Antiarrhythmic drug prescribing decreases for AF patients

Beta-blockers and flecainide have gained favour but overall antiarrhythmic drug (AAD) prescribing has fallen for patients with atrial fibrillation (AF), an Australian study has found.

The study, which assessed GP antiarrhythmic drug prescribing patterns for AF patients between 2009 and 2018, saw overall prescriptions decrease from 72% to 60%.

Class III (amiodarone and sotalol), IV (verapamil and diltiazem) and V (digoxin) prescribing helped steer the trend, falling from 17% to 13%, 11% to 7% and 29% to 15%, respectively.

Meanwhile Class I (flecainide and disopyramide) and II (atenolol, bisoprolol, labetalol, metoprolol and nebivolol) prescriptions rose from 4% to 5% and 36% to 38%, the authors wrote in the Internal Medicine Journal.

Sotalol was most frequently prescribed, with half of all studied patients receiving the drug despite a decreased prescription rate from 11% to 7%.

Finally, flecainide use increased from 4% to 5% (4.9%), just overtaking amiodarone prescribing which fell from 7% to 5% (4.7%).

AADs’ overall decline may be driven by clinical trial and guideline updates, which suggested the drugs could increase mortality, the authors wrote.

In particular, satolol (Class III) has demonstrated a higher all-cause mortality rate versus placebo or no treatment and digoxin (Class V) showed no reduction in heart failure patients’ overall mortality.

The authors also suggested catheter ablation growth could have impacted AAD prescribing, after another Australian study “reported a 48-fold increase (from 71 in 1997 to 3,480 in 2016) in annual cases of catheter ablation using PBS and Medicare Benefits Schedule data”.

Though that study showed a decrease in flecainide prescribing, the latest “observed increase [in flecainide use] was in line with its mention as one of the first-line rhythm-controlling agents for paroxysmal AF”, the authors wrote, noting that the previous study also included patients without AF and with neuropathic pain and that reduced prescription for neuropathic pain could explain that overall decline.

Finally, increased beta-blocker prescriptions might reflect their use for first-line control as well as co-existing conditions such as hypertension, congestive heart failure and ischaemic heart disease, they wrote.

The study adds to “limited research on whether recommendation changes have influenced the prescribing of [antiarrhythmic drugs] in Australian patients with AF,” they said.

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