Appropriateness of direct oral anticoagulant prescribing in older subjects with atrial fibrillation discharged from acute medical wards

• Published in: British journal of clinical pharmacology Vol. 90; no. 5; pp. 1231 - 1239
• Main Authors: De Vincentis, Antonio, Soraci, Luca, Arena, Elena, Sciacqua, Angela, Armentaro, Giuseppe, Aucella, Francesco, Corsonello, Andrea, Aucella, Filippo, Antonelli Incalzi, Raffaele
• Format: Journal Article
• Language: English
• Published: England 01.05.2024
• Subjects: Administration, Oral; Age Factors; Aged; Aged, 80 and over; Anticoagulants - administration & dosage; Anticoagulants - adverse effects; atrial fibrillation; Atrial Fibrillation - drug therapy; direct oral anticoagulants; Drug Interactions; drug–drug interactions; Factor Xa Inhibitors - administration & dosage; Factor Xa Inhibitors - adverse effects; Factor Xa Inhibitors - therapeutic use; Female; Hospitalization - statistics & numerical data; Humans; inappropriate medications; Inappropriate Prescribing - prevention & control; Inappropriate Prescribing - statistics & numerical data; Italy - epidemiology; Male; older; Patient Discharge; Practice Patterns, Physicians' - standards; Practice Patterns, Physicians' - statistics & numerical data; Italy; direct oral anticoagulants; atrial fibrillation; older; inappropriate medications; drug–drug interactions
• ISSN: 0306-5251; 1365-2125; 1365-2125
• DOI: 10.1111/bcp.16010

Aims Knowledge on the prescriptive practice of direct oral anticoagulants (DOACs) in older subjects with atrial fibrillation (AF) hospitalized in acute medical wards is limited. This study aimed to evaluate the prevalence and appropriateness of DOAC prescriptions in hospitalized older subjects with AF, discharged from acute medical wards. Methods We analysed a cohort of 609 subjects with AF, aged ≥65 years (mean age 85 years) enrolled from 39 geriatric and nephrology wards in Italy. DOAC prescriptive appropriateness was evaluated according to the summary of product characteristics (smPC), 2019 Beers and STOPP criteria, and drug–drug interactions (DDIs). Results At hospital discharge, 33% of patients with AF were prescribed with DOAC, 26% with vitamin‐K antagonist, while 41% did not receive any anticoagulant. Among subjects on DOAC therapy, 31% presented a violation of the smPC criteria (mainly underdosage—17%), while 48% and 18% presented a Beers/STOPP inappropriate prescription, or a DDI, respectively. Older age, lower body mass index (BMI), cancer and higher estimated glomerular filtration rate (eGFR) were independently associated with DOAC underdosage or missed prescription (age: adjusted odds ratio [aOR] 1.06, 95% confidence interval [95% CI] 1.00–1.12 for underdosage; eGFR: aOR 1.04, 95% CI 1.02–1.07 for underdosage; BMI: aOR 0.95, 95% CI 0.91–0.99 for missed prescription; cancer: aOR 1.93, 95% CI 1.19–3.13 for missed prescription). Conclusions This study showed a suboptimal DOAC prescriptive practice in older in‐patients, with frequent missed prescription and DOAC underdosage. Contrary to current recommendations, physicians appear overly concerned by bleeding risk in real‐life older and frailer subjects. Strategies should be developed to promote appropriate DOAC prescription in the hospital setting.