Real‐World Adherence and Persistence with Direct Oral Anticoagulants in Adults with Atrial Fibrillation

Abstract

BACKGROUND Evidence of adherence and persistence patterns in anticoagulation (AC) therapy comparing treatment-na€ ıve and non-na€ ıve patients is lacking. The objective of this study was to evaluate patterns of medication adherence and persistence in a real-world setting among AC-na€ ıve and ACexperienced patients with atrial fibrillation (AF) who were treated with direct oral anticoagulants (DOACs). METHODS AF patients newly initiating a DOAC with a minimum of 6 months of continuous health plan enrollment pre and postindex date (first DOAC prescription) were identified from the Truven Health MarketScan Commercial and Medicare Supplemental databases (2009)(2010)(2011)(2012)(2013). DOAC adherence (proportion of days covered [PDC]), persistence, and predictors of adherence were assessed at 6 and 12 months postindex. RESULTS Of 66,090 AF patients included, 46.6% (n=30,826) were AC na€ ıve and 53. 4% (n=35,264) were AC experienced (age: 66.9 AE 12.7 vs 70.4 AE 11.4 yrs, p<0.001; male: n=19,132 [62.1%] vs n=21,691 [61.5%], p=0.14, respectively). A majority of patients received dabigatran as their index DOAC (n=49,210; 74.5%). The mean PDC in AC-na€ ıve versus AC-experienced patients at 6 and 12 months of follow-up was 72.3% versus 83.3% (p<0.001) and 63.7% versus 79.9% (p<0.001), respectively. Persistence with DOAC therapy in AC-na€ ıve and AC-experienced patients at 6 and 12 months ranged from 59.3% and 76.3% (p<0.0001) to 31.6% and 50.2% (p<0.0001), respectively. Predictors of higher DOAC adherence were older age and higher number of concomitant medications. Predictors of lower adherence were higher number of comorbidities and AC-na€ ıve user status. CONCLUSION Medication adherence and persistence with DOACs declined over time and both were suboptimal and lower (at 6 and 12 mo postindex) in AC-na€ ıve compared to AC-experienced patients. These findings can help target future strategies or interventions for patient education and long-term AC management especially in those patients na€ ıve to DOAC therapy. Future investigation should examine potential reasons for differences in DOAC adherence and persistence between AC-experienced versus AC-na€ ıve patients and the implications for patient outcomes.

Risk of hospitalised bleeding in comparisons of oral anticoagulant options for the primary treatment of venous thromboembolism

“…For instance, concerns have been raised about use of DOACs among patients with kidney disease, because impaired renal function may lead to DOAC accumulation and increased bleeding risk (Lega et al , ). Compliance to DOACs in real‐world settings may also be poorer than typically exhibited among RCT participants (Tsai et al , ; Shore et al , , ; Garkina et al , ; Manzoor et al , ). Furthermore, no VTE RCTs have conducted comparisons between DOACs.…”

Outcomes of systematic anticoagulation management in pharmacist and nurse specialized clinics

“…Despite the emergence of the direct oral anticoagulants (DOAC), warfarin is still one of the mainstay oral anticoagulants used to treat over 4 million patients in the United States and over 40 000 outpatient prescriptions are being written annually . Indicated for primary and secondary prevention of venous and arterial thrombosis, warfarin does not come without challenges, primarily stemming from maintenance of patients' international normalized ratio (INR) within a narrow therapeutic window .…”

“…Indicated for primary and secondary prevention of venous and arterial thrombosis, warfarin does not come without challenges, primarily stemming from maintenance of patients' international normalized ratio (INR) within a narrow therapeutic window . Given that recent data suggest that DOAC users may have suboptimal adherence and persistence over time, and individuals with renal dysfunction or mechanical heart valves will still require treatment with warfarin therapy, it is important to continually assess contemporary practice models that optimize anticoagulation‐related clinical outcomes.…”

“…users may have suboptimal adherence and persistence over time, 3 and individuals with renal dysfunction or mechanical heart valves will still require treatment with warfarin therapy, it is important to continually assess contemporary practice models that optimize anticoagulationrelated clinical outcomes.…”

What do our patients think they know about atrial fibrillation? … Is that asking the right question?

“…In most published series, only about 60% of patients with a CHA 2 DS 2 -VASc score of ≥2 are prescribed oral anticoagulation 5 6. Recent work examining the persistence of therapy in patients with AF who are prescribed a novel oral anticoagulant agent showed that at 1 year only 30%–50% remained on therapy 7. The operative question is: are we failing our patients or are our patients making well-informed decisions about their own care (taking into account their own values and personal finances) that happen to frequently diverge from the guidelines?…”