Appropriateness of Dabigatran and Rivaroxaban Prescribing for Hospital Inpatients.
Ontology highlight
ABSTRACT: Background
Recent approval of the new oral anticoagulants dabigatran and rivaroxaban has led to rapid changes in anticoagulant prescribing practices. Postmarketing reports have highlighted safety concerns with these agents, and their use outside of evidence-based recommendations was noted at the authors' centre.Objectives
To determine the incidence of and risk factors associated with inappropriate prescribing of dabigatran and rivaroxaban.Methods
This retrospective cohort study investigated randomly selected dabigatran or rivaroxaban prescriptions for patients admitted to a tertiary teaching hospital between January 2010 and December 2012. Appropriateness of prescribing was determined from the documented indication, drug dosage, patient's renal function, and presence of drug interactions, if applicable.Results
Among a total of 321 medication orders reviewed, the incidence of inappropriate use was 31.2% (34/109) for dabigatran and 26.9% (57/212) for rivaroxaban. Of the 97 reasons for inappropriate use that were identified, the most common were prescribing for an unapproved indication (49/97 [50.5%]), concomitant prescribing of another anticoagulant (22/97 [22.7%]), and high prescribed dose (9/97 [9.3%]). The prescribing service was found to be an independent risk factor for inappropriate prescribing (p = 0.041). Corrections were made to 23.1% (21/91) of the incorrect regimens before hospital discharge. In a sensitivity analysis using calculated ideal body weight to estimate renal function, the overall incidence of inappropriate prescribing increased to 31.5% (101/321).Conclusions
The proportion of patients with inappropriate prescribing of dabigatran or rivaroxaban in clinical practice was higher than expected. Educational interventions and pharmacy-led initiatives with a focus on appropriate indications, concomitant anticoagulant prescribing, and review of dosage regimens are recommended to improve patient safety.
SUBMITTER: Chowdhry U
PROVIDER: S-EPMC4924939 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:Background and Objectives: Appropriate dosing of direct oral anticoagulants (DOACs) is required to avoid under- and overdosing that may precipitate strokes or thromboembolic events and bleedings, respectively. Our objective was to analyze the appropriateness of DOAC dosing according to the summaries of product characteristics (SmPC). Furthermore, determinants for inappropriate prescribing were investigated. Methodology: Retrospective cohort study of hospitalized patients aged ≥60 years with at least one DOAC intake during hospital stay. Descriptive analyses were used to summarize the characteristics of the study population. Chi-square test was used to evaluate differences between DOACs. Binary logistic regression analysis was performed to assess determinants for inappropriate prescribing. Results: For the 772 included patients, inappropriate dosing occurred in 25.0% of hospitalizations with 23.4, 21.9, and 29.7% for dabigatran, rivaroxaban, and apixaban, respectively (p = 0.084). Underdosing was most prevalent for apixaban (24.5%) compared to dabigatran (14.0%) and rivaroxaban (12.8%), p < 0.001. In 67.1% (apixaban), 26.7% (dabigatran), and 51.2% (rivaroxaban) of underdosed DOAC cases according to the SmPC, the dose would be considered appropriate according to the European Heart Rhytm Association (EHRA) guidelines. Overdosing was observed in 4.5% (apixaban), 4.7% (dabigatran), and 7.7% (rivaroxaban) of patients. For all DOACs, our analysis showed an age ≥80 years (p = 0.036), use of apixaban (p = 0.026), DOAC use before hospitalization (p = 0.001), intermediate renal function (p = 0.014), and use of narcotic analgesics (p = 0.019) to be associated with a higher rate of inappropriate prescribing. Undergoing surgery was associated with a lower odds of inappropriate prescribing (p = 0.012). For rivaroxaban, use of medication for hypothyroidism (p = 0.027) and the reduced dose (p < 0.001) were determinants for inappropriate prescribing. Treatment of venous thromboembolism was associated with less errors (p = 0.002). For apixaban, severe renal insufficiency (p < 0.001) and initiation in hospital (p = 0.016) were associated with less and the reduced dose (p < 0.001) with more inappropriate prescribing. No determinants were found in the dabigatran subgroup. Conclusions: Inappropriate DOAC prescribing is frequent with underdosing being the most common drug related problem when using the SmPC as reference. More appropriate prescriptions were found when taking the EHRA guidelines into account. Analysis of determinants of inappropriate prescribing yielded insights in the risk factors associated with inappropriate DOAC prescriptions.
| S-EPMC6218888 | biostudies-literature
Project description:BackgroundProton pump inhibitors (PPIs) have proven clinical efficacy for a variety of indications. However, there is emerging evidence of adverse events associated with their long-term use. The emergence of these adverse events has reinforced the need to regularly evaluate the appropriateness of continuing PPI therapy, and to use only the lowest effective dose for the minimally indicated duration.ObjectivesTo characterize the appropriateness of PPI orders continued or initiated in the internal medicine and family practice units of Vancouver General Hospital, to detect adverse events associated with PPI use, and to explore the impact of multidisciplinary teaching and provision of educational resources on health care practitioners' views about PPI use.MethodsA chart review was conducted for patients admitted (for at least 24 hours) between January 1 and December 31, 2015, for whom a hospital formulary PPI was prescribed. An educational initiative, which included interprofessional in-service sessions, a PPI prescribing infographic, a PPI prescribing card, and a patient counselling sheet, was implemented. The impact of these interventions was assessed using a qualitative survey of health care practitioners.ResultsOf the 258 patients whose charts were reviewed, 175 had a PPI prescription before hospital admission, and 83 were initiated on PPI therapy during their hospital stay. Overall, 94 (36%) of the patients were receiving PPIs without an appropriate indication. Community-acquired pneumonia and Clostridium difficile infections were the most common adverse events potentially associated with PPI use. In-service sessions and educational resources on PPI prescribing were reported to affect the clinical practice of 24 (52%) of the 46 survey respondents.ConclusionsThe results of this study emphasize the need for ongoing re-evaluation of long-term PPI therapy at the time of admission, during the hospital stay, and upon discharge. Implementing multidisciplinary teaching and providing educational resources may encourage more appropriate prescribing.
| S-EPMC6209498 | biostudies-literature
Project description:BackgroundDabigatran and rivaroxaban are new oral anticoagulants that are eliminated through the kidneys. Their use in dialysis patients is discouraged because these drugs can bioaccumulate to precipitate inadvertent bleeding. We wanted to determine whether prescription of dabigatran or rivaroxaban was occurring in the dialysis population and whether these practices were safe.Methods and resultsPrevalence plots were used to describe the point prevalence (monthly) of dabigatran and rivaroxaban use among 29977 hemodialysis patients with atrial fibrillation. Poisson regression compared the rate of bleeding, stroke, and arterial embolism in patients who started dabigatran, rivaroxaban, or warfarin. The first record of dabigatran prescription among hemodialysis patients occurred 45 days after the drug became available in the United States. Since then, dabigatran and rivaroxaban use in the atrial fibrillation-end-stage renal disease population has steadily risen where 5.9% of anticoagulated dialysis patients are started on dabigatrian or rivaroxaban. In covariate adjusted Poisson regression, dabigatran (rate ratio, 1.48; 95% confidence interval, 1.21-1.81; P=0.0001) and rivaroxaban (rate ratio, 1.38; 95% confidence interval, 1.03-1.83; P=0.04) associated with a higher risk of hospitalization or death from bleeding when compared with warfarin. The risk of hemorrhagic death was even larger with dabigatran (rate ratio, 1.78; 95% confidence interval, 1.18-2.68; P=0.006) and rivaroxaban (rate ratio, 1.71; 95% confidence interval, 0.94-3.12; P=0.07) relative to warfarin. There were too few events in the study to detect meaningful differences in stroke and arterial embolism between the drug groups.ConclusionsMore dialysis patients are being started on dabigatran and rivaroxaban, even when their use is contraindicated and there are no studies to support that the benefits outweigh the risks of these drugs in end-stage renal disease.
| S-EPMC4363265 | biostudies-literature
Project description:BackgroundAntimicrobial resistance (AMR) is presently considered an emergent major global public health concern and excessive and/or inappropriate use of broad-spectrum antimicrobials contribute to the development of AMR.ObjectiveTo evaluate the appropriateness of carbapenems and piperacillin-tazobactam use in a tertiary care hospital.MethodsA retrospective, observational, cross-sectional, drug-utilization study was conducted. The study included all adult hospitalized patients who had received at least one dose of the antimicrobials during their admission for the period between 1 January 2016 and 31 December 2017. The appropriateness of antimicrobial therapy was evaluated according to the Infectious Diseases Society of America (IDSA) guidelines with the consideration of the institutional antibiogram.ResultsOverall, 2731 patients received 5005 courses with one of the antimicrobials, for a total of 5045.9 defined daily doses (DDD) of imipenem-cilastatin, 6492.3 of meropenem and 15,595 of piperacillin-tazobactam (4.93, 6.34 and 15.24 DDD/100 bed days, respectively). The mean age of the patients who received either antimicrobial was 55.5 ± 20.3 years, with a 14-day average length of hospital stay. About half (52%) of the prescriptions were written for patients treated in the medical ward. Pneumonia (26.6%) and sepsis (24.9%) were the most common indication for the initiation of antimicrobial therapy. Of the assessed prescriptions, only 2787 (56.5%) were prescribed appropriately, with 2142 (43.5%) deemed inappropriate. The three most common reasons for inappropriate prescription were: the spectrum of activity was too broad (44.6%), followed by antimicrobial use without culture request (32.4%), and failure of suitable antimicrobial de-escalation (19.9%).ConclusionsThe study indicates that the overall rate of inappropriateness was high, emphasizing the need to develop initiatives to effectively improve broad-spectrum antimicrobial prescribing.
| S-EPMC7679439 | biostudies-literature
Project description:To further develop and validate previously published national prescribing appropriateness criteria to assist in identifying drug-related problems (DRPs) for commonly occurring medications and medical conditions in older (≥65 years old) Australians. RAND/UCLA appropriateness method. A panel of medication management experts were identified consisting of geriatricians/pharmacologists, clinical pharmacists and disease management advisors to organisations that produce Australian evidence-based therapeutic publications. This resulted in a round-one panel of 15 members, and a round-two panel of 12 members. Agreement on all criteria. Forty-eight prescribing criteria were rated. In the first rating round via email, there was disagreement regarding 17 of the criteria according to median panel ratings. During a face-to-face second round meeting, discussion resulted in retention of 25 criteria after amendments, agreement for 14 criteria with no changes required and deletion of 9 criteria. Two new criteria were added, resulting in a final validated list of 41 prescribing appropriateness criteria. Agreement after round two was reached for all 41 criteria, measured by median panel ratings and the amount of dispersion of panel ratings, based on the interpercentile range. A set of 41 Australian prescribing appropriateness criteria were validated by an expert panel. Use of these criteria, together with clinical judgement and other medication review processes such as patient interview, is intended to assist in improving patient care by efficiently detecting potential DRPs related to commonly occurring medicines and medical conditions in older Australians. These criteria may also contribute to the medication management education of healthcare professionals.
| S-EPMC3467596 | biostudies-literature
Project description:BackgroundAntibiotics are some of the most commonly prescribed drugs in the Emergency Department (ED) and yet data describing the overall appropriateness of antibiotic prescribing in the ED is scarce.ObjectivesTo describe the appropriateness of antibiotic prescribing in the ED.MethodsA retrospective, observational study of current practice. All patients who presented to the ED during the study period and were prescribed at least one antibiotic were included. Specialists from Infectious Disease, Microbiology and Emergency Medicine and a Senior Pharmacist assessed antibiotic appropriateness against evidence-based guidelines.ResultsA total of 1019 (13.6%) of patient presentations involved the prescription of at least one antibiotic. Of these, 640 (62.8%) antibiotic prescriptions were assessed as appropriate, 333 (32.7%) were assessed as inappropriate and 46 (4.5%) were deemed to be not assessable. Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% versus 22.9%; difference 14.1%, 95% CI 7.2%-21.0%). Patients who met quick Sepsis-related Organ Failure Assessment (qSOFA) criteria were more likely to be prescribed inappropriate antibiotics (56.7% versus 36.1%; difference 20.5%, 95% CI, 2.4%-38.7%). There was no difference in the incidence of appropriate antibiotic prescribing based on patient gender, disposition (admitted/discharged), reason for antibiotic administration (treatment/prophylaxis) or time of shift (day/night).ConclusionsInappropriate administration of antibiotics can lead to unnecessary adverse events, treatment failure and antimicrobial resistance. With over one in three antibiotic prescriptions in the ED being assessed as inappropriate, there is a pressing need to develop initiatives to improve antibiotic prescribing to prevent antibiotic-associated patient and community harms.
| S-EPMC6337898 | biostudies-literature
Project description:ObjectivesTo explore the processes leading to inappropriate use of medicines for elderly patients admitted for acute care.DesignQualitative study with semistructured interviews with doctors, nurses, and pharmacists; focus groups with inpatients; and observation on the ward by clinical pharmacists for one month.SettingFive acute wards for care of the elderly in Belgium.Participants5 doctors, 4 nurses, and 3 pharmacists from five acute wards for the interviews; all professionals and patients on two acute wards for the observation and 17 patients (from the same two wards) for the focus groups.ResultsSeveral factors contributed to inappropriate prescribing, counselling, and transfer of information on medicines to primary care. Firstly, review of treatment was driven by acute considerations, the transfer of information on medicines from primary to secondary care was limited, and prescribing was often not tailored to elderly patients. Secondly, some doctors had a passive attitude towards learning: they thought it would take too long to find the information they needed about medicines and lacked self directed learning. Finally, a paternalistic doctor-patient relationship and difficulties in sharing decisions about treatment between prescribers led to inappropriate use of medicines. Several factors, such as the input of geriatricians and good communication between members of the multidisciplinary geriatric team, led to better use of medicines.ConclusionsIn this setting, improvements targeted at the abilities of individuals, better doctor-patient and doctor-doctor relationships, and systems for transferring information between care settings will increase the appropriate use of medicines in elderly people.
| S-EPMC1261188 | biostudies-literature
Project description:BackgroundRivaroxaban was reported as effective as traditional therapies for the acute treatment of venous thromboembolism (VTE) with fewer major bleeding complications in the seminal Einstein program and is now a recommended option for the treatment of VTE around the world.ObjectiveTo report the safety and efficacy of rivaroxaban in daily care for the management of acute VTE in the United Kingdom.Patients/methodThe FIRST registry is a UK-only, multicenter, noninterventional, observational VTE study (NCT02248610). Consecutive patients diagnosed with acute VTE, managed with rivaroxaban, were recruited and followed for up to 5 years. The primary outcomes were treatment-emergent symptomatic objectively diagnosed recurrent VTE, major and clinically relevant nonmajor bleeding (CRNMB), and all-cause mortality.ResultsA total of 1262 participants were recruited between 2014 and 2018. Participants were heterogeneous, with age range 18 to 95 years, weight 35 to 234 kg, and maximum body mass index 64.4 kg/m2. The median duration of treatment exposure was 135 days (interquartile range [IQR], 84-307) and overall follow-up 497 days (IQR, 175-991). There were seven episodes of symptomatic VTE recurrence, 0.6%, (0.74/100 patient-years; 95% confidence interval [CI], 0.19-1.28). There were 79 of 1239 (6.4%), 8.66 of 100 patient-years (95% CI, 6.90-10.73) first episodes of major or CRNMB, which were most frequently reported by women aged <50 years as abnormal vaginal bleeding.ConclusionsRivaroxaban is an effective and safe single drug modality for the treatment of VTE in daily practice in the United Kingdom. Data to determine the optimal anticoagulation therapy for women of childbearing age are needed.
| S-EPMC8531140 | biostudies-literature
Project description:We aimed to examine the comparative effectiveness and safety between dabigatran and rivaroxaban in atrial fibrillation patients.We conducted a population-based, retrospective, new-user cohort study based on the National Health Insurance claims database in Taiwan. Adult atrial fibrillation patients who initiated dabigatran (N=10 625) or rivaroxaban (N=4609) between June 1, 2012 and May 31, 2014 were identified as the overall population. A propensity score was derived using logistic regression to model the probability of receipt of rivaroxaban as a function of potential confounders. Altogether, 4600 dabigatran users were matched with 4600 rivaroxaban users to create a propensity score-matched population. The marginal proportional hazards model was applied among the propensity score-matched population as the primary analysis, and the proportional hazards model with adjustment of the quintiles of the propensity score among the overall population was used as the secondary analysis. Rivaroxaban users had a higher risk of all-cause death than dabigatran users (hazard ratio 1.44, 95%CI 1.17-1.78 in the primary analysis and hazard ratio 1.47, 95%CI 1.23-1.75 in the secondary analysis). Rivaroxaban users also possessed a higher risk of gastrointestinal hemorrhage needing transfusion than dabigatran users in the primary analysis (hazard ratio 1.41, 95%CI 1.02-1.95), but the difference diminished in the secondary analysis (hazard ratio 1.20, 95%CI 0.92-1.56). The risks of ischemic stroke, acute myocardial infarction, arterial embolism/thrombosis, and intracranial hemorrhage were similar between the 2 groups.Rivaroxaban therapy was associated with a statistically significant increase in all-cause death compared with dabigatran therapy in atrial fibrillation patients.
| S-EPMC5533025 | biostudies-other
Project description:People who smoke make up a significant number of those admitted to hospital (NICE 2014). Being admitted to hospital can present a unique opportunity to attempt to stop smoking. Many smokers find quitting very difficult (Rigotti et al 2007), in large part due to them living and working in environments that contain many cues and triggers associated with nicotine consumption and smoking behaviours. Hospitals generally do not contain such environmental prompts to smoke. In the community, smokers have access to numerous types of support including GP's, pharmacies and Stop Smoking Services (SSS). Once admitted to hospital access to such support is significantly diminished. Given that many patients may be highly motivated to attempt to stop smoking due to heightened concerns about their health and being in an environment not associated with their smoking habits, it seems prudent to ensure there is access to all the levels of smoking cessation support available outside of the hospital. Not providing such support neglects implementing an evidence based, cost-effective health intervention in a major health setting (NICE 2014). A SSS pathway was designed that enabled existing hospital healthcare staff to be trained to identify patients that smoke, ask if the patient is considering quitting or abstaining whilst in hospital. If motivated to quit or abstain, to complete an assessment. This being based around dependence to nicotine and motivation to quit. Access to all available stop smoking medications should be included. Medication should only be provided alongside some level of motivational support up to discharge. Training core staff was felt to be the best option. They are available outside of office hours and access hospital systems such as pharmacy more readily than satellite staff. On discharge the patient is 'handed over' to SSS for continued contact and support once at home. Over 200 staff are trained to complete the assessment and support inpatients to stop or abstain. Approximately 30-35 referrals are made to the local SSS each month, the quit rate at 4 weeks averaging around 40-45%. Most referrals are seen from cardiology and respiratory. All hospital departments should identify staff to be trained to offer cessation support to their patients .
| S-EPMC4645840 | biostudies-other