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Warfarin Versus the Non-vitamin K Oral Anticoagulants (NOACs) in Clinical Practice

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Pharmacology".

Deadline for manuscript submissions: closed (30 May 2019) | Viewed by 24821

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Special Issue Editors

Prof. Shailendra Anoopkumar-Dukie

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Guest Editor

School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD 4215, Australia
Interests: oxidative stress; cell signaling; inflammation; cancer research; neuroscience; lipid peroxidation; antioxidants; cytotoxicity; neuroinflammation; cancer treatment; treatment resistance; pharmacokinetic drug interactions; anticoagulant therapy; warfarin; atrial fibrillation therapy; chemotherapy; adverse drug effects
Special Issues, Collections and Topics in MDPI journals

Ms. Nijole Bernaitis

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Guest Editor

Griffith University School of Pharmacy and Pharmacology, Gold Coast, QLD, Australia
Interests: cardiovascular medicine; anticoagulants; patient outcomes; quality use of medicines

Special Issue Information

Dear Colleagues,

On behalf of the Journal of Clinical Medicine (JCM) editorial team, we are delighted to present a new Special Issue on the topic of “Warfarin versus the Non-Vitamin K Oral Anticoagulants (NOACs) in Clinical Practice”, Guest Edited by Associate Professor Shailendra Anoopkumar-Dukie and Ms Nijole Bernaitis from the Griffith University School of Pharmacy and Pharmacology, Gold Coast, Queensland, Australia.

Introduction of the NOACs has provided options for anticoagulant therapy for patients with thromboembolic disease. Numerous factors, including health systems, clinical patient characteristics, and both prescriber and patient preferences, now influence choice of anticoagulant and associated efficacy and safety of agents. Differences in health outcomes with individual anticoagulants may be seen according to geographic region, ethnicity, and health management systems. Knowledge and understanding of the factors influencing the quality use of anticoagulants can contribute to identifying which population groups may get most benefit from anticoagulants. This may ultimately help in optimising patient outcomes with individual anticoagulants.

This Special Issue of the Journal of Clinical Medicine aims to examine advances in optimising oral anticoagulant therapy in clinical practice with application to different settings using real-world data. Of particular interest is the evaluation of health outcomes associated with anticoagulant use in different populations. International comparative outcomes and factors influencing these outcomes from real-world or observational data may further assist selection of appropriate anticoagulation for specific populations or individuals.

Dr. Shailendra Anoopkumar-Dukie
Ms. Nijole Bernaitis
Guest Editors

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Keywords

Warfarin, Rivaroxaban, Apixaban, Dabigatran, Edoxaban
Comparative effectiveness
Health outcomes
Pharmacoeconomic comparison
Real world or observational data
Patient management
Population health
Calcification

Published Papers (6 papers)

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Research

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12 pages, 1079 KiB

Open AccessArticle

Effectiveness and Safety of Direct Oral Anticoagulant for Secondary Prevention in Asians with Atrial Fibrillation

by Jiesuck Park, So-Ryoung Lee, Eue-Keun Choi, Soonil Kwon, Jin-Hyung Jung, Kyung-Do Han, Myung-Jin Cha, Sang-Bae Ko, Seil Oh and Gregory Y. H. Lip

J. Clin. Med. 2019, 8(12), 2228; https://doi.org/10.3390/jcm8122228 - 17 Dec 2019

Cited by 22 | Viewed by 5168

Abstract

We investigated the effectiveness and safety of direct oral anticoagulants (DOACs) for secondary prevention in patients with atrial fibrillation (AF), particularly focusing on subgroups of patients with severe, disabling, and recent stroke. Using the Korean National Health Insurance Service claims database between January 2010 and April 2018, we selected OAC-naïve patients with non-valvular AF and a history of stroke. Cumulative risks for recurrent stroke, major bleeding, composite outcome (recurrent stroke + major bleeding), and mortality were compared between DOAC and warfarin groups. Among 61,568 patients, 28,839 and 32,729 received warfarin and DOACs, respectively. Compared with warfarin, DOACs were associated with lower risks of recurrent stroke (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.62–0.72), major bleeding (HR 0.73, 95% CI 0.66–0.80), composite outcome (HR 0.69, 95% CI 0.65–0.73), and mortality. DOAC use resulted in a consistent trend of improved outcomes in the subgroups of patients with severe, disabling, and recent stroke. In conclusion, DOACs were associated with lower risks of recurrent stroke, major bleeding, composite clinical outcomes, and mortality in patients with AF and a history of stroke. These results were consistent across all types of DOACs and subgroups of patients with severe, disabling, and recent stroke. Full article

(This article belongs to the Special Issue Warfarin Versus the Non-vitamin K Oral Anticoagulants (NOACs) in Clinical Practice)

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14 pages, 3001 KiB

Open AccessArticle

Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation and Valvular Heart Disease

by Inki Moon, So-Ryoung Lee, Eue-Keun Choi, Euijae Lee, Jin-Hyung Jung, Kyung-Do Han, Myung-Jin Cha, Seil Oh and Gregory Y.H. Lip

J. Clin. Med. 2019, 8(10), 1624; https://doi.org/10.3390/jcm8101624 - 04 Oct 2019

Cited by 10 | Viewed by 3583

Abstract

Background: There are limited data for non-vitamin K antagonist oral anticoagulants (NOACs) impact on outcomes for patients with atrial fibrillation (AF) and valvular heart diseases (VHDs). Methods: We identified patients with AF and associated Evaluated Heartvalves, Rheumatic or Artificial (EHRA) type 2 VHDs, and who had been naïve from the oral anticoagulants in the Korean National Health Insurance Service database between 2014 and 2016 (warfarin: n = 2671; NOAC: n = 3058). For analyzing the effect of NOAC on primary prevention, we excluded those with a previous history of ischemic stroke, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding events. To balance covariates, we used the propensity score weighting method. Ischemic stroke, ICH, GI bleeding, major bleeding, all-cause death, and their composite outcome and fatal clinical events were evaluated. Results: During a follow-up with a mean duration of 1.4 years, NOACs were associated with lower risks of ischemic stroke (hazard ratio (HR): 0.71, 95% confidence interval (CI): 0.53–0.96), GI bleeding (HR: 0.50, 95% CI: 0.35–0.72), fatal ICH (HR: 0.28, 95% CI: 0.07–0.83), and major bleeding (HR: 0.61, 95% CI: 0.45–0.80) compared with warfarin. Overall, NOACs were associated with a lower risk of the composite outcome (HR: 0.68, 95% CI: 0.58–0.80). Conclusions: In this nationwide Asian AF population with EHRA type 2 VHDs, NOAC use was associated with lower risks of ischemic stroke, major bleeding, all-cause death, and the composite outcome compared to warfarin use. Full article

(This article belongs to the Special Issue Warfarin Versus the Non-vitamin K Oral Anticoagulants (NOACs) in Clinical Practice)

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8 pages, 227 KiB

Open AccessArticle

The SAMe-TT₂R₂ Score Predicts Warfarin Control in an Australian Population with Atrial Fibrillation

by Nijole Bernaitis, Gemma Clark, Sarah Kohja, Stephanie Leong and Shailendra Anoopkumar-Dukie

J. Clin. Med. 2019, 8(6), 882; https://doi.org/10.3390/jcm8060882 - 20 Jun 2019

Cited by 8 | Viewed by 3428

Abstract

Background: Warfarin requires regular monitoring with the time in therapeutic range (TTR), a common indicator of control and TTR > 70% is indicative of efficient anticoagulation. The SAMe-TT₂R₂ (sex, age, medical history, treatment, tobacco use, race) model has been utilised as a predictor of warfarin control, with a score ≥ 2 indicative of poor control. However, it has been suggested that race may be over-represented in this model. To date, no Australian studies have applied this model, possibly because race is not routinely recorded. Therefore, the aim of this study was to apply the SAMe-TT₂R₂ model in an Australian population on warfarin managed by both a warfarin care program (WCP) and general practitioner (GP). Methods: Retrospective data was collected for patients receiving warfarin via a WCP in Queensland and whilst being managed by a GP. Patient data was used to calculate the SAMe-TT₂R₂ score and the TTR for each patient. Mean TTR was used for analysis and comparison with the categorised SAMe-TT₂R₂ score. Results: Of the 3911 patients managed by a WCP, there was a significantly lower mean TTR for patients with a SAMe-TT₂R₂ score ≥ 2 compared to 0–1 (78.6 ± 10.7% vs. 80.9 ± 9.5%, p < 0.0001). Of these patients, 200 were analysed whilst managed by a GP and the categorised SAMe-TT₂R₂ score did not result in a statistically different mean TTR (69.3 ± 16.3% with 0–1 vs. 63.6 ± 15.0% with ≥2, p = 0.089), but a score ≥2 differentiated patients with a TTR less than 65%. Conclusions: The SAMe-TT₂R₂ model differentiated Australian patients with reduced warfarin control, despite the exclusion of race. In Australia, the SAMe-TT₂R₂ score could assist clinicians in identifying Australian patients who may obtain reduced warfarin control and benefit from additional interventions such as a dedicated WCP. Full article

(This article belongs to the Special Issue Warfarin Versus the Non-vitamin K Oral Anticoagulants (NOACs) in Clinical Practice)

9 pages, 221 KiB

Open AccessArticle

Treatment Expectations, Convenience, and Satisfaction with Anticoagulant Treatment: Perceptions of Patients in South-East Queensland, Australia

by Jonathan Gospos and Nijole Bernaitis

J. Clin. Med. 2019, 8(6), 863; https://doi.org/10.3390/jcm8060863 - 17 Jun 2019

Cited by 4 | Viewed by 2753

Abstract

Background: Warfarin has long been the only oral anticoagulant (OAC) available, but options now include non-vitamin K antagonists. Prescribing an OAC may be influenced by patient factors and preferences influenced by dosing, monitoring, and adverse effects, which may ultimately impact patient satisfaction and convenience. The aim of this study was to explore the perception of OAC treatment by Australian patients in terms of treatment expectations, convenience, and satisfaction. Methods: The Perception of Anticoagulant Treatment Questionnaire was distributed to patients dispensed OAC medication from three pharmacies in South-East Queensland. Responses to questions using a five-point Likert scale were collated and mean results utilised to assess expectations, convenience, and satisfaction, including an analysis across demographic groups. Results: A total of 56 (26.8%) surveys were returned, with the majority of respondent’s male (58.2%). Highest mean scores for treatment expectation were for an OAC that was easy to take (4.85 ± 0.79) and that could be taken care of by the respondents themselves (4.11 ± 1.14). The mean overall score for convenience was 68.90 ± 11.44% and for satisfaction 69.43 ± 16.58%. Significantly higher mean convenience scores were found in females and patients with atrial fibrillation. Conclusions: Patients’ highest expectations were for an OAC that would be easy to take, and overall satisfaction and convenience was around 69%. Factors including demographics can influence perceptions of therapy, and addressing individual preferences for OAC therapy may increase ratings of satisfaction and convenience. Full article

(This article belongs to the Special Issue Warfarin Versus the Non-vitamin K Oral Anticoagulants (NOACs) in Clinical Practice)

9 pages, 2065 KiB

Open AccessArticle

The CHA₂DS₂-VASc Score Predicts Major Bleeding in Non-Valvular Atrial Fibrillation Patients Who Take Oral Anticoagulants

by Kuang-Tso Lee, Shang-Hung Chang, Yung-Hsin Yeh, Hui-Tzu Tu, Yi-Hsin Chan, Chi-Tai Kuo and Lai-Chu See

J. Clin. Med. 2018, 7(10), 338; https://doi.org/10.3390/jcm7100338 - 09 Oct 2018

Cited by 14 | Viewed by 3946

Abstract

Background: Patients with atrial fibrillation (AF) are at a substantial risk of ischemic stroke. The CHA₂DS₂-VASc score predicts the risk of thromboembolism, but its role in predicting major bleeding in patients taking oral anticoagulants is unclear. Methods: We used the National Health Insurance Research Database (NHIRD) of Taiwan to identify patients with AF from 2010 to 2016. They were divided into four groups according to the oral anticoagulants. The outcomes were ischemic stroke/systemic thromboembolism, and major bleeding. Results: A total of 279,776 patients were identified. Ischemic stroke or systemic embolism events were observed in 1.73%, 3.62%, 4.36%, and 5.02% of the patients in the apixaban, rivaroxaban, dabigatran, and warfarin groups, respectively. Major bleeding was recorded in 1.18%, 2.66%, 3.23%, and 4.70% of the patients in the apixaban, rivaroxaban, dabigatran, and warfarin groups, respectively. The highest rates for both ischemic stroke and bleeding events occurred in the patients with a CHA₂DS₂-VASc score of five or more. Conclusion: Non-valvular AF patients with high CHA₂DS₂-VASc scores are susceptible to both systemic thromboembolism and major bleeding. The trend was consistently observed in patients who took non-vitamin K oral anticoagulants (NOACs) or warfarin. NOACs might be potentially more effective in reducing overall events. Full article

(This article belongs to the Special Issue Warfarin Versus the Non-vitamin K Oral Anticoagulants (NOACs) in Clinical Practice)

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Review

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21 pages, 3990 KiB

Open AccessReview

Effectiveness and Safety of Direct Oral Anticoagulants versus Vitamin K Antagonists for People Aged 75 Years and over with Atrial Fibrillation: A Systematic Review and Meta-Analyses of Observational Studies

by Anneka Mitchell, Margaret C. Watson, Tomas Welsh and Anita McGrogan

J. Clin. Med. 2019, 8(4), 554; https://doi.org/10.3390/jcm8040554 - 24 Apr 2019

Cited by 36 | Viewed by 5339

Abstract

Older people, are underrepresented in randomised controlled trials of direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation (AF). The aim of this study was to combine data from observational studies to provide evidence for the treatment of people aged ≥75 years. Medline, Embase, Scopus and Web of Science were searched. The primary effectiveness outcome was ischaemic stroke. Safety outcomes were major bleeding, intracranial haemorrhage, gastrointestinal bleeding, myocardial infarction, and mortality. Twenty-two studies were eligible for inclusion. Two studies related specifically to people ≥75 years but were excluded from meta-analysis due to low quality; all data in the meta-analyses were from subgroups. The pooled risk estimate of ischaemic stroke was slightly lower for DOACs. There was no significant difference in major bleeding, mortality, or myocardial infarction. Risk of intracranial haemorrhage was 44% lower with DOACs, but risk of GI bleeding was 46% higher. Our results suggest that DOACs may be preferable for the majority of older patients with AF, provided they are not at significant risk of a GI bleed. However, these results are based entirely on data from subgroup analyses so should be interpreted cautiously. There is a need for adequately powered research in this patient group. Full article

(This article belongs to the Special Issue Warfarin Versus the Non-vitamin K Oral Anticoagulants (NOACs) in Clinical Practice)

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