Trends in direct oral anticoagulant (DOAC) prescribing in English primary care (2014–2019)

Abstract

BackgroundIn England, most prescribing of direct-acting oral anticoagulants for atrial fibrillation (AF) is in primary care. However, there remain gaps in our understanding of dosage and disparities in use. We aimed to describe trends in direct oral anticoagulant (DOAC) prescribing, including dose reduction in people with renal impairment and other criteria, and adherence.MethodsUsing English primary care sentinel network data from 2014 to 2019, we assessed appropriate DOAC dose adjustment with creatinine clearance (CrCl). Our primary care sentinel cohort was a subset of 722 general practices, with 6.46 million currently registered patients at the time of this study.ResultsOf 6 464 129 people in the cohort, 2.3% were aged ≥18 years with a diagnosis of AF, and 30.8% of these were prescribed vitamin K antagonist and 69.1% DOACs. Appropriate DOAC prescribing following CrCl measures improved between 2014 and 2019; dabigatran from 21.3% (95% CI 15.1% to 28.8%) to 48.7% (95% CI 45.0% to 52.4%); rivaroxaban from 22.1% (95% CI 16.7% to 28.4%) to 49.9% (95% CI 48.5% to 53.3%); edoxaban from 10.0% (95% CI 0.3% to 44.5%) in 2016 to 57.6% (95% CI 54.5% to 60.7%) in 2019; apixaban from 30.8% (95% CI 9.1% to 61.4%) in 2015 to 60.5% (95% CI 57.8% to 63.2%) in 2019.Adherence was highest for factor Xa inhibitors, increasing from 50.1% (95% CI 47.7% to 52.4%) in 2014 to 57.8% (95% CI 57.4% to 58.2%) in 2019. Asian and black/mixed ethnicity was associated with non-adherence (OR 1.81, 95% CI 1.56 to 2.09) as was male gender (OR 1.19, 95% CI 1.15 to 1.22), higher socioeconomic status (OR 1.60, 95% CI 1.52 to 1.68), being an ex-smoker (OR 1.12, 95% CI 1.06 to 1.19) and hypertension (OR 1.07, 95% CI 1.03 to 1.17).ConclusionsThe volume and quality of DOAC prescribing has increased yearly. Future interventions to augment quality of anticoagulant management should target disparities in adherence.

DOAC prescribing in people with renal impairment

“…This retrospective cohort study used data from 722 general practices (>6 million patients) to assess prescribing of anticoagulants in people who had non-valvular atrial fibrillation (NVAF) between 2014 and 2019 1. The first anticoagulant prescription was on or after the date of AF diagnosis and to be included in the analysis patients had to have at least 90 days of follow-up.…”

“…The prevalence of NVAF in the eligible population aged ≥18 years was 1.1% (68 765/6 001 675) in 2014, which increased to 2.3% (149 635/6 464 129) in 2019 1. In 2019, 55% of patients with AF were treated with an anticoagulant, with 31% taking a vitamin K analogue (VKA) and 69% taking a DOAC.…”

“…The proportion of people with NVAF who were prescribed a reduced dose of DOAC because of impaired renal function increased during the study period: apixaban (CrCl 15–30mL/min) from 31% to 61%; edoxaban (CrCl 15–50mL/min) from 10% to 58%; rivaroxaban (CrCl 15–50mL/min) from 22% to 50%; and dabigatran (CrCl 30–50mL/min) from 21% to 49% 1…”

“…The authors also studied treatment adherence and found it to be around 50% during the study period, and better among patients taking a DOAC than those taking a VKA 1. In 2019, 46% of patients prescribed a VKA were adherent compared with approximately 58% of those prescribed a DOAC 1.…”

“…A retrospective analysis of prescribing trends for direct-acting oral anticoagulants (DOACs) has highlighted the need to ensure that patients with impaired renal function are receiving the correct dose of DOAC 1…”