Prescribing of Direct Oral Anticoagulants in Atrial Fibrillation Based on Estimation of Renal Function Using Standard and Modified Cockcroft–Gault Equations: A Retrospective Analysis

Kucey, Melissa; Bolt, Jennifer; Albers, Lori; Bell, Ali; Iroh, Nkem; Toppings, Julie

doi:10.4212/cjhp.v69i5.1596

Cited by 3 publications

(7 citation statements)

References 17 publications

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“…We observed a high percentage of underdosing in the present study, in particular for apixaban, confirming earlier studies (Kucey et al, 2016 ; Pattullo et al, 2016 ; Steinberg et al, 2016 ; Basaran et al, 2017 ). This could be due to the relatively more complex dosing instructions for this DOAC, necessitating a dose reduction only when at least 2 out of the 3 following factors are met: serum creatinine ≥ 1.5 mg/dL, weight ≤ 60 kg, and/or age ≥ 80 years.…”

Section: Discussionsupporting

confidence: 92%

“…The main finding of this observational study was that DOACs are frequently dosed inappropriately in patients with AF or VTE despite the fact that they are in use for several years now, with underdosing being more common than overdosing. Inappropriate dosing rates in this study were found in the range reported in the literature for adult AF patients on DOACs (Kucey et al, 2016 ; Steinberg et al, 2016 ; Basaran et al, 2017 ; Shrestha et al, 2017 ). Inappropriate dosing rates in AF patients varied from 7.7 to 42.0% for dabigatran, from 13.0 to 29.8% for rivaroxaban, and from 12.7 to 48.1% for apixaban.…”

Section: Discussionsupporting

confidence: 57%

“…Several studies have reported a poor adherence rate with dosing guidelines for the DOACs regardless of the renal function. These data suggest that inappropriate DOAC dosing is common and varies from 12.8 to 34.0% of adult hospitalized AF patients as well as other patients taking a DOAC (Armbruster et al, 2014 ; Larock et al, 2014 ; Kucey et al, 2016 ; Pattullo et al, 2016 ; Steinberg et al, 2016 ; Basaran et al, 2017 ; Howard et al, 2017 ; Shrestha et al, 2017 ; Whitworth et al, 2017 ).…”

Section: Introductionmentioning

confidence: 99%

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Appropriateness of DOAC Prescribing Before and During Hospital Admission and Analysis of Determinants for Inappropriate Prescribing

et al. 2018

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Background and Objectives: Appropriate dosing of direct oral anticoagulants (DOACs) is required to avoid under- and overdosing that may precipitate strokes or thromboembolic events and bleedings, respectively. Our objective was to analyze the appropriateness of DOAC dosing according to the summaries of product characteristics (SmPC). Furthermore, determinants for inappropriate prescribing were investigated.Methodology: Retrospective cohort study of hospitalized patients aged ≥60 years with at least one DOAC intake during hospital stay. Descriptive analyses were used to summarize the characteristics of the study population. Chi-square test was used to evaluate differences between DOACs. Binary logistic regression analysis was performed to assess determinants for inappropriate prescribing.Results: For the 772 included patients, inappropriate dosing occurred in 25.0% of hospitalizations with 23.4, 21.9, and 29.7% for dabigatran, rivaroxaban, and apixaban, respectively (p = 0.084). Underdosing was most prevalent for apixaban (24.5%) compared to dabigatran (14.0%) and rivaroxaban (12.8%), p < 0.001. In 67.1% (apixaban), 26.7% (dabigatran), and 51.2% (rivaroxaban) of underdosed DOAC cases according to the SmPC, the dose would be considered appropriate according to the European Heart Rhytm Association (EHRA) guidelines. Overdosing was observed in 4.5% (apixaban), 4.7% (dabigatran), and 7.7% (rivaroxaban) of patients. For all DOACs, our analysis showed an age ≥80 years (p = 0.036), use of apixaban (p = 0.026), DOAC use before hospitalization (p = 0.001), intermediate renal function (p = 0.014), and use of narcotic analgesics (p = 0.019) to be associated with a higher rate of inappropriate prescribing. Undergoing surgery was associated with a lower odds of inappropriate prescribing (p = 0.012). For rivaroxaban, use of medication for hypothyroidism (p = 0.027) and the reduced dose (p < 0.001) were determinants for inappropriate prescribing. Treatment of venous thromboembolism was associated with less errors (p = 0.002). For apixaban, severe renal insufficiency (p < 0.001) and initiation in hospital (p = 0.016) were associated with less and the reduced dose (p < 0.001) with more inappropriate prescribing. No determinants were found in the dabigatran subgroup.Conclusions: Inappropriate DOAC prescribing is frequent with underdosing being the most common drug related problem when using the SmPC as reference. More appropriate prescriptions were found when taking the EHRA guidelines into account. Analysis of determinants of inappropriate prescribing yielded insights in the risk factors associated with inappropriate DOAC prescriptions.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 57%

Section: Introductionmentioning

confidence: 99%

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Appropriateness of DOAC Prescribing Before and During Hospital Admission and Analysis of Determinants for Inappropriate Prescribing

et al. 2018

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“…[2][3][4] Several studies have shown that DOACs are frequently prescribed incorrectly with inappropriate dosing varying from 12.8 to 42.8% of AF patients as well as other patients. 3,[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Inappropriate prescribing has been shown to be an independent risk factor for adverse drug events leading to potential clinical consequences including thromboembolism, bleeding, hospitalization and death. 1,20 Older patients are especially susceptible to adverse drug events associated with inappropriate prescribing due to decreased drug metabolism, increased prevalence of hepatic/renal dysfunction, and the higher likelihood of drug-drug interactions as a result of polypharmacy.…”

Section: Introductionmentioning

confidence: 99%

Determinants for under‐ and overdosing of direct oral anticoagulants and physicians' implementation of clinical pharmacists' recommendations

Moudallel

Cornu

Dupont

et al. 2021

Brit J Clinical Pharma

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To analyse the appropriateness of direct oral anticoagulant (DOAC) dosing and determinants for under-and overdosing as well as acceptance and implementation rates of pharmacists' interventions. Methods: Cross-sectional study in a tertiary hospital in hospitalized patients with atrial fibrillation on DOACs in 2019 (n = 1688). Primary outcome was the proportion of patients with inappropriate DOAC prescribing with identification of determinants for under-and overdosing. Secondary outcomes included acceptance and implementation rates of pharmacists' recommendations and determination of reasons for nonacceptance/nonimplementation. Results: Inappropriate prescribing was observed in 16.9% of patients (n = 286) with underdosing (9.7%) being more prevalent than overdosing (6.9%). For all DOACs considered together, body weight<60 kg (odds ratio [OR] 0.46 [0.27-0.77]), edoxaban use (OR 0.42 [0.24-0.74]), undergoing surgery (OR 0.57 [0.37-0.87]) and being DOAC naïve (OR 0.45 [0.29-0.71]) were associated with significantly lower odds of underdosing. Bleeding history (OR 1.86 [1.24-2.80]) and narcotic use (OR 1.67[1.13-2.46]) were associated with significantly higher odds for underdosing. Determinants with a significantly higher odds of overdosing were renal impairment ) and body weight<60 kg ), whereas dabigatran use (OR 0.24 [0.08-0.71]) and apixaban (OR 0.18 [0.10-0.32]) were associated with a significantly lower odds of overdosing compared to rivaroxaban. Physicians accepted the pharmacists' advice in 179 cases (79.2%) consisting of 92 (51.4%) recommendations for underdosing, 82 (45.8%) for overdosing and 5 (2.8%) for contraindications. Conclusion:Inappropriate DOAC prescribing remains common, although there is a slight improvement compared to our study of 2016. Clinical services led by pharmacists help physicians to reduce the number of inadequate prescriptions for high-risk medications such as DOACs.

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“…It provides results in milliliters per minute which can be utilized for medication dosing. This formula has extensively been used in pharmacological studies, both historically and in ongoing studies [37–40]. For CKD categories (staging), these should be corrected (standardized) for BSA of 1.73 m 2 (by multiplying it with BSA of individual and dividing by 1.73) [13].…”

Section: Discussion and Potential Impactmentioning

confidence: 99%

Accurate GFR in obesity—protocol for a systematic review

et al. 2019

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Background Obesity is increasing globally. Chronic kidney disease (CKD) is strongly associated with obesity. Kidney function is commonly estimated with equations using creatinine (such as CKD-EPI equation) which is a product of muscle metabolism. Decisions about categorizing CKD, planning modality of renal replacement therapies, and adjusting dosages of medications excreted by the kidneys are done using these equations. However, it is not well appreciated that creatinine-based equations may not accurately estimate kidney function in obese individuals. We plan a systematic review of diagnostic studies which will compare estimating equations to actual measured kidney function. Methods We will systematically search electronic bibliographic databases including MEDLINE, EMBASE, and the Cochrane Library with no restrictions on language or specific dates. The search terms will be adapted for the different databases using a combination of Medical Subject Heading and relevant keywords contained in titles and abstracts. Our preliminary search strategy using Cochrane, MEDLINE, and EMBASE databases have identified 190, 1246, and 1660 citations, respectively. For all studies selected, we will extract information on general study characteristics, study participant (age, sex, ethnicity, weight, height, BMI, BSA), type and protocol of reference standard utilized, the index test studied, the methodology of measurement of index test, categories of GFR, the proportion of eGFR within 10, 20, 30, 40, and 50% of measured GFR, and bias between eGFR and measured GFR. If the quality of methods and risk of bias are adequate, we will perform a meta-analysis. We will assess the heterogeneity using the χ 2 and the I 2 statistics to examine whether the estimates from studies included could be pooled. Sensitivity and multivariate meta-regression analyses will be performed to assess the effects of clinical factors and socio-demographic characteristics reported in included studies on the meta-analytic estimates. All analysis will be performed using the Comprehensive Meta-analysis software. Discussion This systematic review might help to inform clinicians on the best equation to use in patients with obesity and CKD for staging of CKD and for medication dosing. If no equation is deemed suitable, this review will form a basis for future studies of GFR in obese individuals. Systematic review registration PROSPERO CRD42018104345 Electronic supplementary material The online version of this article (10.1186/s13643-019-1052-2) contains supplementary material, which is available to authorized users.

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Prescribing of Direct Oral Anticoagulants in Atrial Fibrillation Based on Estimation of Renal Function Using Standard and Modified Cockcroft–Gault Equations: A Retrospective Analysis

Abstract: -

Cited by 3 publications

References 17 publications

Appropriateness of DOAC Prescribing Before and During Hospital Admission and Analysis of Determinants for Inappropriate Prescribing

Appropriateness of DOAC Prescribing Before and During Hospital Admission and Analysis of Determinants for Inappropriate Prescribing

Determinants for under‐ and overdosing of direct oral anticoagulants and physicians' implementation of clinical pharmacists' recommendations

Accurate GFR in obesity—protocol for a systematic review

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