Real-world study of direct oral anticoagulant dosing patterns in patients with atrial fibrillation

• Main Authors: Gustafson WL, Saunders J, Vazquez SR, Jones AE, Witt DM
• Format: Article
• Language: English
• Published: Centro de Investigaciones y Publicaciones Farmaceuticas 2019-12-01
• Series: Pharmacy Practice
• Subjects: anticoagulants; thromboembolism; atrial fibrillation; stroke; off-label use; drug-related side effects and adverse reactions; patient outcome assessment; retrospective studies; united states
• Online Access: https://pharmacypractice.org/journal/index.php/pp/article/view/1709
• ISSN: 1885-642X; 1886-3655

Background: Direct oral anticoagulants (DOACs) are preferred for stroke prevention in atrial fibrillation (AF). However, off-label doses have been associated with increased risk of adverse events. Objective: The objective of this study was to compare the frequency and outcomes of labeled versus off-label DOAC dosing in patients with AF. Methods: This retrospective cohort study included adults diagnosed with nonvalvular AF (NVAF), discharged from University of Utah Health on DOAC therapy between 7/1/2017 and 9/30/2017. The primary outcome was off-label DOAC dosing frequency, defined as dosing inconsistent with manufacturer labeling. Secondary outcomes included variables associated with off-label dosing and a composite of adverse events (major bleeding, thromboembolism, and all-cause mortality) in the 90 days following the index hospital discharge. Results: Of 249 included patients, 16.1% were discharged with off-label dosing. Factors associated with off-label dosing included advanced age, lower body mass index, decreased renal function, use of rivaroxaban, and hepatic impairment. The majority of off-label patients (70%) received lower-than-recommended DOAC dosing. Prescriber rationale for off-label prescribing was documented in 25% of patients and included anti-Xa guided dosing, high risk for bleeding or thromboembolism, and prior history of on-therapy adverse events. The rate of adverse events between labeled and off-label DOAC doses was not statistically different (10.0% vs. 6.7%, p=0.299), although this is likely due to small sample size. Conclusions: Off-label DOAC prescribing for stroke prevention in NVAF at University of Utah Health was consistent or lower than previously published studies. Off-label dosing most often involved under-dosing of rivaroxaban. Future research should investigate the role of provider rationale and insight in optimizing DOAC therapy outcomes.