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Mehrpooya M, Barakzehi MR, Nikoobakhsh M. Evaluation of the safety and efficacy of direct oral anticoagulants compared with vitamin-k antagonists in the treatment of left ventricular thrombosis. A systematic review and meta-analysis. Heart Lung 2024; 67:121-136. [PMID: 38754272 DOI: 10.1016/j.hrtlng.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Since the introduction of direct oral anticoagulants (DOACs) and their comparison with vitamin K antagonists (VKAs), conflicting results have been reported regarding the optimal treatment for left ventricular thrombosis (LVT). OBJECTIVES In this meta-analysis, we intend to comprehensively evaluate the safety and efficacy of these treatments. METHODS All clinical trials and cohorts that compared the efficacy or safety of VKAs with DOACs in the treatment of LVTs were systematically searched until April 15, 2023. RESULTS The results of 32 studies with a pooled sample size of 4213 patients were extracted for meta-analysis. DOACs, especially rivaroxaban and apixaban, cause faster resolution, lower mortality, and fewer complications (SSE and bleeding events) than VKAs in the management of LVTs. CONCLUSION Compared with VKAs, DOACs result in significantly faster (only rivaroxaban) and safer resolution of left ventricular thrombosis.
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Affiliation(s)
- Maryam Mehrpooya
- Department of Cardiology, Imam Khomeini Hospital Complex of Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rafi Barakzehi
- Department of Cardiology, Tehran Heart center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Nikoobakhsh
- Department of internal medicine, Yazd Islamic Azad University, Yazd, Iran.
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2
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Kang MG, Ahn JH, Hwang JY, Hwang SJ, Koh JS, Park Y, Bae JS, Chun KJ, Kim JS, Kim JH, Chon MK. Long-acting cilostazol versus isosorbide mononitrate for patients with vasospastic angina: a randomized controlled trial. Coron Artery Dis 2024:00019501-990000000-00215. [PMID: 38595079 DOI: 10.1097/mca.0000000000001366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Cilostazol has a vasodilatory function that may be beneficial for patients with vasospastic angina (VSA). We conducted a randomized, open-label, controlled trial to compare the efficacy and safety of long-acting cilostazol and isosorbide mononitrate (ISMN) for VSA. METHODS The study included patients with confirmed VSA between September 2019 and May 2021. Participants were randomly assigned to receive long-acting cilostazol (test group, 200 mg once daily) or conventional ISMN therapy (control group, 20 mg twice daily) for 4 weeks. The clinical efficacy and safety were evaluated using weekly questionnaires. RESULTS Forty patients were enrolled in the study (long-acting cilostazol, n = 20; ISMN, n = 20). Baseline characteristics were balanced between the two groups. Long acting cilostazol showed better angina symptom control within the first week compared to ISMN [reduction of pain intensity score, 6.0 (4.0-8.0) vs. 4.0 (1.0-5.0), P = 0.005; frequency of angina symptom, 0 (0-2.0) vs. 2.0 (0-3.0), P = 0.027, respectively]. The rate of neurological adverse reactions was lower in the cilostazol group than in the ISMN group (headache or dizziness, 40 vs. 85%, P = 0.009; headache, 30 vs. 70%, P = 0.027). CONCLUSION Long-acting cilostazol provided comparable control of angina and fewer adverse neurologic reactions within 4 weeks compared to ISMN. Long-acting cilostazol provides more intensive control of angina within 1 week, suggesting that it may be an initial choice for the treatment of VSA.
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Affiliation(s)
- Min Gyu Kang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Seok-Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon
| | - Jae Seok Bae
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon
| | - Kook Jin Chun
- Department of Internal Medicine, Pusan National University School of Medicine and Cardiology, Cardiovascular Center and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jeong Su Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Cardiology, Cardiovascular Center and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - June Hong Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Cardiology, Cardiovascular Center and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Min Ku Chon
- Department of Internal Medicine, Pusan National University School of Medicine and Cardiology, Cardiovascular Center and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
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Pan YQ, Jin LS, Qian S, Jiang T, Wang ZN, Chen YL, Qiu YX, Wu YH, Fu JY, Li L, Lin YN, Li YC. Twice-daily rivaroxaban after percutaneous left atrial appendage closure for atrial fibrillation. Front Pharmacol 2024; 15:1344828. [PMID: 38455964 PMCID: PMC10917903 DOI: 10.3389/fphar.2024.1344828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/02/2024] [Indexed: 03/09/2024] Open
Abstract
Background and aim: Rivaroxaban is an emerging oral anticoagulant for postoperative anticoagulation after percutaneous left atrial appendage closure (LAAC). Because a once-daily dosing regimen of rivaroxaban causes fluctuations in the drug plasma concentration, we studied the feasibility and safety of twice-daily rivaroxaban as a postoperative anticoagulation regimen for patients with atrial fibrillation (AF) undergoing LAAC. Methods: This study involved patients with AF who underwent LAAC and took rivaroxaban postoperatively. A total of 326 patients who received a standard total dose (15 or 20 mg) of rivaroxaban based on their creatinine clearance rate were divided into the twice-daily (BID) rivaroxaban group (n = 208) and once-daily (QD) rivaroxaban group (n = 118) according to their anticoagulation strategy. Transesophageal echocardiography was recommended at 3-6 months postoperatively to check for device-related thrombosis (DRT). Clinical outcomes were evaluated during postoperative anticoagulation. Results: The median CHA2DS2-VASc score (4 [3, 5] vs. 4 [3, 5], p = 0.28) and HAS-BLED score (2 [2, 3] vs. 2 [2, 3], p = 0.48) were not significantly different between the groups. During the anticoagulation period (4.1 ± 0.7 vs. 4.1 ± 0.9 months, p = 0.58), 148 (71.2%) patients in the BID group and 75 (63.6%) in the QD group underwent follow-up transesophageal echocardiography. There were no statistically significant differences between the two groups in terms of DRT (1.4% vs. 2.7%, p = 0.60), minor bleeding (8.2% vs. 11.0%, p = 0.39), thromboembolic events (1.0% vs. 0.8%, p = 1.00), major bleeding (0.5% vs. 0.8%, p = 1.00), or death. Conclusion: A short course of twice-daily rivaroxaban following LAAC is a feasible alternative regimen with a low rate of major bleeding events, DRT, and thromboembolic events for patients with AF.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Yue-Chun Li
- Department of Cardiology, Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
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Romagnoli A, Santoleri F, Costantini A, Di Risio A. Adherence, persistence and switching rates of apixaban, dabigatran and rivaroxaban in non-valvular atrial fibrillation: a multicentre real-life analysis at 3 years. Eur J Hosp Pharm 2024; 31:156-161. [PMID: 35961767 PMCID: PMC10895192 DOI: 10.1136/ejhpharm-2022-003338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/02/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Adherence to and persistence with long-term treatment with oral anticoagulants play a significant role in preventing adverse events and mortality in patients with cardiac conditions. The aim of this study was to evaluate the adherence, persistence and switching rate at 3 years in real-life patients with non-valvular atrial fibrillation receiving treatment with first-line new oral anticoagulants. METHODS The study assessed all patients treated with drugs with the ATC codes B01AA, B01AE, B01AF and dispensed in pharmacies in the Lanciano-Vasto-Chieti and Pescara Local Health Units from 1 January 2011 to 30 September 2021. Adherence was calculated as the proportion of days covered; persistence was calculated as the difference in days between the start and end of treatment; and the switching rate was calculated as the difference in days between the start of treatment and the switch. RESULTS A total of 4270 patients were analysed. The absolute adherence figure at 3 years was 0.85. The lowest adherence levels were found in patients treated with dabigatran with an absolute value of 0.72, while the highest levels were found in patients treated with rivaroxaban with an absolute value at 3 years of 0.88. The persistence curves at 3 years of treatment with dabigatran showed a statistically significant difference (p<0.0001) compared with those of rivaroxaban and apixaban. CONCLUSIONS The data collected over a 3-year period showed that adherence and persistence levels and switch data were optimal and comparable in patients with non-valvular atrial fibrillation receiving treatment with either rivaroxaban or apixaban. In contrast, patients treated with dabigatran had worrying adherence and persistence levels.
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Affiliation(s)
- Alessia Romagnoli
- Territorial Pharmaceutical Service, Local Health Unit Lanciano Vasto Chieti, Chieti, Italy
| | | | | | - Angelora Di Risio
- Territorial Pharmaceutical Service, Local Health Unit Lanciano Vasto Chieti, Chieti, Italy
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Dietrich F, Polymeris AA, Albert V, Engelter ST, Hersberger KE, Schaedelin S, Lyrer PA, Arnet I. Intake reminders are effective in enhancing adherence to direct oral anticoagulants in stroke patients: a randomised cross-over trial (MAAESTRO study). J Neurol 2024; 271:841-851. [PMID: 37831125 PMCID: PMC10827905 DOI: 10.1007/s00415-023-12035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) effectively prevent recurrent ischaemic events in atrial fibrillation (AF) patients with recent stroke. However, excellent adherence to DOAC is mandatory to guarantee sufficient anticoagulation as the effect quickly subsides. AIM To investigate the effect of intake reminders on adherence to DOAC. METHODS MAAESTRO was a randomised, cross-over study in DOAC-treated AF patients hospitalised for ischaemic stroke. Adherence was measured by electronic monitoring for 12 months. After an observational phase, patients were randomised to obtain an intake reminder either in the first or the second half of the subsequent 6-month interventional phase. The primary outcome was 100%-timing adherence. Secondary outcomes were 100%-taking adherence, and overall timing and taking adherence. We analysed adherence outcomes using McNemar's test or mixed-effects logistic models. RESULTS Between January 2018 and March 2022, 130 stroke patients were included, of whom 42 dropped out before randomisation. Analysis was performed with 84 patients (mean age: 76.5 years, 39.3% women). A 100%-timing adherence was observed in 10 patients who were using the reminder, and in zero patients without reminder (p = 0.002). The reminder significantly improved adherence to DOAC, with study participants having 2.7-fold increased odds to achieve an alternative threshold of 90%-timing adherence (OR 2.65; 95% CI 1.05-6.69; p = 0.039). A similar effect was observed for 90%-taking adherence (OR 3.06; 95% CI 1.20-7.80; p = 0.019). Overall timing and taking adherence increased significantly when using the reminder (OR 1.70; 95% CI 1.55-1.86, p < 0.01; and OR 1.67; 95% CI 1.52-1.84; p < 0.01). CONCLUSION Intake reminders increased adherence to DOAC in patients with stroke attributable to atrial fibrillation. TRIAL REGISTRATION ClinicalTrials.gov: NCT03344146.
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Affiliation(s)
- Fine Dietrich
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland.
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Valerie Albert
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Burgfelderstrasse 101, 4055, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Isabelle Arnet
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
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Brouillard P, Diallo EH, Masson JB, Raymond JM, Riahi M, Potter B, Kouz R, Potvin J. Real-World Management Strategies of Anticoagulated Atrial Fibrillation Patients After a Clinically Significant Bleeding Episode. Can J Cardiol 2024:S0828-282X(23)02048-2. [PMID: 38181972 DOI: 10.1016/j.cjca.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Systemic anticoagulation for stroke prevention in patients with atrial fibrillation (AF) carries inherent bleeding risks, and determining whether and when to resume anticoagulation after significant bleeding is a common dilemma. We aimed to describe the clinical characteristics of AF patients discharged after a bleeding event, document real-life thromboembolic prevention strategy (TPS), and analyse their associated clinical outcomes. METHODS We retrospectively reviewed the charts of anticoagulated AF patients admitted for bleeding from 2017 to 2019. RESULTS A total of 140 patients were included, with a mean age of 78.6 years. Four discharge groups were defined: 75 patients (53.5%) had optimal anticoagulation (OA), 37 (26.4%) had a suboptimal antithrombotic regimen (SAR; low-dose direct oral anticoagulants without dose-reduction criteria or antiplatelet therapy), 10 (7.1%) were referred for left atrial appendage occlusion (LAAO), and 18 (12.9%) left without any TPS. All-cause mortality at 2 years was high (28.6%) but not statistically different between groups (P = 0.71). Patients discharged with a TPS (OA/SAR/LAAO referral) were more likely to be readmitted for bleeding at 2 years (34% vs 0%; P = 0.002), and those discharged without a TPS had higher rates of stroke (16.6% vs 1.4%; P = 0.003). SAR yielded readmission rates for bleeding similar to resumption of OA (27% vs 34.7%; P = 0.41) but was associated with high rates of death or readmission at 2 years. CONCLUSIONS This real-life cohort reveals that clinicians frequently downgrade or discontinue long-term thromboembolic protection after a bleeding event despite current guideline recommendations to the contrary, and downgrading resulted in bleeding risk similar to OA.
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Affiliation(s)
- Philippe Brouillard
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada.
| | - El Hadji Diallo
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Bernard Masson
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Marc Raymond
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Mounir Riahi
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Brian Potter
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Rémi Kouz
- Département de médecine, Université de Montréal, Montréal, Québec, Canada; Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Jeannot Potvin
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
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Vrijens B, Pironet A, Tousset E. The Importance of Assessing Drug Exposure and Medication Adherence in Evaluating Investigational Medications: Ensuring Validity and Reliability of Clinical Trial Results. Pharmaceut Med 2024; 38:9-18. [PMID: 38135800 PMCID: PMC10824809 DOI: 10.1007/s40290-023-00503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 12/24/2023]
Abstract
The objective of this current opinion paper is to draw global attention to medication adherence, emphasizing its crucial role in drug trials. Frequently, trialists lean on traditional approaches to assess medication adherence, which, while comfortable, may only reveal what trialists desire rather than offering the essential insights needed for informed decision making in drug development. Understanding drug exposure and medication adherence is paramount when evaluating the effectiveness and safety of investigational medications. Without a comprehensive understanding of how patients adhere to their prescribed treatment regimens, the integrity and dependability of clinical trial results can be compromised. This paper emphasizes the need for measures that accurately and reliably assess medication intake behaviors, enabling the differentiation between minor dosing errors and significant deviations that may impact the drug's efficacy and safety. Accurate knowledge of drug exposure empowers researchers to make informed decisions, identify potential confounding factors, and appropriately interpret study outcomes, ultimately ensuring the validity and reliability of the research findings. By prioritizing drug exposure assessment and medication adherence measurement, clinical trials can enhance their scientific rigor, contribute to more accurate evaluations of investigational medications, and ultimately speed up the development process.
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Affiliation(s)
- Bernard Vrijens
- AARDEX Group, 15/1, Rue Bois St Jean, 4102, Liège, Belgium.
- Department of Public Health, Liège University, Liège, Belgium.
| | | | - Eric Tousset
- AARDEX Group, 15/1, Rue Bois St Jean, 4102, Liège, Belgium
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Mody BS, Wadhwa M, Roy R, Echila S. Current Evidence and Expert Opinion on Thromboprophylaxis After Total Knee and Hip Replacement. Cureus 2023; 15:e51089. [PMID: 38274925 PMCID: PMC10808783 DOI: 10.7759/cureus.51089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 01/27/2024] Open
Abstract
An effective anticoagulant provides a balance between the risk for venous thromboembolism (VTE) and bleeding and is crucial in achieving optimal clinical outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR) surgeries. We performed a review of the literature on thromboprophylaxis for patients undergoing total hip or knee replacement. This review article summarizes current guidelines and evidence for anticoagulation along with the expert opinion about pharmacological VTE prophylaxis, particularly non-Vitamin K antagonist oral anticoagulants (NOACs), for patients after total hip or knee replacement. Aspirin for VTE prophylaxis after TKR/THR has been controversial and most of the evidence is reported from observational research. Although the guidelines do not recommend any specific thromboprophylaxis agent, available evidence suggests that NOACs are as effective as low molecular weight heparins (LMWHs) in preventing VTE. Oral administration and the lack of dose monitoring make NOACs easy to use in outpatient settings in cases with challenging treatment compliances. They can be used for two weeks after TKR and five weeks after THR - six weeks after TKR and THR to cover the at-risk period for VTE post-discharge. Owing to the lack of evidence for a head-to-head comparison of NOACs, an anticoagulant with better efficacy and safety may be suggested in special patient populations (elderly, obese patients, or those with renal dysfunction). The expert opinion on pharmacological VTE prophylaxis provided in this article could address some gaps in the management of anticoagulation in patients with total hip or knee replacement.
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Affiliation(s)
- Bharat S Mody
- Joint Replacement Surgery, Welcare Hospital, Vadodara, IND
| | - Manuj Wadhwa
- Orthopaedics & Joint Replacement, Elite Institutes of Orthopaedics & Joint Replacement, Mohali, IND
| | - Ronen Roy
- Orthopaedic Surgery, Fortis Hospitals, Kolkata, IND
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Knaepen L, Delesie M, Vijgen J, Dendale P, Ector J, Desteghe L, Heidbuchel H. Adherence to oral anticoagulation measured by electronic monitoring in a Belgian atrial fibrillation population. Clin Res Cardiol 2023; 112:1812-1823. [PMID: 37498363 PMCID: PMC10698080 DOI: 10.1007/s00392-023-02261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Stroke prevention using oral anticoagulation (OAC) is the first management priority in atrial fibrillation (AF). Despite the importance of good therapy adherence, real-world adherence is still suboptimal. Patient education and adherence monitoring with new technologies are recommended. The main purpose of this sub-analysis of the AF-EduCare trial was to evaluate the effect of personalized follow-up strategies on adherence to OAC. METHODS Regimen adherence was monitored by the electronic Medication Event Monitoring System cap at the start of the trial (M1) and after 12 months (M2), each for three months. Patients were part of one of three education groups (In-person, Online or App-based) or the standard care (SC) group. All are qualified for OAC therapy. RESULTS A total of 768 patients were evaluated (11.8% SC vs. 86.8% any education group, mean age: 70.1 ± 7.9 years). Patients were taking non-vitamin K OAC (once daily 53.8%; twice daily 35.9%) or vitamin K antagonists (9.4%), equally distributed over the different study arms (p = 0.457). Mean therapy adherence was high (M1:93.8 ± 10.8%; M2:94.1 ± 10.1%). During both monitoring periods, the education group scored significantly higher than SC (M1:94.2 ± 10.0% vs. 91.3 ± 15.0%; p = 0.027; M2:94.4 ± 9.3% vs. 91.6 ± 14.0%; p = 0.006). More patients in the In-person and Online groups were able to keep or improve their adherence to > 90% compared to the SC. CONCLUSION Overall adherence to OAC in all study groups, even in SC, was very high, without attrition over time. Nevertheless, targeted education led to a small but significantly improved adherence compared to SC.
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Affiliation(s)
- Lieselotte Knaepen
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium.
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium.
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium.
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Michiel Delesie
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Johan Vijgen
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Paul Dendale
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Joris Ector
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Lien Desteghe
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Hein Heidbuchel
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
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Patti G, Wang R, Marston XL, Yeh YC, Zimmermann L, Ye X, Gao X, Brüggenjürgen B. Anticoagulant Treatment Adherence and Persistence in German Patients with Atrial Fibrillation. Cardiol Ther 2023; 12:371-391. [PMID: 37138193 DOI: 10.1007/s40119-023-00315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
INTRODUCTION Treatment adherence and persistence impact the effectiveness of edoxaban for the prevention of thromboembolism in patients with atrial fibrillation (AF). The objective of this analysis was to assess adherence and persistence of edoxaban vs. other non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKAs). METHODS Utilizing a German claims database, adults with AF with the first pharmacy claim identified for edoxaban, apixaban, dabigatran, rivaroxaban, or VKAs from January 2013 to December 2017 were included in a propensity score-matched analysis. The first pharmacy claim was the index claim. Adherence (i.e., proportion of days covered [PDC]) and persistence (proportion of patients who continued therapy) were compared between edoxaban and other therapies. Patients receiving once-daily (QD) vs. twice-daily (BID) NOAC were also analyzed. RESULTS Overall, 21,038 patients were included (1236 edoxaban, 6053 apixaban, 1306 dabigatran, 7013 rivaroxaban, and 5430 VKA). After matching, baseline characteristics were well balanced across cohorts. Adherence was significantly higher for edoxaban vs. apixaban, dabigatran, and VKAs (all P < 0.0001). Significantly more edoxaban patients continued therapy vs. rivaroxaban (P = 0.0153), dabigatran (P < 0.0001), and VKAs (P < 0.0001). Time to discontinuation was significantly longer for edoxaban vs. dabigatran, rivaroxaban, and VKAs (all P < 0.0001). More patients receiving NOACs QD had a PDC ≥ 0.8 compared with those receiving NOACs BID (65.3 vs. 49.6%, respectively; P < 0.05); persistence rates were comparable between QD and BID groups. CONCLUSIONS Patients with AF receiving edoxaban had significantly higher adherence and persistence compared with those receiving VKAs. This trend was also seen in NOAC QD regimens vs. NOAC BID regimens for adherence. These results provide insight into how adherence and persistence may contribute to the effectiveness of edoxaban for stroke prevention in patients with AF in Germany.
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Affiliation(s)
- Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.
| | - Rosa Wang
- Daiichi Sankyo Inc., Basking Ridge, NJ, USA
| | | | | | | | - Xin Ye
- Daiichi Sankyo Inc., Basking Ridge, NJ, USA
| | - Xin Gao
- OPEN Health, Bethesda, MD, USA
| | - Bernd Brüggenjürgen
- Orthopedic Department, Medical School Hannover at DIAKOVERE Annastift Hospital, Hannover, Germany
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11
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Xu W, Lv M, Wu S, Jiang S, Zeng Z, Fang Z, Qian J, Chen M, Chen J, Zhang J. Severe Bleeding Risk of Direct Oral Anticoagulants Versus Vitamin K Antagonists for Stroke Prevention and Treatment in Patients with Atrial Fibrillation: A Systematic Review and Network Meta-Analysis. Cardiovasc Drugs Ther 2023; 37:363-377. [PMID: 34436708 DOI: 10.1007/s10557-021-07232-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE We aimed to determine the safety of direct oral anticoagulants (DOACs) for stroke prevention and treatment in patients with atrial fibrillation (AF). METHODS A systematic search of four databases (PubMed, EMBASE, Web of Science, and Cochrane Library) was performed to identify randomized controlled trials (RCTs) reporting severe bleeding events in patients taking DOACs or vitamin K antagonists (VKAs). In this frequency-based network meta-analysis, odds ratios and 95% confidence intervals were used for reporting. Based on the surface under the cumulative ranking curves (SUCRA), the relative ranking probability of each group was generated. RESULTS Twenty-three RCTs met the inclusion criteria, and a total of 87,616 patients were enrolled. The bleeding safety of DOACs for stroke prevention and treatment in patients with AF was ranked from highest to lowest as follows: fatal bleeding: edoxaban (SUCRA,80.2), rivaroxaban (SUCRA,68.3), apixaban (SUCRA,48.5), dabigatran (SUCRA,40.0), VKAs (SUCRA,12.9); major bleeding: dabigatran (SUCRA,74.0), apixaban (SUCRA,71.5), edoxaban (SUCRA,66.5), rivaroxaban (SUCRA,22.7), VKAs (SUCRA,15.4); gastrointestinal bleeding: apixaban (SUCRA,55.9), VKAs (SUCRA,53.7), edoxaban (SUCRA,50.5), rivaroxaban (SUCRA,50.4), dabigatran (SUCRA,39.5); intracranial hemorrhage: dabigatran (SUCRA,84.6), edoxaban (SUCRA,74.1), apixaban (SUCRA,65.8), rivaroxaban (SUCRA,24.4), VKAs (SUCRA,1.1). CONCLUSION Based on current evidence, for stroke prevention and treatment in patients with AF, the most safe DOAC is edoxaban in terms of fatal bleeding; dabigatran in terms of major bleeding and intracranial hemorrhage and apixaban in terms of gastrointestinal bleeding. However, given the nature of indirect comparisons, more high-quality evidence from head-to-head comparisons is still needed to confirm them.
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Affiliation(s)
- Wenlin Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Zhiwei Zeng
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Zongwei Fang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jiafen Qian
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Mingrong Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jiana Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China.
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12
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Ido T, Sasaki S, Sotomi Y, Hirata A, Makino N, Hayashi T, Sakata Y, Hirayama A, Higuchi Y. Twice- or once-daily dosing of direct oral anticoagulants and gastrointestinal bleeding in patient with atrial fibrillation. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100203. [PMID: 38558905 PMCID: PMC10978415 DOI: 10.1016/j.ahjo.2022.100203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/06/2022] [Indexed: 04/04/2024]
Abstract
Aims Direct oral anticoagulant (DOAC) is widely used for the prevention of embolic stroke in non-valvular atrial fibrillation (NVAF) patients. However, the gastrointestinal bleeding risk in several DOAC regimens was higher than warfarin, especially in once-daily regimens. Methods and results We conducted a single-center prospective registry of patients with NVAF treated with DOACs: the DIRECT registry (N = 2216; follow-up duration 650 [IQR 103-1574] days, UMIN000033283). All patients were divided into 2 groups: the twice-daily (BID) regimen group (dabigatran and apixaban) versus the once-daily (QD) regimen group (rivaroxaban and edoxaban). Out of 2216 patients, we successfully matched 904 patients in the QD group and 904 patients in the BID group using propensity score. The primary endpoint was gastrointestinal bleeding defined as any bleeding in the gastrointestinal tract that was identified through medical records regardless of bleeding site or severity. The BID group showed a significantly lower gastrointestinal bleeding rate than the QD group (3.5/100 person-year vs. 6.2/100 person-year, log-rank P < 0.0001). The secondary endpoints were all death, stroke, major bleeding, and any bleeding. The rate of major bleeding was significantly lower in patients with BID regimen group (log-rank P = 0.040). In contrast, all death, stroke, and any bleeding did not differ between both groups (log-rank P = 0.280, 0.520 and 0.066, respectively). Conclusions The BID regimen as compared with the QD regimen was associated with reduced risk of gastrointestinal bleeding.
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Affiliation(s)
- Tadakiyo Ido
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita 565-0871, Japan
| | - Shun Sasaki
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
| | - Yohei Sotomi
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita 565-0871, Japan
| | - Akio Hirata
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
| | - Nobuhiko Makino
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
| | - Takaharu Hayashi
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita 565-0871, Japan
| | - Atsushi Hirayama
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
| | - Yoshiharu Higuchi
- Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan
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13
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Wirbka L, Ruff C, Haefeli WE, Meid AD. A prediction model for nonpersistence or nonadherence to direct oral anticoagulants in hospitalized patients with atrial fibrillation. J Manag Care Spec Pharm 2022; 28:1161-1172. [PMID: 36125062 PMCID: PMC10373020 DOI: 10.18553/jmcp.2022.28.10.1161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Medication adherence and persistence is fundamental for drug effectiveness, which is also true for the prevention of strokes in patients with atrial fibrillation (AF). Adherence to direct oral anticoagulants (DOACs) as first-line agents is often high in the early posthospital period. However, adherence often sharply declines (or eventually leads to nonpersistence) in the post-discharge ambulatory period, rendering stroke prevention ineffective. If patients at high risk of nonpersistence or nonadherence could be identified early, they could be offered early intervention measures to improve adherence and/or persistence. OBJECTIVE: To develop and internally validate a predictive model for medication nonadherence and nonpersistence to DOAC treatment in patients with AF after discharge using health insurance claims data. METHODS: We selected health insurance claims data between 2011 and 2016 from 8,055 patients with AF who were newly treated with rivaroxaban or apixaban after a hospital admission for stroke, transient ischemic attack, or AF. In the post-discharge ambulatory period, medication adherence was derived as the proportion of days covered, calculated from drug dispensation data. A maximum permissible 90-day gap between the end of a prescription and the next dispensation was used to estimate persistence. Candidate predictors were either derived from the index hospital admission or summarized from the previous year (eg, comorbidities or medication adherence to long-term treatments, such as ß-blockers, renin-angiotensin system inhibitors, statins, and thyroid hormones). A regularized logistic regression model was fitted using the least absolute shrinkage and selection operator in a split-sample approach (66.7% training data; 33.3% test data) to predict a composite of medication nonadherence/nonpersistence. Discrimination performance was assessed using the area under the receiver operating characteristic curve, the maximum sensitivity/specificity, and the scaled Brier score. A calibration curve fitted by linear regression was used to evaluate model calibration. RESULTS: The average age of the study participants was 79.7 years, 62% were female, and 3,515 patients (44%) were adherent and persistent (median follow-up of 185 days). Medication adherence to previous long-term treatments showed strong predictive properties. The developed model discriminated well (concordance statistic: 0.755), was well calibrated, and showed a scaled Brier score of 0.202 for identification of patients at risk. CONCLUSIONS: The model successfully predicted medication non-adherence/nonpersistence to DOAC treatment after discharge. Such a model could help ensure that targeted interventions are already in place at the time of hospital discharge, potentially preventing strokes and reducing costs. DISCLOSURES: Mr Wirbka is funded by the German Innovation Funds according to § 92a (2) Volume V of the Social Insurance Code (§ 92a Abs. 2, SGBV-Fünftes Buch Sozialgesetzbuch), grant number: 01VSF18019. Dr Haefeli received financial support from Daiichi-Sankyo, app development (https://www.easydoac.de/), and Bayer. He also received personal speaker fees from Bristol Myers-Squibb and Daiichi-Sankyo Online Seminar. Dr Meid is funded by the Physician-Scientist Programme of the Medical Faculty of Heidelberg University.
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Affiliation(s)
- Lucas Wirbka
- Department of Clinical Pharmacology and Pharmacoepidemiology, Center for Internal Medicine, Heidelberg University Hospital, Germany
| | - Carmen Ruff
- Department of Clinical Pharmacology and Pharmacoepidemiology, Center for Internal Medicine, Heidelberg University Hospital, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Center for Internal Medicine, Heidelberg University Hospital, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Center for Internal Medicine, Heidelberg University Hospital, Germany
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14
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Grymonprez M, Capiau A, Steurbaut S, Mehuys E, Boussery K, De Backer TL, Lahousse L. Adherence and persistence to oral anticoagulants in patients with atrial fibrillation: A Belgian nationwide cohort study. Front Cardiovasc Med 2022; 9:994085. [PMID: 36247477 PMCID: PMC9558210 DOI: 10.3389/fcvm.2022.994085] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSince non-vitamin K antagonist oral anticoagulants (NOACs) do not require coagulation monitoring, concerns of lower adherence and persistence to NOACs than vitamin K antagonists (VKAs) have been raised. Moreover, little is known on the frequency of permanent cessation and switching between anticoagulants in patients with atrial fibrillation (AF). Therefore, persistence, reinitiation, switching and adherence to oral anticoagulants (OACs) were investigated.Materials and methodsAF patients with a first OAC prescription claim between 2013 and 2019 were identified in Belgian nationwide data. Persistence, reinitiation and switching were estimated using Kaplan-Meier analyses. Adherence was investigated using the proportion of days covered (PDC). Predictors for non-adherence and non-persistence were identified by multivariable logistic regression.ResultsAmong 277,782 AF patients, 69.6% NOAC and 37.2% VKA users were persistent after 1 year, whereas 44.3% and 18.9% after 5 years, respectively. After one year, 67.1% rivaroxaban, 68.1% dabigatran, 69.8% apixaban, and 76.9% edoxaban users were persistent. Among subjects having discontinued NOAC or VKA treatment, 75.4% and 46.1% reinitiated any OAC within 5 years, respectively. VKAs were more frequently switched to NOACs than vice versa (17.6% versus 2.5% after 1 year). After 1 year, a high PDC (≥ 90%) was observed in 87.8% apixaban, 88.6% dabigatran, 91.3% rivaroxaban, and 94.7% edoxaban users (90.2% NOAC users). Adherence and persistence were higher in older, female subjects, while lower in subjects with dementia or hyperpolypharmacy.ConclusionAdherence and persistence to NOACs were high. However, 10% of subjects were non-adherent after 1 year and one-fourth did not reinitiate anticoagulation within 5 years after NOAC discontinuation.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Center for Pharmaceutical Research, Research Group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
- Department of Hospital Pharmacy, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - Els Mehuys
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
- *Correspondence: Lies Lahousse,
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15
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2). JACC. ASIA 2022; 2:519-537. [PMID: 36624790 PMCID: PMC9823285 DOI: 10.1016/j.jacasi.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/29/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Address for correspondence: Dr Chern-En Chiang, General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. @en_chern
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea,Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand,Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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16
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Polymeris AA, Zietz A, Schaub F, Meya L, Traenka C, Thilemann S, Wagner B, Hert L, Altersberger VL, Seiffge DJ, Lyrer F, Dittrich T, Piot I, Kaufmann J, Barone L, Dahlheim L, Flammer S, Avramiotis NS, Peters N, De Marchis GM, Bonati LH, Gensicke H, Engelter ST, Lyrer PA. Once versus twice daily direct oral anticoagulants in patients with recent stroke and atrial fibrillation. Eur Stroke J 2022; 7:221-229. [DOI: 10.1177/23969873221099477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Data on the safety and effectiveness of once-daily (QD) versus twice-daily (BID) direct oral anticoagulants (DOAC) in comparison to vitamin K antagonists (VKA) and to one another in patients with atrial fibrillation (AF) and recent stroke are scarce. Patients and methods: Based on prospectively obtained data from the observational registry Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients(NOACISP)-LONGTERM (NCT03826927) from Basel, Switzerland, we compared the occurrence of the primary outcome – the composite of recurrent ischemic stroke, major bleeding, and all-cause death – among consecutive AF patients treated with either VKA, QD DOAC, or BID DOAC following a recent stroke using Cox proportional hazards regression including adjustment for potential confounders. Results: We analyzed 956 patients (median age 80 years, 46% female), of whom 128 received VKA (13.4%), 264 QD DOAC (27.6%), and 564 BID DOAC (59%). Over a total follow-up of 1596 patient-years, both QD DOAC and BID DOAC showed a lower hazard for the composite outcome compared to VKA (adjusted HR [95% CI] 0.69 [0.48, 1.01] and 0.66 [0.47, 0.91], respectively). Upon direct comparison, the hazard for the composite outcome did not differ between patients treated with QD versus BID DOAC (adjusted HR [95% CI] 0.94 [0.70, 1.26]). Secondary analyses focusing on the individual components of the composite outcome revealed no clear differences in the risk-benefit profile of QD versus BID DOAC. Discussion and conclusion: The overall benefit of DOAC over VKA seems to apply to both QD and BID DOAC in AF patients with a recent stroke, without clear evidence that one DOAC dosing regimen is more advantageous than the other.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabian Schaub
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Louisa Meya
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valerian L Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Flurina Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ines Piot
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Josefin Kaufmann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Lea Barone
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | | | - Sophie Flammer
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Nikolaos S Avramiotis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
- Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
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17
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Spence JD. Management of Patients with Embolic Stroke of Unknown Source: Interpreting the Evidence in the Light of Clinical Judgement. Curr Neurol Neurosci Rep 2022; 22:389-393. [PMID: 35524921 DOI: 10.1007/s11910-022-01202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To assess the validity of the belief that anticoagulation is not beneficial in patients with embolic stroke of unknown source (ESUS), and to asssess the benefits and safety of direct-acting oral anticoagulants (DOACs). RECENT FINDINGS The failure of randomized trials to show benefit of anticoagulation in ESUS is probably due to misclassification of large artery atherosclerosis (LAA) as ESUS, as defined by a stenosis ≥ 50%. There are important differences among DOACs. There are a number of problems with dabigatran, and rivaroxaban and edoxaban are not suitable for once-daily dosing. Recent evidence from real-world practice indicates that apixaban is more effective and safer than rivaroxaban. Plaque burden should be included in the definition of LAA. Patients in whom a cardioembolic source is strongly suspected should be anticoagulated; antiplatelet agents are not significantly safer than DOACs, and are not effective in cardioembolic stroke.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON, N6G 2V4, Canada.
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Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
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Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Adherence and Persistence with Once-Daily vs Twice-Daily Direct Oral Anticoagulants Among Patients with Atrial Fibrillation: Real-World Analyses from the Netherlands, Italy and Germany. Drugs Real World Outcomes 2022; 9:199-209. [PMID: 34993898 PMCID: PMC9114199 DOI: 10.1007/s40801-021-00289-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
Background Direct oral anticoagulants are available for patients with atrial fibrillation. Objective This study compared adherence and persistence of once-daily (QD) vs twice-daily (BID) direct oral anticoagulants in patients with atrial fibrillation. Methods A cohort study was conducted in three databases in the Netherlands, Italy and Germany. Patients with AF starting direct oral anticoagulants after drug approval date were included. The index date was the date of first dispensing. Study patients were restricted to those aged ≥ 18 years, ≥ 1 year database history and ≥ 1 year follow-up. Adherence to treatment was defined as the proportion of days covered ≥ 80% between the index date and the date of last dispensing of the index regimen (i.e. exposure period). The proportion of days covered was also determined during the 12-month follow-up. Persistence was defined as continuous use from index to treatment discontinuation. Results In the Netherlands, Italy and Germany, respectively, 6068, 32,260 and 167,445 patients were included. The mean age of the patients was 70, 77 and 74 years, and 31%, 40% and 61% were QD users, all respectively. Among QD/BID users, 93/90%, 88/86% and 77/58%, respectively were adherent during the exposure period. Persistence rates at 1 year in QD/BID users were 60/59%, 13/14% and 46/31%, respectively. Conclusions Adherence to treatment was high. In Germany, adherence was markedly higher in QD users compared with BID users. In Italy and the Netherlands, these differences were marginal. Persistence was low in all countries, but discontinuation was temporary. Only in Germany, persistence was markedly lower in BID users vs QD users. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-021-00289-w.
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20
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Ferro EG, Kazi DS, Zimetbaum PJ. Informing the Choice of Direct Oral Anticoagulant Therapy in Patients With Atrial Fibrillation. JAMA 2021; 326:2372-2374. [PMID: 34932097 DOI: 10.1001/jama.2021.21305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Enrico G Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Peter J Zimetbaum
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Harvard Thorndike Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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21
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Arora S, Nair S, Prabhu R, Avanthika C, Jhaveri S, Samayam S, Katta MR, Agarwal P. Role of Direct Oral Anticoagulation Agents as Thromboprophylaxis in Antiphospholipid Syndrome. Cureus 2021; 13:e19009. [PMID: 34824926 PMCID: PMC8610415 DOI: 10.7759/cureus.19009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 01/13/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder that causes venous, arterial and small-vessel thrombosis, pregnancy loss, and premature birth. Cardiac valvular disease, renal thrombotic microangiopathy, thrombocytopenia, hemolytic anemia, and cognitive impairment are some of its other clinical symptoms. Antiphospholipid antibodies cause endothelial cells, monocytes, and platelets to become activated, as well as an increase in tissue factor and thromboxane A2. Complement activation might play a key function in pathogenesis. Long-term oral anticoagulation is used to treat thrombosis, and individuals having arterial episodes should be treated quickly. Patients with systemic lupus erythematosus (SLE), as well as those with solely obstetric antiphospholipid syndrome, should get primary thromboprophylaxis. Obstetric care is based on a combination of medical and obstetric high-risk management, as well as aspirin and heparin therapy. Possible supplementary therapy for this condition is hydroxychloroquine. Statins, rituximab, and novel anticoagulant medicines are all potential future treatments for non-pregnant individuals with antiphospholipid syndrome. We aim to review the role of direct-acting oral anticoagulants (DOACs) as thromboprophylactic drugs in the treatment of APS in this article. The treatment of venous thromboembolism has been transformed by a new class of DOACs. These drugs, such as rivaroxaban, function by inhibiting factor Xa directly. Not only do they have known anticoagulant actions, but they also obviate the need for dosage monitoring and modification, in contrast to warfarin. We conducted an exhaustive literature search of PubMed/MEDLINE and Google Scholar Indexes using the keywords "Antiphospholipid syndrome," "thromboprophylaxis," and "oral anticoagulants" up to September 2021. We found that DOACs have been shown to be non-inferior to warfarin in a variety of anticoagulation situations in a number of high-powered clinical studies. In many hypercoagulable conditions such as APS, DOACs are quickly establishing themselves as first-line therapy. This article is focused on comprehensively reviewing the mechanism of action of DOACs, their role as thromboprophylactic drugs, risks and complications of DOACs, and comparing their efficacy with the standard treatment protocol and warfarin.
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Affiliation(s)
- Shreya Arora
- Internal Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, IND
| | - Shaalina Nair
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Rishab Prabhu
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Chaithanya Avanthika
- Medicine and Surgery, Karnataka Institute of Medical Sciences, Hubli, IND.,Pediatrics, Karnataka Institute of Medical Sciences, Hubli, IND
| | - Sharan Jhaveri
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, IND
| | - Shilpa Samayam
- Internal Medicine, Government Medical College Siddipet, Siddipet, IND
| | - Maanya R Katta
- Internal Medicine, Gandhi Medical College, Hyderabad, IND
| | - Pahel Agarwal
- Internal Medicine, Bhaskar Medical College, Hyderabad, IND
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Brízido C, Ferreira AM, Lopes P, Strong C, Sá Mendes G, Fernandes Gama F, Durazzo A, Rocha Rodrigues G, Matos D, Guerreiro S, Madeira S, Ferreira J, Adragão P, Mendes M. Medication adherence to direct anticoagulants in patients with non-valvular atrial fibrillation - A real world analysis. Rev Port Cardiol 2021; 40:669-675. [PMID: 34503705 DOI: 10.1016/j.repce.2021.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/08/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) changed the landscape of atrial fibrillation (AF) treatment, but also brought with them new challenges in terms of accessibility and compliance. The purpose of this study was to assess adherence to DOACs, and its determinants in a population of AF patients. METHODS Single-center retrospective study including all patients with non-valvular AF treated with a DOAC from the outpatient general cardiology list at a tertiary center, whose first DOAC prescription was between 1 April 2016 and August 2018. The number of pharmacy refills from the day of first prescription to 31 August 2018 was counted (by means of an electronic prescription platform). Medication refill adherence (MRA) was calculated by dividing the total days' supply by the number of days under therapy. Non-compliance was defined as MRA <90%. RESULTS A total of 264 patients (120 men, mean age 74 ± 12 years) met the inclusion criteria. The median CHA2DS2VASC score was 3 (interquartile range (IQR) 2-5) and the median HAS-BLED was 1 (IQR 1-2). Rivaroxaban, apixaban, dabigatran and edoxaban were prescribed in 45%, 41%, 24% and 13% of patients, respectively. During the study 51 patients (19%) used at least two DOACs .Patients took DOACs for a median period of 439 days (IQR 269-638), during which the included population adhered to therapy 90% of the time (IQR 75-100%). Half of the patients (51%) were classified as non-compliant; therapy duration (adjusted odds ratio 1.06 per month, 95% confidence interval (CI) 1.03-1.08, p<0.001), DOACs twice daily (adjusted OR 1.73, 95%CI 1.08-2.75, p=0.022), and higher out-of-pocket costs (adjusted OR 2.13, 95%CI 1.28-3.45, p=0.003) were independent predictors of non-compliance. CONCLUSION Half of the patients (51%) were classified as non-compliant (medication refill adherence <90%). Therapy duration, DOACs twice daily and higher out out-of-pocket costs were independent predictors of non-compliance, which could be targets to improve patient adherence.
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Affiliation(s)
- Catarina Brízido
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal.
| | - António Miguel Ferreira
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro Lopes
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Christopher Strong
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Gustavo Sá Mendes
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Francisco Fernandes Gama
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Anaí Durazzo
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Gustavo Rocha Rodrigues
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Daniel Matos
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Sara Guerreiro
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Sérgio Madeira
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Jorge Ferreira
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro Adragão
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Miguel Mendes
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
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Brízido C, Ferreira AM, Lopes P, Strong C, Mendes GS, Gama FF, Durazzo A, Rodrigues GR, Matos D, Guerreiro S, Madeira S, Ferreira J, Adragão P, Mendes M. Adesão à terapêutica com anticoagulantes diretos em doentes com fibrilhação auricular não valvular – uma análise de mundo real. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2020.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Charlton A, Vidal X, Sabaté M, Bailarín E, Martínez LML, Ibáñez L. Factors associated with primary nonadherence to newly initiated direct oral anticoagulants in patients with nonvalvular atrial fibrillation. J Manag Care Spec Pharm 2021; 27:1210-1220. [PMID: 34464214 PMCID: PMC10391044 DOI: 10.18553/jmcp.2021.27.9.1210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Direct oral anticoagulants (DOACs) are widely used for the prevention of stroke in nonvalvular atrial fibrillation (NVAF); however, real-world primary nonadherence (failing to collect the first prescription) has been measured in very few studies. OBJECTIVE: To report primary nonadherence in NVAF patients who are newly prescribed DOACs and identify associated factors. METHODS: This observational retrospective cohort study used a large primary care database in Catalonia. Patients with NVAF who were newly prescribed a DOAC between January 2009 and December 2015 were identified, and primary nonadherence was measured by comparing prescribing records to pharmacy claims data. Multivariable logistic regression was used to determine associated factors. RESULTS: A total of 12,257 patients met the inclusion and exclusion criteria; of these, 1,276 (10.4%) were primary nonadherent. Primary nonadherence was found to be 12.8% for apixaban, 8.6% for dabigatran, and 10.8% for rivaroxaban. Multivariable logistic regression indicated higher odds of primary nonadherence with apixaban and rivaroxaban compared to dabigatran (apixaban: OR = 1.61, 95% CI = 1.39-1.87; rivaroxaban: OR = 1.28, 95% CI = 1.11-1.47). Patients aged at least 80 years showed lower odds of primary nonadherence compared to those aged less than 65 years (OR = 0.78, 95% CI = 0.66-0.93). A diagnosis of chronic kidney disease was associated with primary nonadherence (OR = 1.27, 95% CI = 1.08-1.50). Whereas, diabetes (OR = 0.85, 95% CI = 0.74-0.97), hypertension (OR = 0.79, 95% CI = 0.70-0.91), and stroke/transient ischemic attack (OR = 0.70, 95% C I =0.59-0.82) were inversely associated with primary nonadherence. CONCLUSIONS: Overall, 10.4% of patients prescribed DOACs were primary nonadherent, failing to collect the first prescription. The percentage could have serious implications for patient outcomes and the real-world cost-effectiveness of prescribing DOACs in NVAF. Rates of primary nonadherence and associated factors may provide useful information for the design and evaluation of adherence interventions. DISCLOSURES: No outside funding was received for this study. The data for this study came from the European Medicines Agency PE-PV project (Grant/Award Number EMA/2015/27/PH). The authors have nothing to disclose. A preliminary version of this work was presented at the European Drug Utilisation Research Group (EuroDURG) Conference, Szeged, Hungary, March 5, 2020.
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Affiliation(s)
- Alethea Charlton
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron, Barcelona, Spain; Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany; and Pettenkofer School of Public Health, Munich, Germany
| | - Xavier Vidal
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mònica Sabaté
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Elena Bailarín
- Fundació Institut Català de Farmacologia (FICF) and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Lina María Leguízamo Martínez
- Autonomous University of Barcelona and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Luisa Ibáñez
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Pastori D, Menichelli D, Cammisotto V, Pignatelli P. Use of Direct Oral Anticoagulants in Patients With Antiphospholipid Syndrome: A Systematic Review and Comparison of the International Guidelines. Front Cardiovasc Med 2021; 8:715878. [PMID: 34414220 PMCID: PMC8368436 DOI: 10.3389/fcvm.2021.715878] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/09/2021] [Indexed: 12/17/2022] Open
Abstract
Antiphospholipid antibody syndrome (APS) requires long-term anticoagulation to prevent recurrent thrombosis. Direct oral anticoagulants (DOACs) have been increasingly used in APS patients, but contradictory guidelines recommendations on their use do exist. We performed a systematic review of literature including studies investigating the role of DOACs in APS patients. At this aim, PubMed and Cochrane databases were searched according to PRISMA guidelines. We identified 14 studies which investigated the use of DOACs in patients with APS, of which 3 randomized clinical trials (RCTs), 1 post-hoc analysis of 3 RCTs, 7 case series and 3 cohort studies (2 prospective and 1 retrospective). Among DOACs, rivaroxaban was the most used (n = 531), followed by dabigatran (n = 90) and apixaban (n = 46). Regarding guidelines indications, the 2019 European Society of Cardiology (ESC) and American Society of Hematology (ASH) guidelines recommend against the use of DOACs in all APS patients. The European League Against Rheumatism (EULAR), British Society for Haematology (BSH), and International Society on Thrombosis and Haemostasis (ISTH) guidance provided more detailed indications stating that warfarin should be the first-choice treatment but DOACs may be considered in patients (1) already on a stable anticoagulation with a DOAC, (2) with low-quality anticoagulation by warfarin, (3) unwilling/unable to undergo INR monitoring, (4) with contraindications or serious adverse events under warfarin. Patients with arterial APS or triple positivity should be treated with warfarin while venous APS with single or double positivity may be candidate to DOACs, but high-quality studies are needed.
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Affiliation(s)
- Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittoria Cammisotto
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Rahme E, Godin R, Nedjar H, Dasgupta K, Tagalakis V. Dose specific effectiveness and safety of DOACs in patients with non-valvular atrial fibrillation: A Canadian retrospective cohort study. Thromb Res 2021; 203:121-130. [PMID: 34000493 DOI: 10.1016/j.thromres.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/14/2021] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been proven to be effective and safe for prevention of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). However, suboptimal adherence, variable dosing and use in patient populations that otherwise would have been excluded from clinical trials may impact the efficacy and safety profile of DOACs in a routine care setting. We compared stroke, bleeding, and mortality rates on and off therapy for standard and low-dose DOACs (apixaban, rivaroxaban, dabigatran) versus warfarin in a Canadian cohort. We also assessed persistence of DOACs compared to warfarin. METHODS We conducted six 1-1 propensity-score matched retrospective cohort analyses using Quebec health administrative databases (2011-2017). NVAF patients (≥18 years) covered by the public medication insurance plan entered the cohort on the first OAC dispensation date. We excluded those with OAC use in the previous year or stroke or bleeding diagnoses in the previous two years. Follow-up ended at death, March 2017 or end of medication coverage by the public plan. Time-dependent Cox regression was applied. RESULTS We evaluated 10,893 patients initiated on apixaban (7206 standard, 3687 low-dose), 10,190 on rivaroxaban (7396 standard, 2794 low-dose), 5884 on dabigatran (2756 standard, 3128 low-dose), and propensity score-matched warfarin users. Across standard-dose DOACs, compared to warfarin, stroke risks were similar; bleeding risks were lower with apixaban (hazard ratio 0.63; 95% confidence interval 0.52-0.77) and dabigatran (0.47; 0.35-0.64) but not rivaroxaban (0.93; 0.79-1.10); death risks were lower with all DOACs. For low-dose DOACs, rivaroxaban demonstrated higher stroke (1.79; 1.21-2.64) and bleeding risks (1.37; 1.09-1.73); other agents had stroke risks similar to warfarin and bleeding risks lower than warfarin; only low-dose dabigatran had lower death risk (0.59; 0.52-0.68). Treatment discontinuation was lower with DOACs versus warfarin with the exception of low-dose rivaroxaban. The risks of stroke were 2-4 folds higher during time off any OAC versus time on warfarin. The risks of death were higher, while the risks of bleeding were generally lower during times off any OAC. CONCLUSIONS Standard-dose DOACs had similar stroke, better persistence and mortality profiles than warfarin. Only standard dose apixaban and dabigatran had better bleeding profiles than warfarin. Low-dose rivaroxaban had worse persistence, stroke and bleeding profiles than warfarin, while low-dose apixaban and dabigatran had similar stroke and better bleeding profiles. Real-world use of DOACs may explain some of the differences observed in Canadian routine care versus the phase III clinical trials.
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Affiliation(s)
- Elham Rahme
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | | | - Hacene Nedjar
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Kaberi Dasgupta
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Vicky Tagalakis
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
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Yagi N, Suzuki S, Nagai K, Tanaka T, Nagahama T, Arita T, Otsuka T, Yamashita T. Current status of oral anticoagulant adherence in Japanese patients with atrial fibrillation: A claims database analysis. J Cardiol 2021; 78:150-156. [PMID: 33663881 DOI: 10.1016/j.jjcc.2021.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely used for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). We investigated the adherence of DOACs for years known to be associated with the effectiveness in Japanese NVAF patients, using a claim database. METHOD We performed a retrospective evaluation of NVAF patients in a claims database in Japan, who initiated dabigatran, rivaroxaban, and apixaban between April 2011 and June 2016. Drug persistence was assessed by Kaplan-Meier method for the initially-prescribed DOAC and all DOACs including switched ones. Proportion of days covered (PDC) was also evaluated in patients with persistent prescription and compared among DOACs. RESULTS In the total of 671 patients, rivaroxaban (47%) was more prescribed than dabigatran (28%) and apixaban (25%). Drug persistence at 3 years was higher in rivaroxaban (69%) than dabigatran (57%) and apixaban (67%). Including switching to other DOACs, persistence of DOACs was 72% at 3 years without significant differences between index-DOACs. In multivariate Cox regression analysis, absence of hypertension, and prior history of cancer were significantly associated with the drug discontinuation of all DOACs. The mean PDC was ~ 95% and the frequency of high-adherent patients (PDC ≥0.80) was more than 90%, which similarly persisted at 3 years and showed no significant differences between index DOACs. CONCLUSION In a real-world Japanese claim data analysis, about 70% of patients under DOAC showed persistence with anticoagulation therapy at 3 years. High adherence to DOACs assessed by PDC (over 90%) persisted to 3 years regardless of the types of DOACs.
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Affiliation(s)
- Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan.
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | | | | | | | - Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
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Gabet A, Chatignoux E, Grave C, Vallée A, Tuppin P, Béjot Y, Olié V. Stroke Incidence and Death in Atrial Fibrillation Patients Newly Treated with Direct Oral Anticoagulants. Clin Epidemiol 2021; 13:131-140. [PMID: 33642879 PMCID: PMC7903960 DOI: 10.2147/clep.s290707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/08/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The objectives were to analyse the determinants of stroke incidence and mortality as a competing event in AF patients newly treated with DOAC and to assess the impact of non-adherence to DOAC treatment. Methods It is a population-based retrospective cohort study using the French national healthcare data system. AF patients aged >20 years were affiliated to the general health insurance scheme (66% of the French population) and newly treated with DOAC between 2012 and 2015 were included and followed for 2 years. Results Overall 76,795 AF patients were newly treated with DOAC in 2015. Stroke incidence reached 10.1 (95% CI: 9.6–10.6) per 1000 person-year and death 39.7 (95% CI: 38.6–40.8) as a competitive risk. Female sex was associated with a lower risk of death but not of stroke. Non-adherence to DOAC treatment increased the risk of both stroke (42%) and death (38%). Acute coronary syndrome was associated with an increased risk of stroke alone, whereas heart failure decompensation, social deprivation, and haemorrhage were associated with an increased risk of death alone. Conclusion Both stroke and death risks remain non-negligible in AF patients treated with DOAC. Non-adherence was associated with an increased risk of stroke and death.
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Affiliation(s)
- Amélie Gabet
- French Public Health Agency, Saint-Maurice, France
| | | | | | - Alexandre Vallée
- Diagnosis and Therapeutic Center, Hotel Dieu, AP-HP, University Paris Descartes, Paris, France
| | - Philippe Tuppin
- General Health Insurance Scheme (Caisse Nationale d'Assurance Maladie), Paris, France
| | - Yannick Béjot
- Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - Valérie Olié
- French Public Health Agency, Saint-Maurice, France
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Liu Z, Xie Q, Xiang Q, Zhang H, Mu G, Zhao Z, Hu T, Wu T, Wang N, Zhang J, Qian Y, Zhou S, Wang Z, Jiang J, Zhang Y, Song H, Cui Y. Anti-FXa-IIa activity test in Asian and its potential role for drug adherence evaluation in patients with direct oral anticoagulants: a nationwide multi-center synchronization study. Cardiovasc Diagn Ther 2020; 10:1293-1302. [PMID: 33224753 DOI: 10.21037/cdt-20-564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The data of anti-FXa-IIa activity detection in Asian population is insufficient, and its potential role for drug adherence evaluation in patients with direct oral anticoagulants (DOACs) remains unclear. This study carried out multi-center anti-FXa-IIa activity detection in Asian, aiming to explore its applicability in Asian population and find its role in adherence evaluation. METHODS We assessed patients' self-reported adherence using the Morisky, Green, and Levine Adherence Scale (MGLS) from six hospitals. Plasma samples were collected for peak and trough concentration determination, and anti-FXa-IIa chromogenic assay was conducted using rivaroxaban/dabigatran calibrators and controls. Multivariate logistic regression models, covariate adjustment and spearman's two-tailed test were conducted in the data analysis. This study had been registered in clinical trials (NCT03666962). RESULTS In total, 271 patients taking rivaroxaban (n=149) or dabigatran (n=122) were enrolled. Among the 271 patients assessed by MGLS questionnaire, 188 persons (69.4%) showed high adherence, 77 persons (28.4%) was in intermediate adherence group, and only 6 patients (2.2%) had low adherence. Patients are more adherent dosed once daily of rivaroxaban compared to twice daily of dabigatran: 75.6% vs. 63.6%. Anti-FXa-IIa activity had good linear correlation with routine coagulation indexes (P<0.001), but no significant association was found between drug adherence and anti-FXa-IIa activity (P>0.05). CONCLUSIONS This study confirms that anti-FXa-IIa activity detection based on target drug calibrations can be used as an effective index for pharmacodynamic evaluation in Asian population, but had limited value in drug adherence evaluation for DOACs. As the limited samples, these findings could serve as a hypothesis-generating effort, and should be validated in further studies with larger sample sizes.
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Affiliation(s)
- Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zinan Zhao
- Department of Pharmacy, Beijing Hospital, Beijing, China
| | - Taotao Hu
- Department of Pharmacy, 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yan Qian
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, Beijing, China
| | - Hongtao Song
- Department of Pharmacy, 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
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30
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Mainbourg S, Cucherat M, Provencher S, Bertoletti L, Nony P, Gueyffier F, Mismetti P, Grange C, Durieu I, Kilo R, Laporte S, Grenet G, Lega JC. Twice- or Once-Daily Dosing of Direct Oral Anticoagulants, a systematic review and meta-analysis. Thromb Res 2020; 197:24-32. [PMID: 33161284 DOI: 10.1016/j.thromres.2020.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/28/2020] [Accepted: 10/09/2020] [Indexed: 02/04/2023]
Abstract
AIM The direct oral anticoagulants (DOAC) have similar half-lives, but the dosing regimen varies between once daily (QD) or twice daily (BID). For some prescribers, the QD regimen improves compliance. Others prefer BID regimens to promote better stability of plasma concentrations, particularly in the event of missed doses. Limited level of evidence provides guidance about the best treatment strategy. The purpose of this study was to compare the treatment effect of QD vs. BID administration of DOACs in major orthopedic surgery (MOS), non-valvular atrial fibrillation (NVAF), venous thromboembolism (VTE), and acute coronary syndrome (ACS). METHODS We conducted a systematic review up to April 2020. We included phase II clinical trials comparing DOAC QD vs BID with same daily dose. We extracted data for the occurrence of major thrombosis (proximal deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke) and major hemorrhage (ISTH criteria and recommendations of the European Medicines Agency for surgical patients). Relative risks (RR) were combined using a fixed and random effects weighted meta-analysis. RESULTS Twelve randomized, controlled, phase II trials were included (10,716 patients), representing 24 dosing regimen comparisons of apixaban, darexaban, edoxaban, rivaroxaban, letaxaban, and dabigatran. There was no difference for major thrombotic event (RRBID/QD = 1.06, 95%IC 0.86-1.30) nor for major bleeding (RRBID/QD = 1.02, 95%IC 0.84-1.23) between the BID vs QD regimens, without heterogeneity (I2 = 0%). CONCLUSION Our study does not support a global difference in term of efficacy and safety of the BID and QD regimens of DOAC in MOS, NVAF, VTE and ACS.
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Affiliation(s)
- S Mainbourg
- Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France; Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France.
| | - M Cucherat
- Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France; Département de pharmacotoxicologie, Hospices Civils de Lyon, Lyon, France
| | - S Provencher
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Ville de Québec, Canada
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, INSERM, UMR1059, Université Jean-Monnet, F-42055 Saint-Etienne, France; Groupe D'Etude Multidisciplinaires des Maladies Thrombotiques (GEMMAT), Lyon, France; INSERM, CIC-1408, CHU de Saint-Etienne, INNOVTE, CHU de Saint-Etienne, F-42055 Saint-Etienne, France
| | - P Nony
- Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - F Gueyffier
- Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France; Groupe D'Etude Multidisciplinaires des Maladies Thrombotiques (GEMMAT), Lyon, France
| | - P Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, INSERM, UMR1059, Université Jean-Monnet, F-42055 Saint-Etienne, France; Groupe D'Etude Multidisciplinaires des Maladies Thrombotiques (GEMMAT), Lyon, France; INSERM, CIC-1408, CHU de Saint-Etienne, INNOVTE, CHU de Saint-Etienne, F-42055 Saint-Etienne, France
| | - C Grange
- Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France; Groupe D'Etude Multidisciplinaires des Maladies Thrombotiques (GEMMAT), Lyon, France
| | - I Durieu
- Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - R Kilo
- Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - S Laporte
- Unité de Recherche Clinique, Innovation, Pharmacologie, Centre hospitalo-universitaire de Saint-Etienne, Saint-Etienne, France
| | - G Grenet
- Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France; Département de pharmacotoxicologie, Hospices Civils de Lyon, Lyon, France
| | - J-C Lega
- Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France; Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France; Groupe D'Etude Multidisciplinaires des Maladies Thrombotiques (GEMMAT), Lyon, France
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Patti G, Haas S. Non-Vitamin K Antagonist Oral Anticoagulants and Factors Influencing the Ischemic and Bleeding Risk in Elderly Patients With Atrial Fibrillation: A Review of Current Evidence. J Cardiovasc Pharmacol 2020; 77:11-21. [PMID: 33060545 PMCID: PMC7774815 DOI: 10.1097/fjc.0000000000000927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/04/2020] [Indexed: 10/31/2022]
Abstract
ABSTRACT Non-vitamin K antagonist oral anticoagulants (NOACs) are a widely prescribed treatment to prevent stroke in patients with nonvalvular atrial fibrillation, and a therapy and preventative measure to prevent recurrences following venous thromboembolism. Optimal use of NOACs requires a thorough knowledge of the pharmacology of these drugs, as well as an understanding of patient factors affecting their use. The 4 NOACs-dabigatran, apixaban, edoxaban, and rivaroxaban are available in a range of doses suitable for differing indications and with a variety of dose reduction criteria. Identification of the correct dose is one of the key challenges in the individualization of treatment. Elderly patients with atrial fibrillation are at a greater risk of both ischemic and bleeding events than younger patients. Consequently, it is essential to achieve balance in anticoagulation strategies. Medication adherence to NOACs is important for safe and effective treatment, particularly in elderly populations. A growing body of evidence shows that once-daily dosing improves adherence and persistence to therapy, without having an impact on bleeding risk.
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Affiliation(s)
- Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy; and
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
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Goette A, Vranckx P. Atrial fibrillation patients undergoing percutaneous coronary intervention: dual or triple antithrombotic therapy with non-vitamin K antagonist oral anticoagulants. Eur Heart J Suppl 2020; 22:I22-I31. [PMID: 33088231 PMCID: PMC7556743 DOI: 10.1093/eurheart/suaa101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
About 20% of all atrial fibrillation (AF) patients develop coronary artery disease, which requires coronary stenting [percutaneous coronary intervention (PCI)]. Thus, this subcohort of AF patients may require aggressive antithrombotic therapy encompassing vitamin K antagonist (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) plus aspirin and a P2Y12 inhibitor. At present, four clinical Phase IIIb trials using dabigatran, rivaroxaban, apixaban, or edoxaban, were published. These studies assessed the impact of NOACs as a part of DAT therapy vs. triple therapy. Compared with triple therapy, NOAC-based DAT has been shown to be associated with reduced major bleeding as well as intracranial haemorrhages. The benefit, however, is somewhat counterbalanced by a higher risk of stent-related ischaemia during the early phase of dual therapy. Thus, triple therapy after stenting is appropriate for at least 14 days with a maximum of 30 days. Thereafter, DAT including a NOAC is the therapy of choice in AF PCI patients to reduce the risk of bleeding during a 1 year of follow-up compared to VKA-based regimes. The present review summarizes the published study results and demonstrates differences in trial design and reported outcomes.
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Affiliation(s)
- Andreas Goette
- St. Vincenz-Hospital, Paderborn, Germany.,Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany.,Atrial Fibrillation Network (AFNET), Münster, Germany
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Hasselt, Belgium
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Purrucker JC, Hölscher K, Kollmer J, Ringleb PA. Etiology of Ischemic Strokes of Patients with Atrial Fibrillation and Therapy with Anticoagulants. J Clin Med 2020; 9:jcm9092938. [PMID: 32932971 PMCID: PMC7564370 DOI: 10.3390/jcm9092938] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Reducing the number of ischemic strokes in patients with atrial fibrillation despite oral anticoagulation remains an important, yet largely unsolved challenge. Therefore, we assessed the etiology of ischemic strokes despite anticoagulation with vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs). Methods: Patients with known atrial fibrillation (AF), treatment with VKA or NOAC, and acute ischemic stroke admitted between 2015 and 2018 (1st half) were identified from the hospital database. Brain imaging data were independently reviewed. An integrated etiologic classification according to the ASCOD system was made. Medication errors (admission INR <2.0 in the VKA- or NOAC-specific concentration <10 ng/mL) or dosage/dosing errors were also analyzed. Results: Of 3610 patients screened, n = 341 were included (VKA, n = 127; NOAC, n = 214). An overall increasing rate of OAC-associated stroke per year was observed. In 95.3% of patients with adequate diagnostic work-up (n = 321/337), at least one additional potential, uncertain, or unlikely non-cardiac cause of stroke was identified. More patients in the VKA than in the NOAC group had a medication error (81/127, 63.8% vs. 102/205, 49.8%; p = 0.013). Conclusions: Stroke risk factors despite atrial fibrillation were highly prevalent. Although less common with NOACs than VKAs, medication errors are still frequent.
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Affiliation(s)
- Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.H.); (P.A.R.)
- Correspondence:
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.H.); (P.A.R.)
| | - Jennifer Kollmer
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.H.); (P.A.R.)
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Maruhashi T, Higashi Y. Antithrombotic therapy for stroke prevention in patients with atrial fibrillation in Japan. Expert Opin Pharmacother 2020; 21:2115-2124. [PMID: 32749891 DOI: 10.1080/14656566.2020.1799976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Stroke remains one of the major public health problems in Japan. The number of patients with atrial fibrillation (AF) has been steadily increasing with the aging of the Japanese population. Appropriate oral antithrombotic therapy is necessary to prevent AF-related stroke and bleeding complications. AREAS COVERED The authors summarize the Japanese guidelines for antithrombotic therapy, as well as the current status of antithrombotic therapy, and future perspectives for antithrombotic therapy for patients with AF in Japan. EXPERT OPINION Further improvement in adherence to guideline-recommended warfarin therapy may be difficult to achieve. After the introduction of direct oral anticoagulants (DOACs) into clinical practice, the proportion of patients with AF receiving oral anticoagulant therapy has increased in Japan. However, the proportion of patients treated with inappropriately reduced doses of DOACs has also been increasing. Inappropriate dose reduction of DOACs simply because of advanced age should be avoided to reduce stroke events in patients with AF. Among patients with AF receiving anticoagulant therapy who have coronary artery disease, inappropriately prolonged triple therapy or dual therapy should be avoided to reduce major bleeding complications. Shortening the duration of triple therapy or dual therapy may be promoted by simplified recommendations in the 2020-updated guidelines supported by solid evidence.
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University , Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University , Hiroshima, Japan.,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital , Hiroshima, Japan
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Capiau A, Mehuys E, Van Tongelen I, Christiaens T, De Sutter A, Steurbaut S, Moudallel S, Rydant S, Vrijens B, de Backer TLM, Boussery K. Community pharmacy-based study of adherence to non-vitamin K antagonist oral anticoagulants. Heart 2020; 106:1740-1746. [DOI: 10.1136/heartjnl-2020-316781] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 12/18/2022] Open
Abstract
ObjectiveThis study aimed to assess implementation adherence (how well the patient’s actual intake matches the prescribed dosing regimen) to non-vitamin K antagonist oral anticoagulants (NOACs) and to explore experiences with and beliefs about NOACs in a real-world sample of long-term NOAC users.MethodsA cross-sectional observational study was conducted in home-dwelling adults who started taking a NOAC at least 1 year prior to inclusion. Pharmacy dispensing data were used to calculate the Medication Possession Ratio (MPR). Patients were recruited in 158 community pharmacies in Flanders, Belgium. They completed a questionnaire collecting basic characteristics and exploring self-reported adherence to NOACs (using the Medication Adherence Report Scale, MARS) and experiences with and beliefs about NOACs (using the Beliefs about Medicines Questionnaire, BMQ).ResultsA total of 766 patients (mean age 76.2±8.8 years, median CHA2DS2-VASc score 4 (IQR=3–4)) were included. The majority (93.5%) used NOAC for stroke prevention in atrial fibrillation. The median MPR was 95.2% (IQR=87.8–99.7) which corresponds with half of the study population not taking their NOAC on at least 17 cumulative days per year. Almost 21% of participants reported non-adherence on the MARS (score <25), with unintentional non-adherence (forgetfulness) most frequently reported (15.4%). Although two-thirds of NOAC users indicated to experience adverse drug reactions, the BMQ demonstrated a positive attitude towards NOAC therapy, where necessity beliefs outweigh the concerns.ConclusionsOur data indicate that long-term NOAC users have high implementation adherence and a positive attitude towards NOAC therapy. However, taking into account patients’ thromboembolic risk and NOACs’ short half-lives, further optimisation of NOAC use seems warranted in this population.
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36
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Persistence with Anticoagulation for Atrial Fibrillation: Report from the GLORIA-AF Phase III 1-Year Follow-up. J Clin Med 2020; 9:jcm9061969. [PMID: 32586056 PMCID: PMC7356563 DOI: 10.3390/jcm9061969] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/02/2020] [Accepted: 06/16/2020] [Indexed: 01/25/2023] Open
Abstract
Background: We aimed to assess the extent to which drug persistence is better with non-vitamin K antagonist oral anticoagulants (NOACs) than vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients and to estimate the difference in therapy persistence depending on NOAC dosing regimen (once daily (QD) vs. twice daily (BID)). Methods: Consecutive patients were followed for 1 year in phase III of the GLORIA-AF registry. Drug persistence was defined as the use of OAC without any discontinuation in >30 days or switching to alternative therapy. Results: Among 21,109 eligible patients in phase III, 17,266 patients who were prescribed OAC at baseline and those who took ≥1 OAC dose were included. The 1-year proportion of patients receiving NOAC and VKA who persisted on treatment was 80% and 75%, respectively. The 1-year persistence with NOACs BID and NOACs QD was 81% and 80%, respectively. Female gender, hypertension, older age, alcohol use, permanent, asymptomatic, and minimally symptomatic AF were associated with better OAC persistence. Region, medication usage predisposing to bleeding, being a current smoker, treatment reimbursement, and proton pump inhibitors were associated with lower OAC persistence. Conclusions: Drug persistence was higher with NOACs (1-year persistence was 80%) than with VKAs (75%). There was little difference in 1-year persistence between NOAC dosing regimens.
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Shehab A, Bhagavathula AS, Abebe TB, Abegaz TM, Elnour AA, Sabbour HM, Uzzafer M, Hersi A, Hamad AK. Patient Adherence to Novel Oral Anticoagulants (NOACs) for the Treatment of Atrial Fibrillation and Occurrence of Associated Bleeding Events: A Systematic Review and Meta-analysis. Curr Vasc Pharmacol 2020; 17:341-349. [PMID: 29359674 DOI: 10.2174/1570161116666180123111949] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Real-world evidence from published observational studies of adherence to Novel Oral Anticoagulants (NOACs) medications and associated clinical outcome events in Atrial Fibrillation (AF) patients, was reviewed systematically. METHODS Observational studies assessing patient adherence to NOACs conducted on AF patients between September 2010 and June 2016 were identified by systematic searching keywords to locate eligible studies, in accordance with Cochrane guidelines. PubMed, Scopus and Google Scholar databases were searched to identify the studies. Meta-analysis was performed using a random effects model with DerSimonian-Laird weighting to obtain pooled effect sizes. RESULTS From 185 potentially relevant citations, 6 studies, comprising 1.6 million AF patients, were included. Among these, successful adherence to NOACs occurred in 75.6%. Adherence levels were higher in patients treated with dabigatran (72.7%) compared with those treated with apixaban (59.9%) or rivaroxaban (59.3%). However, adherence was still suboptimal (relative to an expected 80% adherence rate). Bleeding events in non-adherent patients were found to be 7.5%. CONCLUSION Suboptimal adherence to NOACs among AF patients was highlighted as a significant risk factor that may affect clinical outcomes, with a higher percentage of non-adherent patients having bleeding events. There is an urgent need for research on the effects of specific interventions to improve patient adherence to NOACs and to assess the related outcome factors that may be associated with adherence.
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Affiliation(s)
- Abdulla Shehab
- Department of Internal Medicine, United Arab Emirates University, College of Medicine and Health Sciences, Al Ain, United Arab Emirates
| | - Akshaya S Bhagavathula
- Department of Clinical Pharmacy, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Tamrat B Abebe
- Department of Clinical Pharmacy, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia.,Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institute, Solna, Sweden
| | - Tadesse M Abegaz
- Department of Clinical Pharmacy, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Asim A Elnour
- Faculty of Pharmacy, Program Lead, Fatima College and Health Sciences (FCHS), Al Ain, United Arab Emirates
| | - Hani M Sabbour
- Department of Cardiology, Brown University Warren Alpert School of Medicine, Rhode Island, United States
| | - Masood Uzzafer
- Health Informatics Consultant, Dallas, Texas, United States
| | - Ahmed Hersi
- Department of Cardiac Sciences, King Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Adel K Hamad
- Mohammed bin Khalifa Al Khalifa Cardiac Centre, Bahrain Defence Force Hospital, Ar-Rifaa, Bahrain
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Vitolo M, Lane DA, Boriani G, Lip GYH. The importance of adherence and persistence with oral anticoagulation treatment in patients with atrial fibrillation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f81-f83. [PMID: 32324229 DOI: 10.1093/ehjcvp/pvaa020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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39
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Comparison of Anti-factor Xa Activity Among Three Different Factor Xa Inhibitors in Non-valvular Atrial Fibrillation Patients with Renal Impairment. Clin Drug Investig 2020; 40:567-573. [PMID: 32314297 DOI: 10.1007/s40261-020-00912-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Factor-Xa inhibitors (FXaIs) are widely used for the treatment of non-valvular atrial fibrillation (NVAF). Although we have previously reported the distribution of the anti-factor Xa activity (AXA) values of three different FXaIs in NVAF patients, the differences in the distribution of AXA values among the different FXaIs in patients with renal impairment (RI) have not been fully elucidated. METHODS Trough and peak AXA values were measured in 94 patients taking rivaroxaban, 124 patients taking apixaban, and 66 patients taking edoxaban. Of them, we identified 26 patients with moderate RI [creatinine clearance (CrCl) 30-49 mL/min] and 17 patients with severe RI (CrCl 15-29 mL/min) in the rivaroxaban cohort, 37 patients with moderate RI and 17 patients with severe RI in the apixaban cohort, and 21 patients with moderate RI and 9 patients with severe RI in the edoxaban cohort. AXA values were measured using chromogenic AXA assays. Both trough and peak AXA values were compared between patients with moderate RI and those with severe RI in each cohort, and differences in the peak-to-trough ratio among the different drugs were assessed. RESULTS In the rivaroxaban cohort, the peak AXA value was significantly higher in patients with severe RI than in those with moderate RI. In the apixaban cohort, neither the trough nor peak AXA values significantly differed between patients with moderate RI and those with severe RI. In the edoxaban cohort, the trough AXA value was significantly higher in patients with severe RI than in those with moderate RI, and peak AXA tended to be higher in patients with severe RI. The peak-to-trough ratio of AXA values was significantly lower in patients taking apixaban than in those taking rivaroxaban and edoxaban. CONCLUSION Among Japanese NVAF patients with RI, the peak or trough AXA values were higher in patients with severe RI than in those with moderate RI when taking rivaroxaban and edoxaban, whereas both the peak and trough AXA values were similar between patients with severe RI and those with moderate RI when taking apixaban. The peak-to-trough ratio of AXA values was the lowest in patients taking apixaban.
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40
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Santos J, António N, Rocha M, Fortuna A. Impact of direct oral anticoagulant off-label doses on clinical outcomes of atrial fibrillation patients: A systematic review. Br J Clin Pharmacol 2020; 86:533-547. [PMID: 31631392 DOI: 10.1111/bcp.14127] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/14/2019] [Accepted: 09/07/2019] [Indexed: 12/23/2022] Open
Abstract
AIMS Worldwide observational studies are evidencing discordance between guidelines and real-world practice regarding direct oral anticoagulant drug (DOAC) doses. This systematic review summarizes and evaluate DOACs use in real-world practice. METHODS This review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines searching PubMed (MEDLINE) and Medscape databases. RESULTS Data from 75 studies showed that most of the patients treated with DOACs for stroke prevention in atrial fibrillation received doses in accordance to the guidelines. However, a significant number of patients received off-label doses (25-50% in most of the studies evaluated). DOAC overdosing was associated with increased all-cause mortality and worse bleeding events while underdosing was associated with increased cardiovascular hospitalization and, particularly for apixaban, with a nearly 5-fold increased risk of stroke. CONCLUSION Patients prescribed with off-label DOAC doses did not receive the full benefit of anticoagulation and presented an increased risk of stroke, bleeding and/or adverse effects.
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Affiliation(s)
- Joana Santos
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Natália António
- Laboratory of Pharmacology, Faculty of Medicine, University of Coimbra, Portugal.,Cardiology Department, Coimbra Hospital and Universitary Centre, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Marília Rocha
- Pharmaceutical Service, Coimbra Hospital and Universitary Centre, Portugal
| | - Ana Fortuna
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal.,CIBIT/ICNAS - Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
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41
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Montalescot G, Brotons C, Cosyns B, Crijns HJ, D'Angelo A, Drouet L, Eberli F, Lane DA, Besse B, Chan A, Vicaut E, Darius H. Educational Impact on Apixaban Adherence in Atrial Fibrillation (the AEGEAN STUDY): A Randomized Clinical Trial. Am J Cardiovasc Drugs 2020; 20:61-71. [PMID: 31243691 PMCID: PMC6978445 DOI: 10.1007/s40256-019-00356-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction Adherence to non-vitamin-K oral anticoagulants (NOACs) may be lower than to vitamin K antagonists because NOACs do not require routine monitoring. Objective We assessed the impact of an educational program on adherence and persistence with apixaban in patients with non-valvular atrial fibrillation (NVAF). Methods Patients with NVAF eligible for NOACs with one or more stroke risk factor (prior stroke/transient ischemic attack, age ≥ 75 years, hypertension, diabetes, or symptomatic heart failure) were randomized (1:1) to standard of care (SOC) or SOC with additional educational (information booklet, reminder tools, virtual clinic access). The primary outcome was adherence to apixaban (2.5 or 5 mg twice daily) at 24 weeks. Patients receiving the educational program were re-randomized (1:1) to continue the program for 24 further weeks or to switch to secondary SOC. Implementation adherence and persistence were reassessed at 48 weeks. Results In total, 1162 patients were randomized (SOC, 583; educational program, 579). Mean implementation adherence ± standard deviation (SD) at 24 weeks was 91.6% ± 17.1 for SOC and 91.9% ± 16.1 for the educational program arm; results did not differ significantly between groups at any time-point. At 48 weeks, implementation adherence was 90.4% ± 18.0, 90.1% ± 18.6, and 89.3% ± 18.1 for continued educational program, SOC, and secondary SOC, respectively; and corresponding persistence was 86.1% (95% confidence interval [CI] 81.3–89.7), 85.2% (95% CI 81.5–88.2), and 87.8% (95% CI 83.4–91.1). Serious adverse events were similar across groups. Conclusion High implementation adherence and persistence with apixaban were observed in patients with NVAF receiving apixaban. The educational program did not show additional benefits. Clinical trial registration This study is registered at ClinicalTrials.gov [NCT01884350]. Electronic supplementary material The online version of this article (10.1007/s40256-019-00356-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gilles Montalescot
- Sorbonne University, ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Carlos Brotons
- Sardenya Primary Health Care Centre-Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Harry J Crijns
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Armando D'Angelo
- Coagulation Service and Thrombosis Research Unit, Scientific Institute San Raffaele, Milan, Italy
| | | | - Franz Eberli
- Department of Cardiology, Stadtspital Triemli, Zurich, Switzerland
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, L7 8TX, United Kingdom
| | - Bruno Besse
- Global Clinical Research, Bristol-Myers Squibb, Paris, France
| | - Anthony Chan
- Internal Medicine, Pfizer Healthcare Ireland, Dublin, Ireland
| | - Eric Vicaut
- Université Paris 7, the ACTION Study Group, Methodology and Statistical Unit, Centre Hospitalier Universitaire Lariboisière (AP-HP), Paris, France
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Perreault S, Denus S, White‐Guay B, Côté R, Schnitzer ME, Dubé M, Dorais M, Tardif J. Oral Anticoagulant Prescription Trends, Profile Use, and Determinants of Adherence in Patients with Atrial Fibrillation. Pharmacotherapy 2019; 40:40-54. [DOI: 10.1002/phar.2350] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
| | - Simon Denus
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
- Montreal Heart Institute Montreal Quebec Canada
| | - Brian White‐Guay
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Robert Côté
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | | | - Marie‐Pierre Dubé
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | - Marc Dorais
- StatSciences Inc. Notre‐Dame‐de‐l’Île‐Perrot Quebec Canada
| | - Jean‐Claude Tardif
- Montreal Heart Institute Montreal Quebec Canada
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
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43
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Kanorskii SG. [How to maintain an adherence to oral anticoagulant in a patient with atrial fibrillation?]. KARDIOLOGIIA 2019; 59:76-83. [PMID: 31849302 DOI: 10.18087/cardio.2019.11.n724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/11/2019] [Indexed: 06/10/2023]
Abstract
Less onerous, compared with warfarin, treatment with direct oral anticoagulants (DOA) can lead to better adherence to treatment of patients with atrial fibrillation (AF). However, in a certain number of patients with AF, who were recommended by DOA, cardioembolic stroke recurs, which is largely due to the patients' failure to comply with medical recommendations. The appointment of DOA as first-line drugs does not guarantee a high adherence of patients with non-valvular AF. For elderly and old patients with AF and numerous comorbidities, the proposal of a simpler pharmacotherapy regimen is especially important. In a number of large modern studies performed in clinical practice, high adherence to rivaroxaban therapy has been established, which may be a result of taking this DOA 1 time per day, its safety and effectiveness.
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44
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Patient adherence to rivaroxaban in deep vein thrombosis, a cohort study in Switzerland: quantitative results. Int J Clin Pharm 2019; 41:1625-1633. [PMID: 31776778 DOI: 10.1007/s11096-019-00928-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Abstract
Background Direct oral anticoagulants (DOACs) have the advantage of being administered orally at a fixed dose without laboratory monitoring, in contrast to the frequent international normalized ratio measurements used to adjust for vitamin K antagonists dosing. Rivaroxaban, has a short half-life. The anticoagulation effect rapidly decreases if medication adherence is suboptimal. Objective The purpose of this quantitative study (called RIVA) is to longitudinally describe adherence to rivaroxaban (implementation and persistence) in patients with deep vein thrombosis (DVT). Setting The community pharmacy of the Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland in collaboration with the angiology division of the Lausanne University Hospital (CHUV). Methods This is an observational study. Patients received rivaroxaban for 3 or 6 months: 15 mg twice a day during the first 3 weeks and then 20 mg once a day until the end of the treatment. Adherence was measured using electronic monitoring. Implementation and adherence were modelled using a generalized estimating equation model. Persistence was represented using a Kaplan-Meier survival curve. Main outcome measure Medication adherence (implementation and persistence). Results Thirty-one consecutive patients were included (68% male, mean age: 47 years old). The collected adherence data consisted of 57 inter-visit phases, 2899 electronic monitoring openings and a median follow-up of 92 days (IQR: 87; 100). Implementation to rivaroxaban was initially high [96.3 (92.8; 98.1)] but decreased during the first 3 weeks, until it reached 89.3 (76.0; 95.6). After the switch from twice a day 15 mg to a once a day 20 mg regimen, implementation increased again and remained stable [95.4 (92.2; 97.3)] for 90 days. Four patients who experienced adverse events discontinued the treatment before the end of the study and were considered non-persistent (clinically appropriate discontinuation). Conclusion Adherence to rivaroxaban in deep vein trombosis is high in persistent patients. Discontinuation is related to rivaroxaban adverse effects/toxicity. Implementation should be reinforced during the twice a day-phase, and this first 3-week experience should help patients and healthcare professionals choose the best timing for the once a day phase.
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45
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2019; 39:1330-1393. [PMID: 29562325 DOI: 10.1093/eurheartj/ehy136] [Citation(s) in RCA: 1267] [Impact Index Per Article: 253.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK, and Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Antwerp University and University Hospital, Antwerp, Belgium
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Hiligsmann M, Cornelissen D, Vrijens B, Abrahamsen B, Al-Daghri N, Biver E, Brandi ML, Bruyère O, Burlet N, Cooper C, Cortet B, Dennison E, Diez-Perez A, Gasparik A, Grosso A, Hadji P, Halbout P, Kanis JA, Kaufman JM, Laslop A, Maggi S, Rizzoli R, Thomas T, Tuzun S, Vlaskovska M, Reginster JY. Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF). Osteoporos Int 2019; 30:2155-2165. [PMID: 31388696 PMCID: PMC6811382 DOI: 10.1007/s00198-019-05104-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
UNLABELLED Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions. INTRODUCTION Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication. METHODS A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken. RESULTS Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it. CONCLUSION These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.
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Affiliation(s)
- M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, the Netherlands.
| | - D Cornelissen
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, the Netherlands
| | - B Vrijens
- Research and Development, AARDEX Group and Department of Public Health, University of Liège, Liege, Belgium
| | - B Abrahamsen
- Open Patient Data Explorative Network, Institute of Clinical Resesarch, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
- NDORMS, University of Oxford, Oxford, UK
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - E Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M L Brandi
- FirmoLab, Fondazione FIRMO e Università di Firenze, Florence, Italy
| | - O Bruyère
- Division of Public Health, Epidemiology and Health Economics, Liège, Belgium and WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, University of Liège, Liege, Belgium
| | - N Burlet
- Global Head of Patient Insights Innovation, Patient Solution Unit, Sanofi, Lyon, France
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - B Cortet
- Department of Rheumatology and EA 4490, University-Hospital of Lille, Lille, France
| | - E Dennison
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
| | - A Diez-Perez
- Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Gasparik
- Department of Public Health, University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
| | - A Grosso
- Patient partner, Geneva, Switzerland
| | - P Hadji
- Frankfurt Centre of Bone Health, Frankfurt, Germany & Philips-University of Marburg, Marburg, Germany
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Catholic University of Australia, Melbourne, Australia
| | - J M Kaufman
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - A Laslop
- Scientific Office, Austrian Federal Office for Safety in Health Care, Vienna, Austria
| | - S Maggi
- CNR Aging Branch-NI, Padua, Italy
| | - R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - T Thomas
- Department of Rheumatology, Hôpital Nord, CHU Saint-Etienne, Saint-Etienne and INSERM U1059, Université de Lyon-Université Jean Monnet, Saint-Etienne, France
| | - S Tuzun
- Department of Physical Medicine and Rehabilitation, Cerrahpaşa Medical Faculty, İstanbul University Cerrahpaşa, Istanbul, Turkey
| | - M Vlaskovska
- Medical Faculty, Department of Pharmacology, Medical University Sofia, Sofia, Bulgaria
| | - J Y Reginster
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
- Division of Public Health, Epidemiology and Health Economics, Liège, Belgium and WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, University of Liège, Liege, Belgium
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Lip GYH, Keshishian A, Li X, Hamilton M, Masseria C, Gupta K, Luo X, Mardekian J, Friend K, Nadkarni A, Pan X, Baser O, Deitelzweig S. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients. Stroke 2019; 49:2933-2944. [PMID: 30571400 PMCID: PMC6257512 DOI: 10.1161/strokeaha.118.020232] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— This ARISTOPHANES study (Anticoagulants for Reduction in Stroke: Observational Pooled Analysis on Health Outcomes and Experience of Patients) used multiple data sources to compare stroke/systemic embolism (SE) and major bleeding (MB) among a large number of nonvalvular atrial fibrillation patients on non–vitamin K antagonist oral anticoagulants (NOACs) or warfarin. Methods— A retrospective observational study of nonvalvular atrial fibrillation patients initiating apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, to September 30, 2015, was conducted pooling Centers for Medicare and Medicaid Services Medicare data and 4 US commercial claims databases. After 1:1 NOAC-warfarin and NOAC-NOAC propensity score matching in each database, the resulting patient records were pooled. Cox models were used to evaluate the risk of stroke/SE and MB across matched cohorts. Results— A total of 285 292 patients were included in the 6 matched cohorts: 57 929 apixaban-warfarin, 26 838 dabigatran-warfarin, 83 007 rivaroxaban-warfarin, 27 096 apixaban-dabigatran, 62 619 apixaban-rivaroxaban, and 27 538 dabigatran-rivaroxaban patient pairs. Apixaban (hazard ratio [HR], 0.61; 95% CI, 0.54–0.69), dabigatran (HR, 0.80; 95% CI, 0.68–0.94), and rivaroxaban (HR, 0.75; 95% CI, 0.69–0.82) were associated with lower rates of stroke/SE compared with warfarin. Apixaban (HR, 0.58; 95% CI, 0.54–0.62) and dabigatran (HR, 0.73; 95% CI, 0.66–0.81) had lower rates of MB, and rivaroxaban (HR, 1.07; 95% CI, 1.02–1.13) had a higher rate of MB compared with warfarin. Differences exist in rates of stroke/SE and MB across NOACs. Conclusions— In this largest observational study to date on NOACs and warfarin, the NOACs had lower rates of stroke/SE and variable comparative rates of MB versus warfarin. The findings from this study may help inform the discussion on benefit and risk in the shared decision-making process for stroke prevention between healthcare providers and nonvalvular atrial fibrillation patients. Clinical Trial Registration— URL: https://www.clinicaltrials.gov/. Unique identifier: NCT03087487.
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Affiliation(s)
- Gregory Y H Lip
- From the Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.).,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.).,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.)
| | - Allison Keshishian
- Health Economics and Outcomes Research, STATinMED Research, Ann Arbor, MI (A.K.)
| | - Xiaoyan Li
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ (X. Li, M.H.)
| | - Melissa Hamilton
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ (X. Li, M.H.)
| | - Cristina Masseria
- Patient Health & Impact, Outcomes & Evidence, Pfizer, Inc, New York, NY (C.M., J.M.)
| | - Kiran Gupta
- US Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ (K.G., A.N.)
| | - Xuemei Luo
- Patient Health & Impact, Outcomes & Evidence, Pfizer, Inc, Groton, CT (X. Luo)
| | - Jack Mardekian
- Patient Health & Impact, Outcomes & Evidence, Pfizer, Inc, New York, NY (C.M., J.M.)
| | - Keith Friend
- Worldwide Medical, Bristol-Myers Squibb Company, Lawrenceville, NJ (K.F.)
| | - Anagha Nadkarni
- US Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ (K.G., A.N.)
| | - Xianying Pan
- Center for Observational Research and Data Sciences, Bristol-Myers Squibb Company, Lawrenceville, NJ (X.P.)
| | - Onur Baser
- Deparment of Internal Medicine, University of Michigan, Ann Arbor (O.B.)
| | - Steven Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA; and Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA (S.D.)
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48
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Liquid chromatographic methods for the determination of direct oral anticoagulant drugs in biological samples: A critical review. Anal Chim Acta 2019; 1076:18-31. [DOI: 10.1016/j.aca.2019.03.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
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49
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Lin SY, Kuo CH, Yeh SJ, Tsai LK, Liu YB, Huang CF, Tang SC, Jeng JS. Real-World Rivaroxaban and Apixaban Levels in Asian Patients With Atrial Fibrillation. Clin Pharmacol Ther 2019; 107:278-286. [PMID: 31376150 PMCID: PMC6977317 DOI: 10.1002/cpt.1601] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/23/2019] [Indexed: 12/12/2022]
Abstract
This study aims to measure the plasma levels of rivaroxaban and apixaban among Asian patients with atrial fibrillation and compare the results with expected drug levels from clinical studies. A total of 73 patients taking rivaroxaban and 105 patients taking apixaban were enrolled. Peak and trough levels were measured using ultra-high performance liquid chromatography with tandem mass spectrometry. The percentage of those with drug levels within the expected range reported in clinical studies was significantly higher in the apixaban group than in the rivaroxaban group, both for trough (84.8% vs. 64.4%; P = 0.002) and peak levels (76.9% vs. 33.8%; P < 0.001). After adjusting for age, sex, kidney function, appropriate dose, and adherence, patients taking rivaroxaban were still less likely to have peak and trough levels within the expected drug levels. Our real-world data suggests that Asian patients taking rivaroxaban are more likely to have out-of-expected drug levels than those taking apixaban.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Bin Liu
- Department of Internal Medicine, Cardiovascular Center and Division of Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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50
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Qvarnström M, Kahan T, Kieler H, Brandt L, Hasselström J, Wettermark B. Medication persistence to antihypertensive drug treatment – a cross-sectional study of attitudes towards hypertension and medication in persistent and non-persistent patients. Blood Press 2019; 28:309-316. [DOI: 10.1080/08037051.2019.1627858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Miriam Qvarnström
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Helle Kieler
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lena Brandt
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hasselström
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Björn Wettermark
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Healthcare Development, Public Healthcare Services Committee, Stockholm County Council, Stockholm, Sweden
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