Arrhythmia

NOACs extend anticoagulation use into high risk patients


The introduction of novel oral anticoagulants (NOACs) has broadened the use of anticoagulation including to older patients and those at higher risk of having a stroke, experience at an Australian hospital suggests.

A study at the Royal Adelaide Hospital compared initial anticoagulant use in patients before and after the introduction of NOACs in 2014.

It found warfarin was still the most widely used anticoagulant (65.4%) after the introduction of NOACs. However patient demographics changed significantly to older (median 77yrs), predominately female (54.4%) and those with a history of stroke (27.9%).

A subgroup analysis of patients with atrial fibrillation showed half were prescribed warfarin and half were prescribed either apixaban, rivaroxaban or dabigatran.

They were also older and were almost three times more likely to have had a previous stroke compared to the pre-NOAC cohort.

Introduction of NOACs resulted in a shift to a greater proportion of patients with a higher risk of stroke and lower risk of bleeding, the study found.

“Since the introduction of the [NOACs], patients who may have previously received no therapy or suboptimal treatment were now more likely to be receiving anticoagulation, suggesting an appropriate change in prescribing practice,” it concluded.

Dr Gillian Caughey, from the hospital’s department of clinical pharmacology, told the limbic the findings highlight the risk versus benefit balance that clinicians need to consider when prescribing anticoagulant therapy for their patients.

“I think that prescribing oral anticoagulants especially in these older patients where they have a lot of other comorbid conditions is very complex for clinicians.”

“Obviously the balance between having a stroke – which is obviously a potentially catastrophic, life threatening event by comparison to a bleed which can have severe implications – is really something that the clinician and the patient will ideally undertake together.”

And the findings suggested clinicians were using appropriate caution.

“One of the really encouraging things we found in our study was that patients that did actually have a higher risk of bleeding, were less likely to receive a NOAC in that period after their availability. I think that’s really important given the limited availability of an antidote to reverse the effect of those drugs.”

“Clinicians are actually looking at those risk factors for bleeding and those at highest risk aren’t the ones receiving the NOACs.”

Dr Caughey said the evidence to date suggested there had been an appropriate uptake of NOACs in practice, however outcomes data was still accumulating since their introduction in Australia.

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