Low persistence to rivaroxaban or warfarin among patients with new venous thromboembolism at a safety net academic medical center

Patel, Sweta; Wang, Tina; Outler, Desire Lashalle; Elliott, Jennifer; Knauss, Michael; Peasah, Samuel K.; Akbashev, Mikhail

doi:10.1007/s11239-019-01959-x

Cited by 7 publications

(10 citation statements)

References 14 publications

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“…3 More recent studies and studies evaluating patients with VTE reported nonpersistent rates varying from 5 to 60% during a follow-up period between 2 months and 4 years. 4,5,8,10,[21][22][23][24][25] The persistence rate of the current study fits in this variation of DOAC nonpersistence. In the previous studies, lower persistence rates were seen in patients with a longer follow-up period, in anticoagulant-naïve patients and in patients treated with dabigatran.…”

Section: Doac Nonpersistencesupporting

confidence: 73%

Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC

Elling,

Hak,

Bos

et al. 2023

Thromb Haemost

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Introduction Current guideline suggests a switch from vitamin K antagonist (VKA) to direct oral anticoagulant (DOAC) in patients with low time in therapeutic range (TTR<70%). Poor INR control may be the result of poor compliance, and might therefore be associated with subsequent DOAC intake. Therefore, this study evaluates the effect of previous TTR and other measures of INR control on DOAC non-adherence and non-persistence, in patients who switched from VKA to DOAC. Methods 437 patients who switched from VKA to DOAC between 2012 and 2019 were included using data from Certe Thrombosis Service, IADB.nl pharmacy community database University Groningen and Statistics Netherlands. DOAC prescriptions were used to determine non-adherence and non-persistence. INR control (i.e. TTR, time under therapeutic range (TUR) and INR variability) was assessed during the last 180 days of VKA use. Multivariable regression models were applied to determine the association between INR control and DOAC non-persistence / non-adherence. Results On VKA, 67.7% of the patients had a TTR below 70%. DOAC non-persistence was 39.8% (95% CI 33.4-45.5%) during a median follow-up of 34.4 months [IQR 19.1-49.2]. Approximately 80% of persistent patients were DOAC-adherent. Low TTR was not associated with DOAC non-persistence (HR 1.14, 95% CI 0.69-1.87) and DOAC non-adherence (OR 1.38, 95% CI 0.67-2.84), nor were TUR and INR variability. Conclusion Previous INR control during VKA therapy is not associated with subsequent DOAC non-adherence and non-persistence. This study suggests that INR control on VKA cannot, and therefore should not be used for predicting DOAC adherence or persistence.

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Section: Doac Nonpersistencesupporting

confidence: 73%

Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC

Elling,

Hak,

Bos

et al. 2023

Thromb Haemost

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“…Adherence to anticoagulants post‐discharge may also be quite low. One study demonstrated an adherence rate of approximately 50% for both warfarin and rivaroxaban at 90 days post‐discharge 26 . It is possible that adherence after 90 days is even lower.…”

Section: Methodsmentioning

confidence: 99%

“…One study demonstrated an adherence rate of approximately 50% for both warfarin and rivaroxaban at 90 days post-discharge. 26 It is possible that adherence after 90 days is even lower. Therefore, we felt that a time period of 90 days would be optimal in order to capture pertinent safety outcomes while still maintaining a reasonable period after prescription of the anticoagulant within which to assume a patient would still be adherent to therapy.…”

Section: Study Outcomesmentioning

confidence: 99%

Inpatient pharmacy‐driven antithrombosis stewardship efforts on warfarin to direct oral anticoagulant conversions

White

Bos

Nawarskas

et al. 2023

J Am Coll Clin Pharm

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Background Over 6 million people in the United States require anticoagulation. Current guidelines recommend direct oral anticoagulants (DOACs) over warfarin for select indications due to increased safety and similar efficacy. However, data suggest warfarin to DOAC conversion occurs in less than 5% of patients. Objectives To assess rates of conversion from warfarin to DOACs and the rate of inpatient pharmacist assessment for warfarin to DOAC conversions using an evidence‐based DOAC checklist. Methods In this retrospective cohort study, all patients ≥18 years old admitted on warfarin from January 1, 2018 to February 28, 2020 were identified via query of the electronic health record (EHR). Patients were excluded if discharged to hospice or if anticoagulation was permanently discontinued. In January 2019, an evidence‐based checklist was developed by the inpatient antithrombosis stewardship team and embedded into an EHR‐based standardized clinical documentation form prompting pharmacist assessment for DOAC therapy. Autoregressive integrated moving average (ARIMA) models were utilized to compare pre‐ and post‐implementation rates of pharmacist‐driven evaluation for warfarin to DOAC switch along with actual conversion rates. Additional outcomes were documented reasons for not switching and proportion of newly‐switched patients referred to our antithrombosis clinic. Results Ultimately, 538 inpatient encounters were included (237 pre‐implementation of the DOAC eligibility checklist; 301 post‐implementation). Warfarin to DOAC conversions increased from a mean of 1.08 patients/month pre‐implementation of the DOAC eligibility checklist to 3.62 patients/month post‐implementation (p < 0.0001). Likewise, pharmacist evaluation for switch increased significantly from a mean of 2.00 patients/month pre‐implementation of the DOAC eligibility checklist to 17.69 patients/month post‐implementation (p < 0.0001). In addition, referrals to the anticoagulation clinic significantly increased from a mean of 1.08–4.08 patients/month (p < 0.0001). Conclusion Use of an evidence‐based checklist embedded into the inpatient EHR increased warfarin to DOAC conversions and supported overall antithrombosis stewardship efforts. Conversion rates remained fairly low. Further opportunity exists to optimize patient safety and health systems savings with ongoing stewardship efforts.

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“…[12][13][14][15] We categorized the presentation of the first VTE as unprovoked or provoked, because patients with unprovoked VTE are at higher risk of recurrent VTE than patients with provoked VTE. Provoked VTE was defined as malignancy-associated VTE (ie, cancer diagnosis within 6 months preceding incident VTE), pregnancy, trauma, surgery, or hospital admission for ≥3 consecutive days within 3 months before incident VTE) (24)(25)(26). HAS-BLED scores were calculated to assess bleeding risk before the index date.…”

Section: Covariatesmentioning

confidence: 99%

Trajectories of Oral Anticoagulation Adherence and Associated Clinical Outcomes During Long-Term Anticoagulation Among Medicare Beneficiaries With Venous Thromboembolism

et al. 2023

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Background: Little is known about anticoagulation medication nonadherence patterns impacting effectiveness and safety outcomes in clinical practice. Objective: We identified adherence trajectories of extended therapy with direct-acting oral anticoagulants (DOACs) and warfarin after 6 months initial anticoagulant therapy among Medicare beneficiaries with venous thromboembolism (VTE). We further assessed the associated recurrent VTE and major bleeding risks. Methods: Using group-based trajectory models, this retrospective cohort study identified distinct beneficiary subgroups with similar adherence patterns of extended-phase anticoagulant treatment (DOACs or warfarin) for patients with VTE who completed 6 months of initial anticoagulant treatment. We examined associations between adherence trajectories and risks of recurrent VTE and major bleeding using inverse probability treatment weighted Cox proportional hazards models. Results: Compared with no extended treatment, consistently high DOAC adherence was associated with decreased recurrent VTE risk (hazard ratio [HR] = 0.33, 95% confidence interval [CI] = 0.21-0.51) without increased major bleeding risk, and consistently high warfarin adherence was associated with decreased recurrent VTE risk (HR = 0.62, 95% CI = 0.40-0.95) and increased major bleeding risk (HR = 1.64, 95% CI = 1.12-2.41). Gradually declining adherence to DOACs (HR = 1.80, 95% CI = 1.07-3.03) or warfarin (HR = 2.34, 95% CI = 1.57-3.47) was associated with increased bleeding risk with no change in recurrent VTE risk. Conclusion and relevance: This real-world evidence suggests persistently adhering to extended DOAC therapy is associated with lower recurrent VTE risk without increasing major bleeding among Medicare beneficiaries with VTE. Persistently adhering to extended warfarin therapy was associated with lower recurrent VTE risk but higher major bleeding risk.

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Low persistence to rivaroxaban or warfarin among patients with new venous thromboembolism at a safety net academic medical center

Cited by 7 publications

References 14 publications

Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC

Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC

Inpatient pharmacy‐driven antithrombosis stewardship efforts on warfarin to direct oral anticoagulant conversions

Trajectories of Oral Anticoagulation Adherence and Associated Clinical Outcomes During Long-Term Anticoagulation Among Medicare Beneficiaries With Venous Thromboembolism

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