Safety and Effectiveness of Direct Oral Anticoagulants vs Warfarin in People With Atrial Fibrillation and Dementia

Fanning, Laura; Lau, Wallis C.Y.; Mongkhon, Pajaree; Man, Kenneth K C; Bell, Jane; Ilomäki, Jenni; Dārziņš, Pēteris; Lau, Kui Kai; Wei, Li; Wong, Ian C. K.

doi:10.1016/j.jamda.2019.11.022

Cited by 25 publications

(56 citation statements)

References 49 publications

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“…Regarding the comparative effectiveness and safety of NOACs versus VKAs, only one retrospective cohort study provided some preliminary data, illustrating similar stroke/SE and other major bleeding risks, a significantly lower intracranial bleeding risk, and significantly higher gastrointestinal bleeding and mortality risks for NOACs versus warfarin in AF patients with dementia ( Fanning et al., 2020 ). However, analyses were not time-dependent, and results may have been influenced by selective prescribing and pooling of NOAC data, necessitating cautious interpretation of these results.…”

Section: Resultsmentioning

confidence: 99%

“…Furthermore, dabigatran in frail patients ( Hohmann et al., 2019 ) and edoxaban in patients prone to fall ( Steffel et al., 2016 ) illustrated similar benefit-risk profiles as compared to warfarin, whereas rivaroxaban showed a non-inferior to inferior safety profile in frail patients ( Martinez et al., 2018 ; Hohmann et al., 2019 ). As only one study examined the effectiveness and safety of NOACs as compared to warfarin in AF patients with dementia, illustrating a similar stroke/SE and major bleeding risk, as opposed to a higher gastrointestinal bleeding and mortality risk, there is an urgent need for more research on the effectiveness and safety of individual NOACs in dement AF patients ( Fanning et al., 2020 ).…”

Section: Discussionmentioning

confidence: 99%

“…Data on the effectiveness and safety of OACs, especially NOACs, in AF patients with dementia are limited. Unfortunately, phase III RCTs did not include AF patients with dementia due to inability to comply with study-related procedures or to give an informed consent, so no randomized data in this population is available (Connolly et al, 2009;Lopes et al, 2010;Ruff et al, 2010;Granger et al, 2011;Patel et al, 2011;Giugliano et al, 2013;Fanning et al, 2020). However, some observational studies have provided exploratory data on this topic, illustrating the benefit of OAC continuation over discontinuation, as seen in the oldest AF patients ≥90 years old (eTable 7).…”

Section: Dementiamentioning

confidence: 99%

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Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

et al. 2020

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Background and Objective: Atrial fibrillation (AF), the most common cardiac arrhythmia, typically increases with age. Oral anticoagulants (OACs) are the cornerstone of treatment to reduce the associated risk for systemic thromboembolism. Four large randomized controlled trials (RCTs) have shown that non-vitamin K antagonist oral anticoagulants (NOACs) are non-inferior to vitamin K antagonists (VKAs) in preventing stroke and systemic embolism, as well as regarding their risk for major bleeding. However, as vulnerable geriatric patients with AF were largely underrepresented in these trials, physicians are faced with the challenge of choosing the right anticoagulant for geriatric patients in real-life clinical practice. In this vulnerable patient group, NOACs tend to be underused or underdosed due to concerns of excessive fall-related intracranial bleeding, cognitive impairment, multiple drugdrug interactions, low body weight or impaired renal function. As life expectancy continues to rise worldwide, the number of geriatric patients substantially increases. Therefore, there is an urgent need for a critical appraisal of the added value of NOACs in geriatric patients with AF at high thromboembolic and bleeding risk. Methods and Results: This systematic review provides an overview of the literature on the impact of increased age (≥75 years), multimorbidity, polypharmacy, increased falling risk, frailty and dementia on the effectiveness and safety of NOACs as compared to VKAs, after searching the Medline database. Moreover, a meta-analysis on the impact of increased age ≥75 years old was performed after pooling results from 6 post hoc analyses of RCTs and 6 longitudinal observational cohort studies, highlighting the superior effectiveness (hazard ratio (HR) 0.83, 95% confidence interval (CI) [0.74-0.94] for stroke/SE; HR 0.77, 95%CI [0.65-0.92] for mortality) and non-inferior safety (HR 0.93, 95%CI [0.86-1.01] for major bleeding; HR 0.58, 95%CI [0.50-0.67] for intracranial bleeding; HR 1.17, 95%CI [0.99-1.38] for gastrointestinal bleeding) of NOACs versus VKAs in older AF patients.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Dementiamentioning

confidence: 99%

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Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

et al. 2020

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“…The diagnosis data within THIN is recorded by general practitioners using the Read classification system 15 . The quality of THIN data has been validated 16 and diagnosis and prescribing information have been used in previous dementia and anticoagulant studies 17–21 . The protocol for this study was approved by the THIN Scientific Review Committee (reference number 18THIN043).…”

Section: Methodsmentioning

confidence: 99%

Patterns and factors influencing oral anticoagulant prescription in people with atrial fibrillation and dementia: Results from UK primary care

Mongkhon

Alwafi

Fanning

et al. 2020

Brit J Clinical Pharma

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Aims Oral anticoagulant (OAC) is recommended for preventing stroke in atrial fibrillation (AF). However, the OAC utilisation in AF patients with dementia or cognitive impairment (CI) is limited. This study aimed to examine the prevalence of OAC prescriptions in AF patients with dementia/CI and to identify factors associated with OAC treatment within 180 days after dementia/CI diagnosis. Methods Using The Health Improvement Network database, the annual trends of OAC between 2000 and 2015 were calculated. Multivariable logistic regression was performed to identify factors associated with OAC treatment. Results The prevalence rate of OAC prescriptions increased from 6.1% in 2000 to 45.9% in 2015. Among OAC users, the proportion of direct oral anticoagulants (DOACs) use increased significantly from 0.1% in 2011 to 33.8% in 2015 (P‐trend < 0.001), while the proportion of vitamin K antagonist use decreased by 28.6% from 100% in 2000 to 71.4% in 2015 (P‐trend < 0.001). In the multivariable analysis, younger age, very old age, female sex, higher Charlson Comorbidity Index, having a HAS‐BLED score ≥3, a history of intracranial bleeding, falls and polypharmacy were significantly associated with lower odds of receiving OAC. Conclusions In UK primary care, OAC use increased from 2000 to 2015 in AF patients with dementia/CI, with a substantial increase in use of DOACs. Characteristics related to frailty are associated with lower odds of OAC prescription. Given the increasing use of DOACs in patients with dementia/CI, further studies are needed to investigate the safety and effectiveness of DOACs in this important patient group.

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“…Только в одном ретроспективном когортном исследовании РКП, датированном 2020 г. [41], представлены предварительные результаты сравнения эффективности и безопасности ПОАК и варфарина у пациентов с деменцией. По сравнению с варфарином лечение ПОАК ассоциировалось со снижением риска внутричерепного кровотечения на 73% (ОР 0,27; 95%ДИ 0,08-0,86), с аналогичным риском инсульта/СЭ (ОР 0,91; 95%ДИ 0,67-1,25) и большого кровотечения (ОР 0,87; 95%ДИ 0,59-1,28), но с 2кратным увеличением риска ЖКК (ОР 2,11; 95%ДИ 1,30-3,42) и смерти от всех причин (ОР 2,06; 95%ДИ 1,60-2,65).…”

Section: деменцияunclassified

The Oral Anticoagulants Administration in Elderly Patients with Geriatric Syndromes: What's New?

Vorobyeva

Ткачева

2020

Racionalʹnaâ farmakoterapiâ v kardiologii

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The administration of oral anticoagulants in elderly patients with geriatric syndromes such as senile asthenia syndrome, falls and high risk of falls, dementia, polymorbidity, polypharmacy are discussed in the article. The evidence base for the anticoagulants taking in patients with atrial fibrillation aged ≥75, ≥80, ≥85 and ≥90 years, in patients with atrial fibrillation and various geriatric syndromes, as well as in elderly patients with venous thromboembolic complications and frailty syndrome is presented. Most studies indicate significant advantages of direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) over the vitamin K antagonist warfarin in elderly patients with geriatric syndromes. An updated version of the FORTA consensus document, which aims to optimize the prescription of medicines for the elderly, is also presented. Apixaban has a FORTA-A safety class and is the safest oral anticoagulant in elderly patients.

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Safety and Effectiveness of Direct Oral Anticoagulants vs Warfarin in People With Atrial Fibrillation and Dementia

Cited by 25 publications

References 49 publications

Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Patterns and factors influencing oral anticoagulant prescription in people with atrial fibrillation and dementia: Results from UK primary care

The Oral Anticoagulants Administration in Elderly Patients with Geriatric Syndromes: What's New?

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