but severe liver injury and more frequent gastrointestinal disorders. A low risk of kidney injury with DOAC therapy can also not be excluded.Electronic supplementary materialThe online version of this article (10.1007/s40264-018-0668-9) contains supplementary material, which is available to authorized users.

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“…The study findings can be applied to current practice where warfarin is considered and continues to be used and, more generally, if the barriers to warfarin use also impede the uptake of DOACs. In Australia and elsewhere, DOAC dispensing has increased concomitantly with decreasing warfarin, although warfarin remains commonly prescribed [44,[47][48][49][50][51][52][53][54][55], and recent surveys show that warfarin is favoured amongst a significant proportion of clinicians [56], particularly for patients in whom use is established. In Australia, reports indicate that around one-quarter to one-third of initial anticoagulant prescribing is for warfarin [48,49,54].…”

Section: Implications For Current Practicementioning

confidence: 99%

“…Recent studies report a high proportion of uncoagulated patients, for example, 32% [43] and 57% [52], and evidence also demonstrates that doctors remain cautious about bleeding risks, leading to non-evidence-based DOAC use. One large multicentre study of general practice patients showed that 40% of patients with AF and 40% of those at a high risk of stroke were not receiving anticoagulation despite trends towards increasing DOAC use [51]. Moreover, DOACs have been preferentially prescribed to younger patients, those with lower bleeding risks, fewer comorbidities and/or with lower stroke risk [50][51][52][53].…”

Section: Implications For Current Practicementioning

confidence: 99%

“…One large multicentre study of general practice patients showed that 40% of patients with AF and 40% of those at a high risk of stroke were not receiving anticoagulation despite trends towards increasing DOAC use [51]. Moreover, DOACs have been preferentially prescribed to younger patients, those with lower bleeding risks, fewer comorbidities and/or with lower stroke risk [50][51][52][53]. This has also been shown to occur in Australia, where patients with lower comorbidity burden are preferentially prescribed higher dose DOACs [57].…”

Section: Implications For Current Practicementioning

confidence: 99%

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Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

et al. 2020

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Background: Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods: We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results: One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86-1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions: Specialist feedback in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration: ANZCTRN12611000076976 Retrospectively registered.

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Patterns of long‐term use of non‐vitamin K antagonist oral anticoagulants for non‐valvular atrial fibrillation: Quebec observational study

Abstract: Older, high-risk patients are less likely to initiate NOACs than VKAs. NOAC users show a higher long-term persistence than VKA users, and older, high-risk patients are less likely to discontinue anticoagulation treatment.

Cited by 20 publications

References 33 publications

Persistence of oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study

Persistence of oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study

Non-bleeding Adverse Events with the Use of Direct Oral Anticoagulants: A Sequence Symmetry Analysis

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

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