The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation

Fernández, Carmen Suárez; Gullón, Alejandra; Formiga, Francesç

doi:10.2217/cer-2019-0197

Cited by 16 publications

(17 citation statements)

References 99 publications

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“…The difference in the results identified can be explained by confounding in a non-randomised comparison, but are more likely explained by an effect already well recognised in clinical practice: inadequate NOAC use at reduced doses is associated with a slightly better safety profile, but with a noticeable reduction in the effectiveness of stroke prevention [ 56 , 57 ]. Another explanation for these results could be that proposed by Fernández et al 2020, who suggested that those NOACs with simpler dosage adjustment (by only one adjustment criterion–renal function, such as for rivaroxaban) could be correlated with less probability of dosage error by physicians and, therefore, with fewer thromboembolic events rates in real life [ 58 ]. This suggests that reduced doses of NOACs should only be used when indicated according to drug labelling and not when physicians perceive an increased risk of bleeding.…”

Section: Discussionmentioning

confidence: 99%

Real-world cost-effectiveness analysis of NOACs versus VKA for stroke prevention in Spain

et al. 2022

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Aims A Markov model was adapted to assess the real-world cost-effectiveness of rivaroxaban, dabigatran and apixaban. Each of these non-vitamin K antagonist oral anticoagulants was compared with vitamin K antagonist for stroke prevention in patients with non-valvular atrial fibrillation in Spain. Methods All inputs were derived from real-world studies: baseline patient characteristics, clinical event rates, as well as persistence rates for the vitamin K antagonist treatment option. A meta-analysis of real-world studies provided treatment effect and persistence data for rivaroxaban, dabigatran and apixaban, each compared with vitamin K antagonist therapy. The model considered 3-month cycles over a lifetime horizon. The model outcomes included different costs, quality-adjusted life years and life-years gained. Sensitivity analyses were performed to test the robustness of the model. Results When compared with vitamin K antagonist, rivaroxaban incurred incremental costs of €77 and resulted in incremental quality-adjusted life years of 0.08. The incremental cost per quality-adjusted life year was €952. For the same comparison, the incremental cost per quality-adjusted life year for dabigatran was €4,612. Finally, compared with vitamin K antagonist, the incremental cost per quality-adjusted life year for apixaban was €32,015. The sensitivity analyses confirmed the robustness of the base case results. The probabilities to be cost-effective versus vitamin K antagonist were 94%, 86% and 35%, respectively, for rivaroxaban, dabigatran and apixaban, considering a willingness-to-pay threshold of €22,000 per quality-adjusted life year gained, based on a cost-effectiveness study of the Spanish National Health System. Conclusion These results suggest that rivaroxaban and dabigatran are cost-effective versus vitamin K antagonist for stroke prevention in non-valvular atrial fibrillation, from the Spanish National Health System perspective.

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Section: Discussionmentioning

confidence: 99%

Real-world cost-effectiveness analysis of NOACs versus VKA for stroke prevention in Spain

et al. 2022

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“…The bleeding risk should be minimized rather than contraindicating or underdosing the anticoagulant. Various studies indicate that inappropriate prescription of NOACs is not uncommon, especially underdosing [74]. In the SAGE-AF study, underdosing of NOACs was more common than overdosing.…”

Section: Underdosingmentioning

confidence: 99%

“…Underdosing of NOACs has been observed in several countries [74,[76][77][78][79][80]. Dosing of rivaroxaban (adjusted according to kidney function) may be simpler than that of other NOACs, which is slightly more limited by various factors (creatinine, weight, age, treatment with P-glycoprotein inhibitors).…”

Section: Underdosingmentioning

confidence: 99%

“…The main factors associated with underdosing are advanced age, kidney failure, co-morbidities and having a high risk of bleeding and thromboembolic events. Doctors must not choose lower dose of NOACs just out of a fear of bleeding (thus ignoring the risk of stroke) [74]. Under-dosing of NOACs in patients with AF may be associated with reduced effectiveness for stroke prevention, with similar or even increased bleeding than with the standard dose [81].…”

Section: Underdosingmentioning

confidence: 99%

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Expert Recommendations on the Usage of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) from India: Current Perspective and Future Direction

Pai

Kumar²,

George

et al. 2022

Cardiol Ther

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Non-vitamin K antagonist oral anticoagulants (NOACs) are a new class of anticoagulant drugs used in the prevention and treatment of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulation requires the integration of the correct type and dose of oral anticoagulants based on patient characteristic, and therefore therapy needs to be individualized for each patient. Growing scientific evidence from studies on NOACs has led to a better understanding of their benefits and safety. A large amount of available data creates a necessity for an adaptable practical document for the usage of NOACs in India. The current consensus, developed by experts from India, aims to give recommendations on various frequently raised clinical questions with regards to NOACs and its usage. This practical document provides a platform upon which future guidelines, policies, training, and education for the use of NOACs can be tailored.

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“…Sin embargo, a pesar de esta recomendación, un número significativo de pacientes no se encuentran anticoagulados o no están tomando el tratamiento antitrombótico de manera apropiada, sea por un insuficiente control de la anticoagulación en los que están tomando antagonistas de la vitamina K (AVK) o porque los tratados con anticoagulantes orales de acción directa (ACOD) toman dosis inadecuadas para sus características clínicas [9][10][11] . Este tratamiento antitrombótico inapropiado ocurre con más frecuencia en las personas de mayor edad, posiblemente por un excesivo miedo al riesgo de hemorragias asociado al tratamiento anticoagulante en esta población, a pesar del riesgo elevado de ictus [12][13][14] .…”

Section: Introductionunclassified

Prescripción de anticoagulación oral en el paciente geriátrico con fibrilación auricular

Ramírez-Prieto¹,

Pombo-Bartelt²,

Rojas-Calderón³

et al. 2021

ACM

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Determinar la prevalencia de prescripción de anticoagulación oral en pacientes > 60 años con fibrilación auricular no valvular (FANV). Métodos: Estudio observacional, transversal, retrospectivo en el que se revisaron los expedientes de pacientes > 60 años que acudieron a la consulta externa de especialidades (cardiología, medicina interna, geriatría) de un hospital de segundo nivel de atención en Querétaro, México, con el diagnóstico de FANV del 1 de julio al 30 de septiembre de 2019. Se analizaron el perfil clínico y el tratamiento anticoagulante. Resultados: Se incluyeron 300 pacientes (edad media: 77.2 ± 8.3 años; 53.3% mujeres; 81.0% atendidos en cardiología). El 91% presentaban un riesgo tromboembólico elevado, el 22.7% un riesgo hemorrágico elevado y el 1.7% contraindicaciones para la anticoagulación. La presencia de comorbilidades fue frecuente. El 82.7% estaban tomando anticoagulantes orales de acción directa (ACOD), el 11.0% antagonistas de la vitamina K (AVK), y el 6.3% no estaban tomando ningún tratamiento anticoagulante. El 29.3% de los pacientes estaban tomando anticoagulantes orales de manera inadecuada, siendo las dos principales causas la prescripción de dosis de ACOD no ajustada a edad, peso y nivel de creatinina y la administración de ACOD sin indicación de acuerdo con el riesgo tromboembólico. De los pacientes que tomaban AVK, solo el 39.4% presentaban una anticoagulación en rango terapéutico. De los tratados con ACOD, el 48.0% tomaban rivaroxabán, principalmente con una dosis de 20 mg/día (73.1%). Conclusiones: El riesgo tromboembólico en pacientes geriátricos con FANV es elevado. En menos del 2% existe una contraindicación para la anticoagulación. En tres de cada diez pacientes se prescriben de manera inadecuada los anticoagulantes orales.Palabras clave: Geriátrico. Antagonistas de la vitamina K. Anticoagulación. Anticoagulantes orales de acción directa. Fibrilación auricular.

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The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation

Cited by 16 publications

References 99 publications

Real-world cost-effectiveness analysis of NOACs versus VKA for stroke prevention in Spain

Real-world cost-effectiveness analysis of NOACs versus VKA for stroke prevention in Spain

Expert Recommendations on the Usage of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) from India: Current Perspective and Future Direction

Prescripción de anticoagulación oral en el paciente geriátrico con fibrilación auricular

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