Trends in initiation of direct oral anticoagulant therapies for atrial fibrillation in a national population-based cross-sectional study in the French health insurance databases

Abstract

ObjectiveUnlike several other national health agencies, French health authorities recommended that the newer direct oral anticoagulant (DOAC) agents only be prescribed as second choice for the treatment of newly diagnosed non-valvular atrial fibrillation (NVAF), with vitamin K antagonists (VKA) remaining the first choice. We investigated the patterns of use of DOACs versus VKA in the treatment of NVAF in France over the first 5 years of DOAC availability. We also identified the changes in patient characteristics of those who initiated DOAC treatment over this time period.MethodsBased on the French National Health Administrative Database, we constituted a population-based cohort of all patients who were newly treated for NVAF between January 2011 and December 2015. Trends in drug use were described as the percentage of patients initiating each drug at the time of treatment initiation. A multivariate analysis using logistic regression model was performed to identify independent sociodemographic and clinical predictors of initial anticoagulant choice.ResultsThe cohort comprised 814 446 patients who had received a new anticoagulant treatment for NVAF. The proportion of patients using DOACs as initial anticoagulant therapy reached 54% 3 months after the Health Ministry approved the reimbursement of dabigatran for NVAF, and 61% by the end of 2015, versus VKA use. In the multivariate analysis, we found that DOAC initiators were younger and healthier overall than VKA initiators, and this tendency was reinforced over the 2011–2014 period. DOACs were more frequently prescribed by cardiologists in 2012 and after (adjusted OR in 2012: 2.47; 95% CI 2.40 to 2.54).ConclusionDespite recommendations from health authorities, DOACs have been rapidly and massively adopted as initial therapy for NVAF in France. Observational studies should account for the fact that patients selected to initiate DOAC treatment are healthier overall, as failure to do so may bias the risk–benefit assessment of DOACs.

Use of oral anticoagulation therapy in the first 3 months after the diagnosis of atrial fibrillation in Israel: A population‐based study

“…The ESC guidelines for AF treatment encourage OAC treatment in high‐risk AF patients, and the introduction of NOACs that are safer and more comfortable for patients probably contributed to this increase in OAC use. In fact, multiple other studies mostly from Europe and the United States have attested to the rapid and massive adoption of all NOAC drugs in recent years 12,18,19,25‐34 . It is, thus, important to add data from different world regions to this literature.…”

Assessment of Outcomes of Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation and Multiple Chronic Conditions

“… 35 Indeed, the choice of anticoagulant in patients with multiple conditions is complex. Recent data suggest that physicians are more likely to prescribe DOACs to healthier patients with fewer comorbidities, 12 while higher CHA 2 DS 2 -VASc and HAS-BLED scores are associated with lower probability of DOAC prescription compared with warfarin. 13 Our findings of similar effectiveness of all 3 anticoagulants for stroke prevention are assuring and will lend confidence to clinicians regarding DOAC use even in complex patients.…”

“… 9 , 10 , 11 Despite their increasing use, studies reveal that DOACs are more likely to be initiated in healthier patients with fewer comorbidities. 12 , 13 High-risk patients with MCC not only have higher stroke and bleeding risk, but also make up to 50% of newly diagnosed patients with AF. 9 Therefore, it is critically important to understand the efficacy and safety of DOACs in these patients.…”

Relationship between the Renal Function and Adverse Clinical Events in Patients with Atrial Fibrillation: A Japanese Multicenter Registry Substudy

“…Due to the convenience of DOACs over warfarin, such as the needlessness of anticoagulation monitoring and less food interactions, DOACs are widely used in clinical settings instead of the conventional anticoagulant treatment, warfarin. Huiart et al reported that 61% of AF patients initially used one of the four DOACs as their anticoagulation therapy [9].…”