Aya F Ozaki1,2, Austin S Choi1, Quan T Le1, Dennis T Ko3,4, Janet K Han5,6, Sandy S Park5,6, Cynthia A Jackevicius1,2,3,7,4. 1. Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.). 2. Pharmacy Department (A.F.O., C.A.J.), VA Greater Los Angeles Healthcare System, Los Angeles, CA. 3. ICES, Toronto, Canada (D.T.K., C.A.J.). 4. University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Canada (D.T.K., C.A.J.). 5. Division of Cardiology (J.K.H., S.S.P.), VA Greater Los Angeles Healthcare System, Los Angeles, CA. 6. Division of Cardiology, University of California, Los Angeles, Los Angeles, CA (J.K.H., S.S.P.). 7. University Health Network, Pharmacy Department, Toronto, Canada (C.A.J.).
Abstract
BACKGROUND: Stroke reduction with direct oral anticoagulants (DOACs) in atrial fibrillation (AF) is dependent on adherence and persistence in the real-world setting. Individual study estimates of DOAC adherence/persistence rates have been discordant. Our aims were to characterize real-world observational evidence for DOAC adherence/persistence and evaluate associated clinical outcomes in patients with AF. METHODS AND RESULTS: PubMed, EMBASE, and CINAHL were searched from inception to June 2018. Observational studies that reported real-world DOAC adherence/persistence in patients with AF were included. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Outcomes included DOAC mean proportion of days covered or medication possession ratio, proportion of good adherence (proportion of days covered/medication possession ratio ≥80%), persistence, DOAC versus vitamin K antagonists persistence, and clinical outcomes associated with nonadherence/nonpersistence. Forty-eight observational studies with 594 784 unique patients with AF (59% male; mean age 71 years) were included. The overall pooled mean proportion of days covered/medication possession ratio was 77% (95% CI, 75%-80%), proportion of patients with good adherence was 66% (95% CI, 63%-70%), and proportion persistent was 69% (95% CI, 65%-72%). The pooled proportion of patients with good adherence was 71% (95% CI, 64%-78%) for apixaban, 60% (95% CI, 52%-68%) for dabigatran, and 70% (95% CI, 64%-75%) for rivaroxaban. Similar patterns were found for pooled persistence by agent. The pooled persistence was higher with DOACs than vitamin K antagonists (odds ratio, 1.44 [95% CI, 1.12-.86]). DOAC nonadherence was associated with an increased risk of stroke (hazard ratio, 1.39 [95% CI, 1.06-1.81]). CONCLUSIONS: Suboptimal adherence and persistence to DOACs was common in patients with AF, with 1 in 3 patients adhering to their DOAC <80% of the time, which was associated with poor clinical outcomes in nonadherent patients. Although it is convenient that DOACs do not require laboratory monitoring, greater effort in monitoring for and interventions to prevent nonadherence may be necessary to optimize stroke prevention. Increased clinician awareness of DOAC nonadherence may help identify at-risk patients.
BACKGROUND:Stroke reduction with direct oral anticoagulants (DOACs) in atrial fibrillation (AF) is dependent on adherence and persistence in the real-world setting. Individual study estimates of DOAC adherence/persistence rates have been discordant. Our aims were to characterize real-world observational evidence for DOAC adherence/persistence and evaluate associated clinical outcomes in patients with AF. METHODS AND RESULTS: PubMed, EMBASE, and CINAHL were searched from inception to June 2018. Observational studies that reported real-world DOAC adherence/persistence in patients with AF were included. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Outcomes included DOAC mean proportion of days covered or medication possession ratio, proportion of good adherence (proportion of days covered/medication possession ratio ≥80%), persistence, DOAC versus vitamin K antagonists persistence, and clinical outcomes associated with nonadherence/nonpersistence. Forty-eight observational studies with 594 784 unique patients with AF (59% male; mean age 71 years) were included. The overall pooled mean proportion of days covered/medication possession ratio was 77% (95% CI, 75%-80%), proportion of patients with good adherence was 66% (95% CI, 63%-70%), and proportion persistent was 69% (95% CI, 65%-72%). The pooled proportion of patients with good adherence was 71% (95% CI, 64%-78%) for apixaban, 60% (95% CI, 52%-68%) for dabigatran, and 70% (95% CI, 64%-75%) for rivaroxaban. Similar patterns were found for pooled persistence by agent. The pooled persistence was higher with DOACs than vitamin K antagonists (odds ratio, 1.44 [95% CI, 1.12-.86]). DOAC nonadherence was associated with an increased risk of stroke (hazard ratio, 1.39 [95% CI, 1.06-1.81]). CONCLUSIONS: Suboptimal adherence and persistence to DOACs was common in patients with AF, with 1 in 3 patients adhering to their DOAC <80% of the time, which was associated with poor clinical outcomes in nonadherent patients. Although it is convenient that DOACs do not require laboratory monitoring, greater effort in monitoring for and interventions to prevent nonadherence may be necessary to optimize stroke prevention. Increased clinician awareness of DOAC nonadherence may help identify at-risk patients.
Authors: Josep Redon; Maria Jose Forner; Jose Miguel Calderon; Fernando Martinez; Antonio Fernandez; Inmaculada Sauri; Javier Diaz; Ruth Uso; Jose Luis Trillo Journal: Sci Rep Date: 2022-04-12 Impact factor: 4.379
Authors: Annie McDermott; Nadejda Kim; Leslie R M Hausmann; Jared W Magnani; Chester B Good; Terrence M A Litam; Maria K Mor; Toluwa D Omole; Walid F Gellad; Michael J Fine; Utibe R Essien Journal: J Gen Intern Med Date: 2022-09-23 Impact factor: 6.473
Authors: Fine Dietrich; Alexandros A Polymeris; Isabelle Arnet; Philippe A Lyrer; Melina Verbeek; Stefan T Engelter; Kurt E Hersberger; Sabine Schaedelin Journal: J Neurol Date: 2021-06-03 Impact factor: 4.849
Authors: Aditya Bhat; Shaun Khanna; Henry H L Chen; Arnav Gupta; Gary C H Gan; A Robert Denniss; C Raina MacIntyre; Timothy C Tan Journal: Circ Cardiovasc Qual Outcomes Date: 2021-03-05
Authors: Myrthe M A Toorop; Qingui Chen; Marieke J H A Kruip; Felix J M van der Meer; Melchior C Nierman; Laura Faber; Lies Goede; Suzanne C Cannegieter; Willem M Lijfering Journal: J Thromb Haemost Date: 2021-11-23 Impact factor: 16.036
Authors: Katelyn W Sylvester; Alisia Chen; Andrea Lewin; John Fanikos; Samuel Z Goldhaber; Jean M Connors Journal: Res Pract Thromb Haemost Date: 2022-05-05