Inappropriate direct oral anticoagulant prescriptions in patients with non-valvular atrial fibrillation: cross-sectional analysis of the French CACAO cohort study in primary care

Emilie Ferrat; Julie Fabre; Philippe Galletout; Emmanuelle Boutin; Julien Le Breton; Vincent Renard; Paul Frappé; Sylvie Bastuji-Garin

doi:10.3399/bjgp20X714005

Inappropriate direct oral anticoagulant prescriptions in patients with non-valvular atrial fibrillation: cross-sectional analysis of the French CACAO cohort study in primary care

Br J Gen Pract. 2021 Jan 28;71(703):e134-e139. doi: 10.3399/bjgp20X714005. Print 2021.

Authors

Emilie Ferrat¹, Julie Fabre², Philippe Galletout², Emmanuelle Boutin³, Julien Le Breton¹, Vincent Renard¹, Paul Frappé⁴, Sylvie Bastuji-Garin⁵

Affiliations

¹ Primary Care Department, School of Medicine, University of Paris-Est Créteil, Créteil; INSERM, IMRB, CEpiA Team (Clinical Epidemiology and Ageing), University of Paris-Est Créteil, Créteil.
² Primary Care Department, School of Medicine, University of Paris-Est Créteil, Créteil.
³ University of Paris-Est Créteil, Créteil; Clinical Research Unit (URC Mondor), Assistance Publique Hôpitaux de Paris (APHP), Hôpital Henri Mondor, Créteil.
⁴ Department of General Practice, University of Saint-Etienne, Saint-Etienne.
⁵ University of Paris-Est Créteil, Créteil; Department of Public Health, APHP, Hôpital Henri Mondor, Créteil.

Abstract

Background: Direct oral anticoagulants (DOACs) account for an increasing proportion of prescriptions in patients with non-valvular atrial fibrillation (NVAF) in primary care. Inappropriate dosing of DOACs is a common problem, with under-dosing being a particular issue. However, conflicting results have been reported about the factors independently associated with inappropriate dosing.

Aim: To describe inappropriate prescriptions of DOACs among patients in the CACAO French nationwide general practice cohort, and to identify the factors independently associated with inappropriate DOAC doses.

Design and setting: Cross-sectional baseline analysis of the CACAO French national multicentre prospective cohort of adult patients in primary care receiving an oral anticoagulant who were recruited between April and October 2014.

Method: A total of 1111 patients from the CACAO cohort who received a DOAC for NVAF were included in this study. Inappropriate prescriptions of DOACs were described (inappropriate dosage, contraindications, non-indications, interactions, and non-compliance with the precautions for use). Multivariate logistic models were used to investigate factors associated with inappropriate DOAC dosing (under-dosing and over-dosing).

Results: Overall, 438 patients (39.4%) received at least one inappropriate DOAC prescription. The most common inappropriate prescription was inappropriate dosage (n = 374, 33.7%), particularly under-dosing (n = 348, 31.3%). Multivariate analysis revealed that factors independently associated with under-dosing were older age, prescription of apixaban or dabigatran, and a CHA2DS2-VASc score ≥2 vs. a score = 1. Factors with over-dosing were kidney failure, a HAS-BLED score ≥3, and older age.

Conclusion: The appropriateness of DOAC prescribing for NVAF can be improved, especially in older patients, and in patients with kidney failure, a higher risk of ischaemic stroke, and/or a higher risk of bleeding. GPs have a key role in increasing the proportion of appropriate DOAC prescriptions via informational, educational, and/or management strategies.

Keywords: atrial fibrillation; cohort studies; direct oral anticoagulants; prescription; primary care; public health.

Publication types

Multicenter Study

MeSH terms

Administration, Oral
Adult
Aged
Anticoagulants / therapeutic use
Atrial Fibrillation* / drug therapy
Brain Ischemia*
Cohort Studies
Cross-Sectional Studies
Humans
Inappropriate Prescribing / prevention & control
Prescriptions
Primary Health Care
Prospective Studies
Stroke* / prevention & control

Substances

Anticoagulants