https://digitalcommons.wustl.edu/cgi/viewcontent.cgi?article=10660&context=open_access_pubs

American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism.

Background
Evidence of adherence and persistence patterns in anticoagulation (AC) therapy comparing treatment-naive and non-naive patients is lacking. The objective of this study was to evaluate patterns of medication adherence and persistence in a real-world setting among AC-naive and AC-experienced atrial fibrillation (AF) patients treated with direct oral anticoagulants (DOACs).

Methods
AF patients newly initiating a DOAC with a minimum of 6 months of continuous health plan enrollment pre and post-index date (first DOAC prescription) were identified from the Truven Health MarketScan® Commercial and Medicare Supplemental databases (2009-2013). DOAC adherence (proportion of days covered [PDC]), persistence, and predictors of adherence were assessed at 6 and 12 months post-index.

Results
Of 66,090 AF patients included, 46.6% (n=30,826) were AC-naive and 53.4% (n=35,264) were AC-experienced (age: 66.9±12.7 vs. 70.4±11.4 years, p<0.001; male: n=19,132 (62.1%) vs. n=21,691 (61.5%), p=0.14, respectively). A majority of patients received dabigatran as their index DOAC (n=49,210; 74.5%). The mean PDC in AC-naive vs. AC-experienced patients at 6 and 12 months of follow-up was 72.3% vs. 83.3% (p<0.001) and 63.7% vs. 79.9% (p<0.001), respectively. Persistence with DOAC therapy in AC-naive and AC-experienced patients at 6 and 12 months ranged from 59.3% and 76.3% (p<.0001) to 31.6% and 50.2% (p<.0001), respectively. Predictors of higher DOAC adherence were older age and higher number of concomitant medications. Predictors of lower adherence were higher number of comorbidities and AC-naive user status.

Conclusion
Medication adherence and persistence with DOACs declined over time and both were suboptimal and lower (at 6 and 12 months post-index) in AC-naive compared to AC-experienced patients. These findings can help target future strategies or interventions for patient education and long-term AC management especially in those patients naive to DOAC therapy. Future investigation should examine potential reasons for differences in DOAC adherence and persistence between AC-experienced vs. AC-naive patients and the implications for patient outcomes.

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Real-World Adherence and Persistence with Direct Oral Anticoagulants in Adults with Atrial Fibrillation

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) are widely used for prevention of stroke secondary to nonvalvular atrial fibrillation (NVAF) Increased use of NOACs is partially a result of simplified regimens compared with warfarin, which has been associated with poor adherence and persistence to therapy Few studies have assessed adherence to NOACs, especially using contemporary data now that multiple NOACs are available OBJECTIVE: To evaluate adherence to NOACs in a cohort of newly diagnosed NVAF patients who are commercially insured METHODS: Incident, treatment-naive NVAF patients were identified in 2013 from a large claims database Patients were included who initiated rivaroxaban, dabigatran, or apixaban within 30 days after diagnosis Subjects were required to have 12 months of pre-index information to assess demographic and clinical characteristics (comorbidities, CHA2DS2-VASc, and HAS-BLED scores) Adherence to the index medication and adherence to any oral anticoagulant was as

Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention in Incident, Treatment-Naïve Nonvalvular Atrial Fibrillation.

Adherence to medication, commonly reported as being 50% in chronic diseases, is of great concern in healthcare Medication non-adherence is particularly apparent in chronic diseases, where treatment is often preventative and may provide little or no symptomatic relief or feedback for the patient A lot of research has been undertaken to describe the extent of non-adherence to long-term anticoagulation therapy, particularly with vitamin K antagonists and more recently with direct oral anticoagulants However, the literature is scarce with respect to describing adherence to anticoagulation in terms of the behavioural aspects that influence medicine use Utilizing the COM-B (capability, opportunity, motivation and behaviour) psychological model of non-adherence, we present the available evidence, not only in terms of describing the extent of the non-adherence problem, but also describing why patients do not adhere, offering theory-driven and evidence-based solutions to improve long-term adherence to chronic anticoagulation therapy Lessons learned are not only applicable within the field of anticoagulation but throughout haematology

https://onlinelibrary.wiley.com/doi/pdf/10.1111/bjh.14134

Adherence to long‐term anticoagulation treatment, what is known and what the future might hold

BACKGROUND: Few studies have assessed adherence to non-vitamin K antagonist oral anticoagulants (NOACs), especially using contemporary data now that multiple NOACs are available. OBJECTIVE: To compare adherence and treatment patterns among NOACs for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). METHODS: Incident and treatment-naive NVAF patients were identified during 2013-2014 from a large claims database in this retrospective cohort study. Patients were included who initiated rivaroxaban, dabigatran, or apixaban within 30 days after diagnosis. Adherence to the index medication and adherence to any oral anticoagulant was assessed using the proportion of days covered (PDC) at 3, 6, and 9 months. The number of switches and gaps in therapy were also evaluated. Analyses were stratified by stroke risk scores, and a logistic regression model was used to control for factors that may predict high adherence. RESULTS: Dabigatran had lower adherence (PDC = 0.76, 0.64, 0.57) compared wit...

/pdf/adherence-to-rivaroxaban-dabigatran-and-apixaban-for-stroke-5d7fnmpwb7.pdf

Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention for Newly Diagnosed and Treatment-Naive Atrial Fibrillation Patients: An Update Using 2013-2014 Data

Background Non-vitamin K oral anticoagulants (NOACs) became available in the Netherlands in 2008, providing another antithrombotic treatment besides vitamin K antagonists (VKAs) and antiplatelet agents (APAs). Objective To describe the patterns of antithrombotic drug use between 2008 and 2013 by examination of dispensing data form community pharmacies in the Netherlands; to determine the concomitant use of NOACs with VKAs and APAs and switching between the drug classes; and to compare adherence to NOACs with adherence to APAs. Setting An observational retrospective study was conducted using routinely collected dispensing data from Dutch community pharmacies. Methods For each calendar year, the numbers of NOAC, VKA, and APA users were calculated. Adherence was determined for NOACs and APAs by the percentage of days covered by medication (PDC). Information on the prescribed daily dose of VKAs was unavailable. Main outcome measures Comparison of age, sex, and co-medications of users of the three drug classes; concomitant use of different antithrombotic drug classes and switching between these in each year; and mean PDC and percentages of all users with a PDC above 80 %. Results NOAC use increased during the study period to 29,687 users in 2013. In that year there were 484,024 VKA users and 1313,032 APA users. Compared with users of VKAs, NOAC users were slightly younger and more frequently used antiarrhythmic drugs and beta blockers as co-medications. Substantial numbers of patients were dispensed potentially harmful combinations in 2013: 820 subjects were dispensed NOACs together with VKAs, and 684 subjects were dispensed NOACs, VKAs, and APAs concomitantly. Mean adherence to NOACs was 84.2 % compared with 87.3 % to APA. One in four NOAC users had a PDC lower than 80 % compared with one in five APA users. Conclusion Our findings show increasing use of NOACs by outpatients. The number of patients taking potentially harmful combinations of antithrombotic drugs was substantial. Adherence to NOACs in daily practice may be suboptimal to prevent thrombotic events.

/pdf/trends-in-antithrombotic-drug-use-and-adherence-to-non-zv28nen2l4.pdf

Susan Hanemaaijer

Papers

Trends in antithrombotic drug use and adherence to non-vitamin K oral anticoagulants in the Netherlands