The prescription of direct oral anticoagulants in the elderly: An observational study of 19 798 Ambulatory subjects

Barben, Jérémy; Menu, Didier; Rosay, Clémentine; Vovelle, Jérémie; Mihai, Anca-Maria; Nuss, Valentine; d’Athis, Philippe; Putot, Alain; Manckoundia, Patrick

doi:10.1111/ijcp.13420

Cited by 6 publications

(3 citation statements)

References 35 publications

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“…In accordance with the literature, GPs were the main prescribers of oral AT renewals [ 23 ] whereas hospital physicians and cardiologists were the main prescribers (75%) of oral AT combination initiations [ 9 ].…”

Section: Discussionsupporting

confidence: 57%

Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study

Zerah

Bonnet-Zamponi

Ajrouche

et al. 2021

JCM

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With the increase in prevalence of cardiovascular diseases, multimorbidity, and medical progress, oral antithrombotic (AT) combinations are increasingly prescribed. The aims of this study were to estimate the incidence of oral AT combinations, their appropriateness (defined as indications compliant with guidelines), and the related risk of major bleeding (i.e., leading to hospitalization) or death, among new users. We conducted a 5-year historical cohort study, using the French national healthcare database, including all individuals ≥ 45 years old with a first delivery of oral ATs between 1 January 2013 and 31 December 2017. The cumulative incidence of oral AT combinations was estimated with the Fine and Gray method, taking into account the competitive risk of death. We compared the cumulative incidence of major bleeding according to the type of oral AT treatment initiated at study entry (monotherapy or oral AT combinations). During the study period, 22,220 individuals were included (mean (SD) age 68 (12) years). The cumulative incidence of oral AT combinations at 5 years was 27.8% (95% confidence interval (CI) 26.8–28.9). Overall, 64% of any oral AT combinations did not comply with guidelines. The cumulative incidence of major bleeding and death in the whole cohort at 5 years was 4.1% (95% CI 3.7–4.6) and 10.8% (95% CI 10.1–11.6), respectively. Risk of major bleeding increased among individuals with oral AT combinations versus oral AT monotherapy at study entry (subdistribution hazard ratio sHR: 2.16 (1.01–4.63)); with no difference in terms of death. The use of oral AT combinations among oral AT users is frequent, often inappropriately prescribed, and associated with an increased risk of major bleeding.

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Section: Discussionsupporting

confidence: 57%

Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study

Zerah

Bonnet-Zamponi

Ajrouche

et al. 2021

JCM

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“…However, older people are the main consumers of oral ATs and the most at risk population for inappropriate oral AT prescriptions and adverse drug events [25]. In a recent French observational study focusing on the use of direct oral anticoagulants in older outpatients (i.e aged 75 years and older; N = 19,798 outpatients) [26], Barben et al showed that first prescriptions came primarily from specialists other than cardiologists (45.4%) or general practitioners (44.4%), and least often from cardiologists (10.2%). Regarding refill prescriptions, the prescribers for the vast majority were general practitioners (94.3%); other specialists made up 3.8% of prescribers and cardiologists only 1.8%.…”

Section: Discussionmentioning

confidence: 99%

Impact of a Prescription Support Tool to Improve Adherence to the Guidelines for the Prescription of Oral Antithrombotics: The Combi-AT Randomized Controlled Trial Using Clinical Vignettes

Zerah

Bonnet-Zamponi

Dechartres

et al. 2019

JCM

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Ensuring the appropriateness of prescriptions of oral antithrombotics (ATs, including antiplatelet and anticoagulant agents) is a crucial safety issue, particularly for patients with multiple chronic conditions. Our main objective was to assess the impact of a prescription support tool, synthesized from international guidelines on oral ATs in adult outpatients, on improving physician adherence to the guidelines for prescription of oral ATs. A web-based, open randomized controlled trial using clinical vignettes was conducted in France from November 2018 to February 2019. General practitioners and cardiologists with outpatient practice were contacted to participate in a web-based survey involving three clinical vignettes illustrating cases of adult outpatients with common neuro-cardiovascular diseases. They were asked to answer four multiple-choice questions related to the number of oral AT(s), drug class, dosage and duration of the prescription. Physicians assigned to the experimental arm had access to the prescription support tool. Physicians assigned to the control arm had no access to the tool. The primary outcome measure was the appropriate prescription of oral ATs (i.e., complied with guidelines in terms of the number, drug class, dosage and duration of prescription). An intent-to-treat analysis was performed using a logistic mixed model with a clinical vignette effect and a physician effect nested in the arm of the trial. Four hundred and forty-one general practitioners and 37 cardiologists were randomized to the experimental (n = 238) and to the control arm (n = 240), respectively. In the experimental arm, 55.0% of the prescriptions were appropriate versus 29.4% in the control arm (Odds Ratio (OR): 3.61 (2.60 to 5.02)). Access to the first prescription support tool synthesizing the use of oral ATs for outpatients significantly improved the rate of appropriate oral AT prescriptions according to the guidelines.

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“…While prescribing oral anticoagulation, the physician must account for possible comorbidities and the impact of polypharmacy in the elderly that might result in considerable variability of drug effects [47,48]. A post-hoc analysis of the ARISTOTLE trial showed a significant increase of mortality, thromboembolic events, and bleeding complications with the number of concomitant drugs in patients under therapy with either apixaban or warfarin [49].…”

Section: Polypharmacymentioning

confidence: 99%

Coagulation and Aging: Implications for the Anesthesiologist

Tschan

Bolliger

2021

Curr Anesthesiol Rep

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Purpose of Review This narrative review focuses on aging-related modifications in coagulation resulting in increased thromboembolic and hemorrhagic risk of the elderly. We further discuss the current evidence and emerging data relating the perioperative treatment of elderly patients with antithrombotic therapy. Recent Findings Relevant changes in all elements of the Virchow’s triad can be found with aging. Increased blood stasis due to immobility, progressive endothelial dysfunction with altered microcirculation, elevated concentrations of several coagulation factors, and increased platelet reactivity all lead to a procoagulant state. Elderly people are, therefore, commonly treated with oral anticoagulation and antiplatelet drugs. This antithrombotic therapy might be essentially causative for their increased bleeding risk. Summary Elderly patients are at increased risk for thromboembolism due to changes in the hemostatic system in combination with frailty and multimorbidity. Both the thromboembolic due to aging and bleeding risk due to antithrombotic therapy need special attention in the elderly surgical patients.

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The prescription of direct oral anticoagulants in the elderly: An observational study of 19 798 Ambulatory subjects

Cited by 6 publications

References 35 publications

Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study

Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study

Impact of a Prescription Support Tool to Improve Adherence to the Guidelines for the Prescription of Oral Antithrombotics: The Combi-AT Randomized Controlled Trial Using Clinical Vignettes

Coagulation and Aging: Implications for the Anesthesiologist

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