Switching of oral anticoagulants in patients with nonvalvular atrial fibrillation: A narrative review

Abstract

Approval of direct-acting oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation (AF) was an important milestone, providing a wider range of treatment options and creating the possibility for drug switching after initiation. In addition to improved utilisation of oral anticoagulants (OACs) for stroke prevention, reports of switching among OACs are growing in the literature; switching may influence clinical outcomes, healthcare costs and patient satisfaction. This review aimed to summarise the current literature on the pattern of OAC switching in patients with AF, including reasons for switching and clinical consequences following switching. A literature search was conducted in PubMed, Scopus and Embase on 27 June 2020. We included 39 articles published after 2013, following the introduction of apixaban. The review found that switching among OACs was common in clinical practice, significantly varying with the type of OAC. Studies reporting the reason for switching and clinical outcomes were comparatively limited. The decision to switch was often related to safety issues (usually bleeding), poor anticoagulation control and ease of use. Patient characteristics, clinical conditions and drug interactions were found to be associated with switching from OACs. Findings regarding bleeding outcomes following switching were inconsistent, possibly confounded by the rationale for switching and the switching protocol. Noting the limited number of studies included and their relatively short follow-up periods, switching did not have a significant impact on the risk of stroke and other thrombotic outcomes. Further prospective studies are needed to understand better potential rationales for switching and the clinical outcomes.

Incidence and Predictors of Switching and Dose Change of Direct Oral Anticoagulants among Elderly Patients with Nonvalvular Atrial Fibrillation: A 5-Year Analysis of a Large Administrative Database

“…Notably, the availability of multiple NOACs created an opportunity to switch among them, potentially contributing to practice variation. Switching between NOACs is a prescriber’s choice, which may be related to several clinical-, patient-, or drug-related issues, while a change in dose of NOACs should be strictly related to patients’ characteristics in compliance with current recommendations and labelling/packaging inserts [ 18 ]. However, to date, several studies suggest inappropriate criteria for changing the type and dosing of NOACs [ 19 , 20 ] and no studies combining predictors of switching between NOAC and a reduction in their dosage have been published.…”

“…The switching rate of NOACs ranges from 3 to 30% and varies depending on the timing of the authorisation of each NOAC, the duration of follow-up, study population, and the type of molecule [ 21 , 22 ]. As by the current analysis, switching rates are usually higher for dabigatran than for any other OAC, and it was usually the least preferred agent to switch to from another OAC in all studies published to date [ 18 ]. This finding has been confirmed even in our analysis and may be related to a poorer safety profile, twice-daily dosing and the imminent generication that could lead to doubts on the effectiveness of equivalent drugs placed on the market.…”

“…Advanced age, which can increase the risk of bleeding and stroke, particularly when other conditions, such as active cancer, subsist [ 24 ], has been usually associated with a lower likelihood of switching among NOACs [ 18 , 25 , 26 , 27 ], especially in Europe [ 28 ]. In our series of elderly patients with NVAF, a switching among NOAC occurred in approximately 10% during the 5 years of observation, with the highest percentage increase in favour of edoxaban, probably due to the fact that it is the most recently introduced molecule on the market.…”

Prescribing Trends of Oral Anticoagulants from 2010 to 2020 in Shanghai, China: A Retrospective Study

“… 37 – 39 Nevertheless, it is uncertain whether switching from warfarin to NOACs could benefit the patients. 40 One study found reduced risk of gastrointestinal bleeding, intracranial hemorrhage, and all-cause mortality in patients switching from warfarin to dabigatran compared with warfarin users. 41 Whereas, another study reported that patients switching to rivaroxaban had an increased risk of gastrointestinal bleeding.…”

Oral Anticoagulant Discontinuation and Its Predictors in Patients with Atrial Fibrillation

“…In several studies that used prescription data [ 26 , 27 , 28 , 34 ], dabigatran was associated with higher discontinuation compared to other DOACs. However, those studies usually considered switching, which is more prevalent among dabigatran users [ 37 , 38 , 39 ], as discontinuation.…”