Discontinuation of non-Vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: a population-based cohort study using primary care data from The Health Improvement Network in the UK

Abstract

ObjectiveTo determine discontinuation rates, patterns of use and predictors of discontinuation of non-vitamin K antagonist oral anticoagulants (NOACs) among patients with non-valvular atrial fibrillation (NVAF) in the first year of therapy.DesignPopulation-based cohort study.SettingUK primary care.Population11 481 patients with NVAF and a first prescription (index date) for apixaban, dabigatran or rivaroxaban (January 2012 to December 2016) with at least 1 year of follow-up and at least one further NOAC prescription in the year following the index date were identified. 1 year rates and patterns of discontinuation were described.Primary and secondary outcome measuresOutcome measures were the percentage of patients who, in the first year from starting NOAC therapy, discontinued with their oral anticoagulant (OAC) therapy (discontinuation was defined as a gap in OAC therapy of >30 days); switched OAC within 30 days; discontinued and reinitiated OAC therapy. Predictors of discontinuation were also evaluated.Results1 year discontinuation rates according to the index NOAC were 26.1% for apixaban, 40.0% for dabigatran and 29.6% for rivaroxaban. Reinitiation rates were 18.1% for apixaban, 21.7% for dabigatran and 17.3% for rivaroxaban, and switching rates were 2.8% for apixaban, 8.8% for dabigatran and 4.9% for rivaroxaban. More than 93% of reinitiations were with the index NOAC. Patients starting on dabigatran were more likely to switch OAC therapy than those starting on apixaban; ORs 4.28 (95% CI 3.24 to 5.65) for dabigatran and 1.89 (95% CI 1.49 to 2.39) for rivaroxaban. Severely reduced renal function was a predictor of any discontinuation, OR 1.77 (95% CI 1.28 to 2.44).ConclusionWhile the majority of patients with NVAF in the UK initiating NOAC treatment received continuous therapy in the first year of treatment, a substantial proportion of patients experienced gaps in treatment leaving them less protected against thromboembolism during these periods.

Comparison of Direct Oral Anticoagulant Use for the Treatment of Non-Valvular Atrial Fibrillation in Pivotal Clinical Trials vs. the Real-World Setting: A Population-Based Study from Southern Italy

“…Among RW DOAC initiators, the proportion of patients discontinuing treatment over a median follow-up of almost two years was 30% (versus 20% in RE-LY) for dabigatran, 20% (versus 24% in ROCKET AF) for rivaroxaban, and 16% (versus 25% in ARISTOTLE) for apixaban. Our results are in line with findings from recent observational studies [ 26 , 27 , 28 ]. In particular, a long-term study on the use of DOACs in clinical practice conducted by the Karolinska Institute showed that discontinuation rate was lower for apixaban (11.5, 7.5–16.8) users compared to rivaroxaban (23.9, 18.6–30.1, p -value = 0.001) and dabigatran (30, 23.4–37.9, p -value < 0.001 30%) users [ 26 ], in line with our results.…”

“…Other RW studies showed a higher rate of discontinuation than those seen in our study, but with the same trend among individual DOAC groups. A population-based cohort study using a UK primary care setting found that the discontinuation rates were respectively 40.0% for dabigatran, 29.6% for rivaroxaban, and 26.1% for apixaban during the first year of treatment [ 27 ]. A recent meta-analysis on RW data comparing persistence of DOAC users treated for NVAF showed that the pooled proportion of persistence for all follow-up durations (3–36 months) from 36 studies was 69% [ 28 ].…”

Safety and efficacy of non-vitamin K antagonist oral anticoagulants for prevention of thromboembolism in adults with systemic right ventricle: Results from the NOTE international registry

“…Notably, in non-CHD patients, a significantly higher incidence of NOACs cessation has been described in both drug registration trials and real-life studies. For instance, 1-year discontinuation rate was 14% with apixaban [8] and 15% with dabigatran [6] during drug trials, while, in a recent real-life study in a large cohort in the UK, NOACs treatment cessation occurred in 26.1% of patients on apixaban, 40.0% on dabigatran and 29.6% on rivaroxaban at 1 year of follow-up [18]. One could speculate that ACHD patients are more likely to continue taking prescribed medication thanks to the health-related education they have received since childhood.…”

Percutaneous Left Atrial Appendage Occlusion: A View From the UK

“…A UK population-based cohort study of 11,481 patients with AF who were treated with a DOAC between January 2012 and December 2016 found that almost a third of patients had discontinued DOAC treatment within 1 year. [ 16 ] The majority of these patients (60.4%) had a gap of at least 30 days without stroke protection before eventually reinitiating treatment with a vitamin K antagonist or DOAC. However, a significant percentage (n=813, 7.1%) still remained without anticoagulation following this period.…”