Inappropriate direct oral anticoagulant prescriptions in patients with non-valvular atrial fibrillation: cross-sectional analysis of the French CACAO cohort study in primary care
Open Access
- 30 November 2020
- journal article
- research article
- Published by Royal College of General Practitioners in British Journal of General Practice
- Vol. 71 (703), e134-e139
- https://doi.org/10.3399/bjgp20x714005
Abstract
Background Direct oral anticoagulants (DOACs) account for an increasing proportion of prescriptions in patients with non-valvular atrial fibrillation (NVAF) in primary care. Inappropriate dosing of DOACs is a common problem, with under-dosing being a particular issue. However, conflicting results have been reported about the factors independently associated with inappropriate dosing. Aim To describe inappropriate prescriptions of DOACs among patients in the CACAO French nationwide general practice cohort, and to identify the factors independently associated with inappropriate DOAC doses. Design and setting Cross-sectional baseline analysis of the CACAO French national multicentre prospective cohort of adult patients in primary care receiving an oral anticoagulant who were recruited between April and October 2014. Method A total of 1111 patients from the CACAO cohort who received a DOAC for NVAF were included in this study. Inappropriate prescriptions of DOACs were described (inappropriate dosage, contraindications, non-indications, interactions, and non-compliance with the precautions for use). Multivariate logistic models were used to investigate factors associated with inappropriate DOAC dosing (under-dosing and over-dosing). Results Overall, 438 patients (39.4%) received at least one inappropriate DOAC prescription. The most common inappropriate prescription was inappropriate dosage (n = 374, 33.7%), particularly under-dosing (n = 348, 31.3%). Multivariate analysis revealed that factors independently associated with under-dosing were older age, prescription of apixaban or dabigatran, and a CHA2DS2-VASc score ≥2 vs. a score = 1. Factors with over-dosing were kidney failure, a HAS-BLED score ≥3, and older age. Conclusion The appropriateness of DOAC prescribing for NVAF can be improved, especially in older patients, and in patients with kidney failure, a higher risk of ischaemic stroke, and/or a higher risk of bleeding. GPs have a key role in increasing the proportion of appropriate DOAC prescriptions via informational, educational, and/or management strategies.Keywords
This publication has 15 references indexed in Scilit:
- Effect of Renal Function on Dosing of Non–Vitamin K Antagonist Direct Oral Anticoagulants Among Patients With Nonvalvular Atrial FibrillationAnnals of Pharmacotherapy, 2017
- Areas of improvement in anticoagulant safety. Data from the CACAO study, a cohort in general practicePLOS ONE, 2017
- Off-Label Dosing of Non-Vitamin K Antagonist Oral Anticoagulants and Adverse OutcomesJournal of the American College of Cardiology, 2016
- Identification of risk factors for inappropriate and suboptimal initiation of direct oral anticoagulantsJournal of Thrombosis and Thrombolysis, 2016
- 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTSEuropean Journal of Cardio-Thoracic Surgery, 2016
- 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTSEP Europace, 2016
- Dabigatran use in Danish atrial fibrillation patients in 2011: a nationwide studyBMJ Open, 2013
- Emergency Hospitalizations for Adverse Drug Events in Older AmericansThe New England Journal of Medicine, 2011
- A Novel User-Friendly Score (HAS-BLED) To Assess 1-Year Risk of Major Bleeding in Patients With Atrial FibrillationSocial psychiatry. Sozialpsychiatrie. Psychiatrie sociale, 2010
- Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based ApproachSocial psychiatry. Sozialpsychiatrie. Psychiatrie sociale, 2010