George C Leef1,2, Alexander C Perino1,2, Mariam Askari2, Jun Fan2, P Michael Ho3,4, Christoph B Olivier1, Lisa Longo5, Kenneth W Mahaffey1,6, Mintu P Turakhia1,2,7. 1. Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. 2. Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA. 3. Veterans Affairs Eastern Colorado Health Care System, Denver, CO, USA. 4. University of Colorado School of Medicine, Denver, CO, USA. 5. Department of Veteran Affairs, Pharmacy Benefits Management Services, USA. 6. Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. 7. Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA.
Abstract
BACKGROUND: Direct oral anticoagulants (DOACs) have strict dosing guidelines, but recent studies indicate that inappropriate dosing is common, particularly in chronic kidney disease (CKD), for which it has been reported to be as high as 43%. Since 2011, the Veterans Health Administration (VA) has implemented anticoagulation management programs for DOACs, generally led by pharmacists, which has previously been shown to improve medication adherence. OBJECTIVE: We investigated the prevalence of overdosing and underdosing of DOACs in the VA. METHODS: Using data from the TREAT-AF cohort study (The Retrospective Evaluation and Assessment of Therapies in AF), we identified VA patients with newly diagnosed atrial fibrillation (AF) and receipt of a DOAC between 2003 and 2015. We classified dosing as correct, overdosed, or underdosed based on the Food and Drug Administration-approved dosing criteria. RESULTS: Of 230 762 patients, 5060 received dabigatran (77.3%) or rivaroxaban (22.7%) within 90 days of AF diagnosis (age 69 [10[ years; CHA2DS2-VASc 1.6 [1.4]), of which 1312 (25.9%) had CKD based on estimated glomerular filtration rate <60. Overall, 93.6% of patients, 83.2% with CKD, received appropriate DOAC dosing. Incorrect dosing increased with worsening renal function. CONCLUSION: Compared to recent studies of commercial payers and health-care systems, incorrect dosing of DOACs is less common across the VA. Pharmacist-led DOAC management or similar anticoagulation management interventions may reduce the risk of incorrect dosing across health-care systems.
BACKGROUND: Direct oral anticoagulants (DOACs) have strict dosing guidelines, but recent studies indicate that inappropriate dosing is common, particularly in chronic kidney disease (CKD), for which it has been reported to be as high as 43%. Since 2011, the Veterans Health Administration (VA) has implemented anticoagulation management programs for DOACs, generally led by pharmacists, which has previously been shown to improve medication adherence. OBJECTIVE: We investigated the prevalence of overdosing and underdosing of DOACs in the VA. METHODS: Using data from the TREAT-AF cohort study (The Retrospective Evaluation and Assessment of Therapies in AF), we identified VA patients with newly diagnosed atrial fibrillation (AF) and receipt of a DOAC between 2003 and 2015. We classified dosing as correct, overdosed, or underdosed based on the Food and Drug Administration-approved dosing criteria. RESULTS: Of 230 762 patients, 5060 received dabigatran (77.3%) or rivaroxaban (22.7%) within 90 days of AF diagnosis (age 69 [10[ years; CHA2DS2-VASc 1.6 [1.4]), of which 1312 (25.9%) had CKD based on estimated glomerular filtration rate <60. Overall, 93.6% of patients, 83.2% with CKD, received appropriate DOAC dosing. Incorrect dosing increased with worsening renal function. CONCLUSION: Compared to recent studies of commercial payers and health-care systems, incorrect dosing of DOACs is less common across the VA. Pharmacist-led DOAC management or similar anticoagulation management interventions may reduce the risk of incorrect dosing across health-care systems.
Authors: Taylor Dawson; Deborah DeCamillo; Xiaowen Kong; Brian Shensky; Scott Kaatz; Gregory D Krol; Mona Ali; Brian Haymart; James B Froehlich; Geoffrey D Barnes Journal: J Am Heart Assoc Date: 2020-11-05 Impact factor: 5.501