Inappropriate non-vitamin K antagonist oral anticoagulants prescriptions: be cautious with dose reductions

Abstract

Background Non-vitamin K antagonist oral anticoagulants (NOACs) are prescribed to patients with atrial fibrillation (AF) to reduce the risk of stroke. Prescribing the correct dose warrants careful consideration of the prevailing dose criteria that differ per NOAC. Electronic systems are useful to intercept prescriptions that are incorrect based on simple ‘primary’ criteria, for example dosing frequency and drug-drug interactions with concomitant medication. However, these systems do not take into account patient characteristics such as age, renal function or weight, which are crucial elements to determine the NOAC dose. Methods Our goal was to determine the appropriateness of all prescriptions, as compared with the product labelling approved by the European Medicines Agency, to address common pitfalls in prescribing NOACs. AF patients with a first NOAC prescription between January 2012 and December 2016 were identified from our electronic hospital information system (Martini Hospital, Groningen, the Netherlands). Results The study included 3,231 AF patients who had started on an NOAC; 10.7% received an inappropriate dose and the appropriateness of the prescription could not be determined in 14.1%. Underdosing and overdosing occurred in 5.4% and 4.5% of all prescriptions, respectively. A reduced-dose NOAC was a predictor for incorrect prescribing (odds ratio: 2.70, 95% confidence interval: 2.13–3.41). Patient factors were identified that predicted incorrect prescriptions for dabigatran and apixaban. Conclusion An incorrect prescription occurred more often in the reduced-dose NOAC group. Clinical parameters such as renal function are often unknown whilst these are essential to determine the right NOAC and dose. Electronic supplementary material The online version of this article (10.1007/s12471-019-1267-9) contains supplementary material, which is available to authorized users.

An Exploratory Association Analysis of ABCB1 rs1045642 and ABCB1 rs4148738 with Non-Major Bleeding Risk in Atrial Fibrillation Patients Treated with Dabigatran or Apixaban

“…Furthermore, clinicians are reluctant to prescribe these drugs to frail patients or those at high risk of bleeding due to the lack of routine monitoring of the anticoagulant effect; they strictly follow the guidelines recommendations regarding the dosing regimen and monitor more often NOACs-treated patients. This unwillingness to prescribe NOACs is also reported in real-world studies in recent years [53,54]. Periodic monitoring of patients greatly improves treatment compliance.…”

Inappropriate direct oral anticoagulant dosing in atrial fibrillation patients is associated with prescriptions for outpatients rather than inpatients: a single-center retrospective cohort study

“…In a real-world registry in Spain, the rate of underdosing and overdosing of DOAC therapy was 17.5% (93/530) and 14.9% (79/ 530), respectively [16]. Other retrospective studies conducted abroad indicate that 5.4-17.4% patients are prescribed inappropriate reduced doses of DOACs (Additional file 1: Table S2) [17][18][19][20]. In our study, it was found that the rate of underdosing has been decreasing every year.…”

Changes in anticoagulant prescription in Dutch patients with recent-onset atrial fibrillation: observations from the GARFIELD-AF registry

“…Although NOACs have been repeatedly shown to be at least as effective and safe as VKAs in both randomized controlled trials and real-world data, a lack of monitoring could have contributed to a hesitation to shift to a more NOAC based approach. This is not unreasonable, as without a regular check of factors such as renal function, weight or age, patients are often (± 10% in two recent Dutch AFstudies), treated with a too high or too low NOAC dose [16,17]. Moreover, early discontinuation of (N)OAC treatment can be as high as 50% at 6 months in certain patient groups [18,19].…”

“…15 Duke Clinical Research Institute, Durham, USA. 16 Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands. 17 Anticoagulation Clinic Maastricht, Maastricht, the Netherlands.…”