Is the prescription right? A review of non-vitamin K antagonist anticoagulant (NOAC) prescriptions in patients with non-valvular atrial fibrillation. Safe prescribing in atrial fibrillation and evaluation of non-vitamin K oral anticoagulants in stroke prevention (SAFE-NOACS) group

Pharithi, Rebabonye B; Ranganathan, D; O'Brien, Jim; Egom, Emmanuel E.; Burke, C D O Martin; Ryan, Daniel; McAuliffe, Christine; Vaughan, Matthew; Coughlan, Tara; Morrissey, E; McHugh, John; Moore, David; Collins, Rónán

doi:10.1007/s11845-018-1837-7

Cited by 29 publications

(39 citation statements)

References 33 publications

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“…[2][3][4] Recent observational studies highlighted a high prevalence of inappropriateness in the prescription of DOACs, mainly due to errors in the chosen dosages. 5,6 These findings were also confirmed in a recent cluster randomized trial, the SIM-AF study (SIMulation-based technologies to improve the appropriate use of OACs in hospitalized elderly patients with Atrial Fibrillation). In the retrospective phase of the SIM-AF study 44% of patients were inappropriately prescribed at hospital discharge, mainly for underprescription or wrong choice of the antithrombotic drug.…”

Section: Introductionmentioning

confidence: 60%

Appropriateness of prescription of oral anticoagulant therapy in acutely hospitalized older people with atrial fibrillation. Secondary analysis of the SIM‐AF cluster randomized clinical trial

Antoniazzi

Ardoino

Proietti

et al. 2019

Brit J Clinical Pharma

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Aims To assess the appropriateness of oral anticoagulant (OAC) prescription and its associated factors in acutely hospitalized elderly patients. Methods Data were obtained from the prospective phase of SIM‐AF (SIMulation‐based technologies to improve the appropriate use of oral anticoagulants in hospitalized elderly patients with Atrial Fibrillation) randomized controlled trial, aimed to test whether an educational intervention improved OAC prescription, compared to current clinical practice, in internal medicine wards. In this secondary analysis, appropriateness of OAC prescription was assessed at hospital admission and discharge. Results For 246 patients, no significant differences were found between arms (odds ratio 1.38, 95% confidence interval [CI] 0.84–2.28) in terms of appropriateness of OAC prescription. Globally, 92 patients (37.4%, 95% CI = 31.6–43.6%) were inappropriately prescribed or not prescribed at hospital discharge. Among 51 patients inappropriately prescribed, 82% showed errors on dosage, being mainly under‐dosed (n = 29, 56.9%), and among 41 inappropriately not prescribed, 98% were taking an antiplatelet drug. Factors independently associated with a lower probability of appropriateness at discharge were those related to a higher risk of bleeding (older age, higher levels of aspartate aminotransferase, history of falls, alcohol consumption) and antiplatelet prescription at admission. The prescription of OACs at admission was the strongest predictor of appropriateness at discharge (odds ratio = 7.43, 95% CI = 4.04–13.73). Conclusions A high proportion of hospitalized older patients with AF remains inappropriately prescribed or nonprescribed with OACs. The management of these patients at hospital admission is the strongest predictor of prescription appropriateness at discharge.

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Section: Introductionmentioning

confidence: 60%

Appropriateness of prescription of oral anticoagulant therapy in acutely hospitalized older people with atrial fibrillation. Secondary analysis of the SIM‐AF cluster randomized clinical trial

Antoniazzi

Ardoino

Proietti

et al. 2019

Brit J Clinical Pharma

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“…(C) Real‐world studies results concerning dose adjustments of apixaban. (D) Results from direct oral anticoagulants overall adjustments regarding dose appropriateness…”

Section: Resultsmentioning

confidence: 99%

“…Canadian study, 44 where a total of 47 patients were included, among (D) Results from direct oral anticoagulants overall adjustments regarding dose appropriateness 5,9,11,25,27,28,32,34,37,39,40,42,44,[47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64] whom 25 (53%) were receiving apixaban inconsistent with the ARIS-TOTLE trial and the product monograph.…”

Section: Study and Also By A Smallmentioning

confidence: 99%

Impact of direct oral anticoagulant off‐label doses on clinical outcomes of atrial fibrillation patients: A systematic review

Santos

António

Rocha³

et al. 2020

Brit J Clinical Pharma

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Aims Worldwide observational studies are evidencing discordance between guidelines and real‐world practice regarding direct oral anticoagulant drug (DOAC) doses. This systematic review summarizes and evaluate DOACs use in real‐world practice. Methods This review was performed following the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) guidelines searching PubMed (MEDLINE) and Medscape databases. Results Data from 75 studies showed that most of the patients treated with DOACs for stroke prevention in atrial fibrillation received doses in accordance to the guidelines. However, a significant number of patients received off‐label doses (25–50% in most of the studies evaluated). DOAC overdosing was associated with increased all‐cause mortality and worse bleeding events while underdosing was associated with increased cardiovascular hospitalization and, particularly for apixaban, with a nearly 5‐fold increased risk of stroke. Conclusion Patients prescribed with off‐label DOAC doses did not receive the full benefit of anticoagulation and presented an increased risk of stroke, bleeding and/or adverse effects.

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“…This suggests that pharmacists engaging in medication review could focus on dose appropriateness for this specific class. Some have suggested multidisciplinary clinics as a means to ensure safe and effective prescribing and follow‐up . Within hospital, clinical pharmacists have successfully intervened in patients on inappropriate NOACs prescriptions, either suggesting dose adaption, avoidance of interacting drugs, the need for NOAC monitoring, to name a few, 70% of which accepted by the physician .…”

Section: Resultsmentioning

confidence: 99%

“…Conversely, overdosing in renal impairment doubled the bleeding risk but had no impact on stroke occurrence. 34 NOAC are most commonly used in lower doses, compared with higher doses, 35 perhaps suggesting prescribers tend to be overcautious due to potential adverse drug events or eventually as an indirect result of not having as easy and common laboratory data as when prescribing VKAs.…”

Section: Adherence Of Health Care Professionals To Guidelinesmentioning

confidence: 99%

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

Costa

Rydant²,

Antoniou

2020

Evaluation Clinical Practice

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Background This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration. Methods It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide. Results Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self‐management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals. Conclusion On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care.

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Is the prescription right? A review of non-vitamin K antagonist anticoagulant (NOAC) prescriptions in patients with non-valvular atrial fibrillation. Safe prescribing in atrial fibrillation and evaluation of non-vitamin K oral anticoagulants in stroke prevention (SAFE-NOACS) group

Abstract: Our study highlights significant inaccuracies in NOAC prescribing. Patients commenced on NOACs should be assessed and followed up in a multidisciplinary AF clinic to ensure safe and effective prescribing and stroke prevention.

Cited by 29 publications

References 33 publications

Appropriateness of prescription of oral anticoagulant therapy in acutely hospitalized older people with atrial fibrillation. Secondary analysis of the SIM‐AF cluster randomized clinical trial

Appropriateness of prescription of oral anticoagulant therapy in acutely hospitalized older people with atrial fibrillation. Secondary analysis of the SIM‐AF cluster randomized clinical trial

Impact of direct oral anticoagulant off‐label doses on clinical outcomes of atrial fibrillation patients: A systematic review

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

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