February 7, 2023

Appropriateness of Direct Oral Anticoagulant (DOAC) prescribing for New-onset Venous Thromboembolism and Non-valvular Atrial Fibrillation, Issac Nichols, PharmD, Lyndsey Ryan, PharmD, Leah Rappsilber, PharmD, Jessica Gwartney, PharmD, BCPS

Hello my name is isaac nichols a pharmacy pgy1 resident at oklahoma state medical center today we will be talking about the research project appropriateness of direct oral anticoagulants prescribing for new onset venous thromboembolism and non-valvular atrial fibrillation this research project was also worked on by dr lindsey ryan dr leah rap silber and dr jessica

Courtney background information so traditional agents that we’ve used for treating non-valvular atrial fibrillation and vtes were either iv only being heparin or low molecular weight heparin or were old oral agents such as warfarin both of these classes of agents had some fallbacks such as extensive lab monitoring and higher rates of bleeding events compared to some

Of these newer oral agents such as the doax apixaban and rivaroxaban as well as some of the direct thrombin inhibitors such as dabigatran recent studies across the nation and surveys have kind of shown new problems with some of the prescribing centered around incorrect dosing of these new doe acts primary reasons being renal function changes drug interactions as

Well as indications from afib as well as vtes the primary purpose of what this research study is going to be is evaluating the appropriateness of the prescribing patterns here at the osu medical center for apixaban and rivaroxaban specifically in pulmonary embolisms dvts and non-valvular atrial fibrillation our primary methods of what we did in our study it was

A multi-disciplinary quality improvement initiative by retrospective chart review analysis of previous patients that had been at our facility the investigational medications that we looked at were rivaroxaban and pixaband and we looked over the time period of january 1 2021 to april 30th of 2021. our inclusion criteria were patients age older than 18 years old

Diagnosed with new onset non-vaguely atrial fibrillation or vte prescribed one of the investigational medications exclusion criteria included pregnancy previously prescribed one of the investigational medications and previously diagnosed with non-valvular atrial fibrillation or a vte primary patient demographics that we looked at included age gender race height

And weight bmi drug regimens that they were on as well as drug interactions our primary endpoints that we looked at were number or percent of patients with appropriately prescribed doax being rivaroxaban or apixaban for new onset non-valvular atrial fibrillation or vte our secondary endpoints we looked at included number or percent of patients with readmission

Due to a recurrent vte or bleeding event within the next following 30 days after prescribing this was dif divided up based on bmi categories for each of the patients and also we looked at mean time for dose adjustment whether that be renal dosing or drug interaction dosing and transition from alternative anticoagulants prior to being started on one of the douak

Agents demographic we have looked here at 38 in the non-valvular atrial fibrillation group and 41 in the vte group being primarily even through the two difference gender wise we had primarily male in the different groups being 55 percent versus 53 percent in the non-valvular and vte groups average age between the two was primarily different between non-valvular

Being older age averaging about 70 and vtes being of younger age at 57. the range that it was over was vte was 20 to 83 years old and non-valvular atrial fibrillation 47 to 92 years old so a pretty wide range for the vte which might have something to do with why the age difference was so significant height average it was primarily the same uh less than two

Centimeters difference between the two weight average the primary range was about 55 kilos to 145 for non-voluma atrial fibrillation and vte being 59 to 163 the primary average weight was 92 for non-valvular atrial fibrillation and 97.5 for vtes the vmi was largely the same between the two groups being around 31.5 to 32.7 the race difference between the two

Nonviolent atrial fibrillation being primarily white in caucasian at 78.9 percent vtes also a primary majority being 58.5 percent but having a less significant majority than the other group a significant difference was also seen in black or african american group being only one patient out of the nonviolent atrial fibrillation making up 2.6 percent as opposed

To six patients being 14.6 percent in the vte group the following different race and ethnicities down and below were somewhat different being that there was one being native hawaiian or pacific in the bte group and none being in the non-popular atrial fibrillation group drug interaction wise uh there was the majority of drug interactions being with aspirin or

Clopidogrel the anti-platelet agents often found on for some of the comorbidities these patients did have another common one was ssris being an increased bleeding risk and others such as phenytoin or prescopics being a drug interaction issue with some of the metabolism primary endpoints that we did see in the non-valvular atrial fibrillation group we did have

81.58 percent correct prescribing of the apixaban and river rock’s been combined incorrect prescribing was only 18.42 percent being the majority of pixaban but river rocksman given that there was only three out of six being correct the higher percentage in the vce group there was similar kinds of correct prescribing at 87.8 percent combined and 12.2 percent

Incorrect between the combined epixed band and river rock span our secondary endpoints that you can see in the chart on the right the non-valver atrial fibrillation group with bleeding and vte events had one bleed due to epix band in the bmi 30-35 group one bleed and rivaroxaban at the 20-30 group in vte there was only one bleed in the apixaban again in a 30-35

Group important to note here also there were no recurrent vtes that occurred and all of the bleeds that did occur were subsequently handled at the facility the next endpoint that we have secondary was time to dose adjustments in the non-popular atrial fibrillation group the apixaban was zero hours to adjustment and rivaroxaban was 69.67 hours for renal adjustment

In the secondary the time to transition from other anticoagulant was non-violent atrial fibrillation about 4.29 days and 3.07 days for a pick span of river rocks fan respectively and vte was 1.31 and 4.21 days for a pixel van and river rock span respectively important to note here in the secondary time to dose adjustment the vte group does not have any dose

Adjustments that were needed for these so discussion for these results that we’ve seen from the primary endpoint 18.42 percent were incorrect prescribing for non-valvular atrial fibrillation as opposed to 12.2 percent for incorrect describing prescribing for vtes there was a higher rate of incorrect prescribing in the rivarox ram group overall being 36.36

Percent versus only 13.33 for apixaban there was numerically more for a pixaban but there was also the vast majority 60 out of the 71 charts that were seen were the epic span prescribing and only 11 being rivaroxaban the most evident difference was found in the non-valvular atrial fibrillation population which had a 50 incorrect prescribing rate for rivaroxaban

Primary reasons for incorrect prescribing uh was due to overdosing based on the criteria for non-valvular atrial fibrillation in apixaban being the two out of three criteria being a serum creatinine greater than or equal to 1.5 in age greater than or equal to 80 in a weight less than or equal to 60 kilograms other overdosing issues was found with renal function

In rivaroxaban so renal dosing adjustments for creating clearance less than 50 as well as indication for a pixel band being an overdose these patients were prescribed the loading dose 10 milligram twice daily for seven days as opposed to just having five milligrams twice daily or 2.5 depending on the renal dose adjustments for non-valvular atrial fibrillation

Under dosing the pig’s pixband criteria also here so there was an incorrect underdose as a 2.5 as opposed to the five indication for apixaban these patients were prescribed the five milligram or 2.5 milligram bib dosing as opposed to the 10 milligrams twice daily for seven days that is required for the loading dose for a vte also indication for river rock

Spin similarly a loading dose period of three weeks at 50 milligrams twice daily was not given as opposed to just a 20 or 15 milligram daily dose that was needed for non-valvular atrial fibrillation the last primary reason for incorrect prescribing was a drug interaction that was found with apixaban combined with phenytoin which is an ex contraindication that

Was not taken account for when prescribed primary results from the secondary endpoints the time to dose adjustment in non-valvular atrial fibrillation group with rivaroxaban was slightly skewed due to one patient having a 216 hour difference between the actual dose adjustment that needed which skewed the level of our average range pretty significantly all three

Events of the adverse events were gi bleeds none of them being a vze that was recurrent one of them occurred within five days of prescribing one within 10 days and one of them was an actual re-bleed after a patient had a gi bleed on admission in conclusion the rate of incorrect prescribing was slightly less than at other facilities based on previous studies that

They had done at their respective facility but the primary reasons for incorrect prescribing seem to remain similar predominant reason for incorrect prescribing was adjusting for renal function or for the specific two out of three criteria for non-valvular atrial fibrillation in the epix group addressing this gap in care we will be periodically giving education

For the prescribers being the residents as well as some of the attendings at osu medical center as well as a collaborative patient care with clinical pharmacists being on the groups that round with the internal medicine as well as family medicine teams to inform them on differences in prescribing and being on the lookout for any adjustments that need to be made

Additionally we’ll also look into implementing a check system into the electronic prescribing system our epic system that we use to prevent some of these errors from occurring whether that be a required field that needs to be filled out based on indications as well as some of the criteria that are there for specifically apixaban that can also be implemented to

See if we can cut down on some of the incorrect prescribing rates that is all that we have today for this specific research poster thank you for your time

Transcribed from video
Research Week 2022: Nichols By Oklahoma State University Center for Health Sciences