Real-world persistence and adherence to oral anticoagulation for stroke risk reduction in patients with atrial fibrillation

Beyer‐Westendorf, Jan; Ehlken, B; Evers, Thomas

doi:10.1093/europace/euv421

Cited by 145 publications

(126 citation statements)

References 21 publications

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“…In an analysis of data collected from patients with AF in the Dresden NOAC Registry, discontinuation rates with dabigatran (25.8% per year) were similar to those observed with VKAs in daily practice, whereas discontinuation rates with rivaroxaban therapy (13.6% per year) were much lower than those with VKA therapy [12, 15]. Persistence probabilities at 1 year were 53.1, 47.3 and 25.5% with rivaroxaban, dabigatran and VKA, respectively, and adherence with a high medication possession ratio (≥80%) was 61.4% for rivaroxaban and 49.5% for dabigatran [14]. Together, real-life data suggest that, in the long-term, patients receiving DOACs have better protection against stroke or systemic embolism than patients receiving a VKA.…”

Section: Vitamin K Antagonists Vs Direct Oral Anticoagulants: Outcommentioning

confidence: 61%

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Zirlik¹,

Bode²

2016

J Thromb Thrombolysis

111

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Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents—the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]—have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.Electronic supplementary materialThe online version of this article (doi:10.1007/s11239-016-1446-0) contains supplementary material, which is available to authorized users.

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Section: Vitamin K Antagonists Vs Direct Oral Anticoagulants: Outcommentioning

confidence: 61%

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Zirlik¹,

Bode²

2016

J Thromb Thrombolysis

111

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“…In primary care practices in Germany, only approximately 50-60% of DOAC users had good adherence. 25 In contrast, a US Veterans Affairs cohort had good adherence to dabigatran (72%), but poor adherence to dabigatran was associated with increased adverse outcome. 26 In patients with CHA2DS2-VASc score ≥2, poorer adherence was associated with higher stroke risk and a relatively small decrease in bleeding risk.…”

Section: Discussionmentioning

confidence: 97%

Current Status and Outcomes of Direct Oral Anticoagulant Use in Real-World Atrial Fibrillation Patients　― Fushimi AF Registry ―

Yamashita

Uozumi

Hamatani

et al. 2017

Circ J

122

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practice, DOAC have prevailed all over the world. After the release of DOAC, several national guidelines for the management of AF were updated, and now recommend DOAC as broadly preferable to VKA in the vast majority of patients with non-valvular AF. 6 RCT, however, are conducted under idealized and rigorously controlled conditions. Thus, RCT patients are highly selected, and hence are not broadly representative of real-world patients. Also, not many studies have investigated the real-world effectiveness and safety of DOAC in unselected patients; and, according to studies involving general practice settings, the outcomes of DOAC in real-world clinical practice do not necessarily coincide with the RCT outcomes. 7, 8 The aim of this study was therefore to evaluate the change in OAC status over time and the clinical outcomes O ral anticoagulants (OAC) are essential for stroke prevention in patients with atrial fibrillation (AF). The use of conventional OAC, such as a vitamin K antagonist (VKA), reduces stroke by 64%, compared with non-VKA users. 1 Until recently, VKA were the only available OAC but direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, apixaban, and edoxaban) have been introduced for stroke prevention in patients with AF. Recent large-scale randomized clinical trials (RCT) demonstrated the similar efficacy and safety of DOAC, compared with VKA.

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“…Direct comparisons with adherence rates reported in other observational studies are difficult due to methodological issues . However, in those studies that were also based on claims data, adherence rates were situated in the range of 40% to 70%, which are consistent with our findings …”

Section: Discussionmentioning

confidence: 99%

Adherence with direct oral anticoagulants in nonvalvular atrial fibrillation new users and associated factors: a French nationwide cohort study

Maura

Pariente

Alla

et al. 2017

Pharmacoepidemiology and Drug

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PurposeDirect oral anticoagulants (DOACs) have been promoted in patients with nonvalvular atrial fibrillation (nv‐AF) as a more convenient alternative to vitamin K antagonists. We estimated 1‐year dabigatran and rivaroxaban adherence rates in nv‐AF patients and assessed associations between baseline patient characteristics and nonadherence.MethodsThis cohort study included OAC‐naive nv‐AF patients with no contraindications to OAC, who initiated dabigatran and rivaroxaban, using nationwide data from French national health care databases. One‐year adherence was defined by the proportion of days covered of 80% or more over a fixed 1‐year period after treatment initiation. Associations between nonadherence and baseline patient characteristics were assessed using multivariate logistic regression models.ResultsThe population was composed of 11 141 dabigatran (women: 48%; mean age: 74 ± 10.7 y; ≥80 y: 34.9%) and 11 126 rivaroxaban (46.5%; 74 ± 10.9 y; 34.8%) new users. One‐year adherence was 53.3% in dabigatran‐treated and 59.9% in rivaroxaban‐treated patients, consistent with numerous subgroup analyses. A switch to vitamin K antagonist was observed in 14.5% of dabigatran and 11.7% of rivaroxaban patients; 10.2% and 5.9% of patients switched to another DOAC, respectively; and 4.3% of patients died in the 2 cohorts. In patients who did not die or switch during the follow‐up, 1‐year adherence was 69.6% in dabigatran‐treated and 72.3% in rivaroxaban‐treated patients. Having concomitant ischemic heart diseases was associated with an increased risk of nonadherence in the 2 cohorts.ConclusionIn this real‐life study, 1‐year adherence to DOAC is poor in nv‐AF new users. Despite the introduction of DOAC, adherence to OACs may remain a significant challenge in AF patients.

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Real-world persistence and adherence to oral anticoagulation for stroke risk reduction in patients with atrial fibrillation

Abstract: Rivaroxaban and dabigatran demonstrated better persistence than VKA at Day 360. Furthermore, rivaroxaban was associated with better persistence and adherence than dabigatran. Further studies are needed to identify factors responsible for this difference and evaluate the impact on outcomes.

Cited by 145 publications

References 21 publications

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Current Status and Outcomes of Direct Oral Anticoagulant Use in Real-World Atrial Fibrillation Patients　― Fushimi AF Registry ―

Adherence with direct oral anticoagulants in nonvalvular atrial fibrillation new users and associated factors: a French nationwide cohort study

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Real-world persistence and adherence to oral anticoagulation for stroke risk reduction in patients with atrial fibrillation

Cited by 145 publications

References 21 publications

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Current Status and Outcomes of Direct Oral Anticoagulant Use in Real-World Atrial Fibrillation Patients ― Fushimi AF Registry ―

Adherence with direct oral anticoagulants in nonvalvular atrial fibrillation new users and associated factors: a French nationwide cohort study

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Current Status and Outcomes of Direct Oral Anticoagulant Use in Real-World Atrial Fibrillation Patients　― Fushimi AF Registry ―