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Inappropriate non-vitamin K antagonist oral anticoagulants prescriptions: be cautious with dose reductions
M S Jacobs1,2, M van Hulst3,4, Z Campmans5
1Department of Clinical Pharmacy and Toxicology, Martini Hospital, Groningen, The Netherlands. m.s.jacobs@rug.nl.
Background:
Non-vitamin K antagonist oral anticoagulants (NOACs) are prescribed to patients with atrial fibrillation (AF) to reduce the risk of stroke. Prescribing the correct dose warrants careful consideration of the prevailing dose criteria that differ per NOAC. Electronic systems are useful to intercept prescriptions that are incorrect based on simple 'primary' criteria, for example dosing frequency and drug-drug interactions with concomitant medication. However, these systems do not take into account patient characteristics such as age, renal function or weight, which are crucial elements to determine the NOAC dose.
Methods:
Our goal was to determine the appropriateness of all prescriptions, as compared with the product labelling approved by the European Medicines Agency, to address common pitfalls in prescribing NOACs. AF patients with a first NOAC prescription between January 2012 and December 2016 were identified from our electronic hospital information system (Martini Hospital, Groningen, the Netherlands).
Results:
The study included 3,231 AF patients who had started on an NOAC; 10.7% received an inappropriate dose and the appropriateness of the prescription could not be determined in 14.1%. Underdosing and overdosing occurred in 5.4% and 4.5% of all prescriptions, respectively. A reduced-dose NOAC was a predictor for incorrect prescribing (odds ratio: 2.70, 95% confidence interval: 2.13-3.41). Patient factors were identified that predicted incorrect prescriptions for dabigatran and apixaban.
Conclusion:
An incorrect prescription occurred more often in the reduced-dose NOAC group. Clinical parameters such as renal function are often unknown whilst these are essential to determine the right NOAC and dose.
Insights
Incorrect dosing of non-vitamin K antagonist oral anticoagulants (NOACs) is common in atrial fibrillation (AF) patients. Patient-specific factors like renal function are crucial for appropriate NOAC prescribing, yet often overlooked.
Area of Science:
- Cardiology
- Pharmacology
- Health Informatics
Background:
- Non-vitamin K antagonist oral anticoagulants (NOACs) are vital for stroke prevention in atrial fibrillation (AF).
- Accurate NOAC dosing requires adherence to specific criteria that vary by agent.
- Current electronic systems often fail to account for critical patient characteristics influencing NOAC dosage.
Purpose of the Study:
- To evaluate the appropriateness of NOAC prescriptions against European Medicines Agency guidelines.
- To identify common prescribing errors for NOACs in AF patients.
- To analyze the impact of patient-specific factors on NOAC prescription accuracy.
Main Methods:
- Retrospective analysis of 3,231 AF patients with initial NOAC prescriptions from January 2012 to December 2016.
- Comparison of prescriptions against European Medicines Agency-approved product labeling.
- Identification of predictors for incorrect NOAC dosing.
Main Results:
- 10.7% of NOAC prescriptions were deemed inappropriate, with 14.1% unassessable.
- Underdosing (5.4%) and overdosing (4.5%) were observed.
- Reduced-dose NOACs significantly predicted incorrect prescribing (OR: 2.70).
Conclusions:
- Prescribing errors for NOACs are frequent, particularly in reduced-dose regimens.
- Essential clinical parameters like renal function are frequently missing, hindering correct NOAC selection and dosing.
- Improved clinical decision support systems are needed to integrate patient-specific data for optimal NOAC therapy.
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