Gillian Stynes

Oral anticoagulant persistence in patients with non-valvular atrial fibrillation: A cohort study using primary care data in Germany

This study examined characteristics and treatment persistence among patients prescribed oral anticoagulants (OACs) for stroke prevention in non-valvular atrial fibrillation (NVAF). We identified 15,244 patients (51.8% male, 72.7% aged ≥70) with NVAF and no prior OAC therapy who were prescribed apixaban (n = 1,303), rivaroxaban (n = 5,742), dabigatran (n = 1,622) or vitamin-K antagonists (VKAs, n = 6,577) between 1-Dec-2012 and 31-Oct-2014 in German primary care (IMS® Disease Analyzer). We compared OAC persistence using Cox regression over patients’ entire follow-up and using a data-driven time-partitioned approach (before/after 100 days) to handle non-proportional hazards. History of stroke risk factors (stroke/transient ischaemic attack [TIA] 15.2%; thromboembolism 14.1%; hypertension 84.3%) and high bleeding risk (HAS-BLED score≥3 68.4%) was common. Apixaban-prescribed patients had more frequent history of stroke/TIA (19.7%) and high bleeding risk (72.6%) than other OACs. 12-month persistence rates were: VKA 57.5% (95% confidence interval (CI) 56.0–59.0%), rivaroxaban 56.6% (54.9–58.2%), dabigatran 50.1% (47.2–53.1%), apixaban 62.9% (58.8–67.0%). Over entire follow-up, compared to VKA, non-persistence was similar with apixaban (adjusted hazard ratio 1.08, 95% CI 0.95–1.24) but higher with rivaroxaban (1.21, 1.14–1.29) and dabigatran (1.53, 1.40–1.68). Using post-hoc time-partitioned approach: in first 100 days, non-persistence was higher with apixaban (1.37, 1.17–1.59), rivaroxaban (1.41, 1.30–1.53) and dabigatran (1.91, 1.70–2.14) compared to VKA. Compared to apixaban, rivaroxaban non-persistence was similar (1.03, 0.89–1.20), dabigatran was higher (1.39, 1.17–1.66). After 100 days, apixaban non-persistence was lower than VKA (0.66, 0.52–0.85); rivaroxaban (0.97, 0.87–1.07) and dabigatran (1.10, 0.95–1.28) were similar to VKA. Furthermore, rivaroxaban (1.46, 1.13–1.88) and dabigatran (1.67, 1.26–2.19) non-persistence was higher than apixaban. This study describes real-world observations on OAC use, particularly early apixaban use following approval for NVAF, in Germany. We identified potential differential OAC prescribing and higher persistence with apixaban than other OACs after 100 days’ treatment. Larger studies are needed with longer follow-up to establish long-term patterns.

Patient characteristics and bleeding events in nonvalvular atrial fibrillation patients treated with apixaban or vitamin K antagonists: real-world evidence from Italian administrative databases

AIMnThis study aimed to evaluate the risk of major bleeding among two cohorts of nonvalvular atrial fibrillation patients newly initiating a vitamin K antagonist (VKA) or apixaban in a real-world setting in Italy.nnnPATIENTS & METHODSnA retrospective study using a large administrative database of Italian local health units was performed, using data from ten local health units and patients were included from the date of new initiation of apixaban or VKAs from January 2012 to June 2015.nnnRESULTSnRisk of major bleeding was calculated using an adjusted Cox regression model. Compared with VKA, apixaban had a significantly lower risk of major bleeding (hazard ratioxa0=xa00.44 [95% CI: 0.12-0.97]).nnnCONCLUSIONnIn this analysis, apixaban was associated with a lower risk of major bleeding compared with VKA.

Initiation and continuation of oral anticoagulant prescriptions for stroke prevention in non-valvular atrial fibrillation: A cohort study in primary care in France

BACKGROUNDnOral anticoagulants are prescribed in non-valvular atrial fibrillation for stroke prevention; however, little is known about the current management of anticoagulation in France, particularly given the availability of non-vitamin K antagonist oral anticoagulants in recent years.nnnAIMSnTo describe the characteristics of patients prescribed oral anticoagulants, and assess treatment persistence in French primary care.nnnMETHODSnWe conducted a cohort study of patients with non-valvular atrial fibrillation, who were newly prescribed oral anticoagulants between 1 January 2014 and 31 January 2016, using French primary care data (IMS Longitudinal Patient Database). Adjusting for baseline characteristics, risk of non-persistence (switch or discontinuation) was compared using Cox regression.nnnRESULTSnOf 4111 patients, 1710 were newly prescribed vitamin K antagonists, 1257 rivaroxaban, 744 apixaban and 400 dabigatran. The median age was 76 years, and 57.5% were male. History of hypertension was the most common co-morbidity (68.1%). Compared with vitamin K antagonists, non-persistence was higher with rivaroxaban (hazard ratio: 1.28; 95% confidence interval: 1.13-1.45) and dabigatran (hazard ratio: 1.42; 95% confidence interval: 1.20-1.69) and similar with apixaban (hazard ratio: 1.12; 95% confidence interval: 0.96-1.32).nnnCONCLUSIONSnNon-persistence (treatment discontinuation or switch) with vitamin K antagonists was lower than with rivaroxaban and dabigatran in French primary care; however, non-persistence with the newest drug, apixaban, was similar to vitamin K antagonists. Larger studies with longer follow-up are needed to support these findings. This study is registered on ClinicalTrials.gov (NCT02488421).

Modelling the effect of beliefs about asthma medication and treatment intrusiveness on adherence and preference for once-daily vs. twice-daily medication

People with asthma who do not adhere to their maintenance medication may experience poorer asthma control and need more healthcare support than those who adhere. People (Nu2009=u20091010) aged 18–55 years with self-reported asthma, taking one or more asthma maintenance medication(s), from five European countries, participated in a survey using validated scales (Medication Adherence Report Scale [MARS], Asthma Control Test™ [ACT], Beliefs about Medicine Questionnaire [BMQ] and the Asthma Treatment Intrusiveness Questionnaire [ATIQ]). We performed a post hoc evaluation of adherence to maintenance medication, asthma control, beliefs about medication, preferences for once-daily vs. twice-daily asthma maintenance medication and treatment intrusiveness, using structural equation modelling to investigate the relationships between these factors. Most participants reported potential problems with asthma control (ACTu2009<u200919: 76.8% [nu2009=u2009776]), low adherence (median MARSu2009=u20093.40) and preferred once-daily medication (73.5% [nu2009=u2009742/1010]). Non-adherence was associated with worse asthma control (ru2009=u20090.262 [Pu2009<u20090.001]) and a expressed preference for once-daily medication over a twice daily medication that works slightly better (test statistic [T]u2009=u20092.970 [Pu2009=u20090.003]). Participants reporting non-adherence/preferring once-daily medication had negative beliefs about their treatment (BMQ necessity-concerns differential: ru2009=u20090.437 [Pu2009<u20090.001]/Tu2009=u20096.886 [Pu2009<u20090.001]) and found medication intrusive (ATIQ: ru2009=u2009−0.422 [Pu2009<u20090.001]/Tu2009=u20092.689[Pu2009=u20090.007]). Structural equation modelling showed complex relationships between variables, including: (1) high concerns about treatment associated with increased perceived treatment intrusiveness and reduced adherence, which influenced asthma control; (2) high concerns about treatment and healthcare seeking behaviour, which were predictive of preferring twice-daily asthma medication. Concerns about medication and perceived treatment intrusiveness were predictive of poor adherence, and were associated with preference for once-daily asthma medication. Confirm the utility of the PAPA model and NCF in explaining nonadherence linked to poor asthma control.Asthma: Examining beliefs around maintenance medicationEncouraging adherence to maintenance medication for asthma requires a dual approach that considers patient perceptions as well as practicalities. While doctors may prescribe patients with appropriate medication to control asthma, many patients do not adhere to their maintenance regime. The reasons for this are complex, revolving around patient beliefs about long-term medication. Robert Horne at University College London, UK, and co-workers modelled data collected from interviews with 1010 adult patients from five European countries. Over a quarter of patients reported non-adherence and this was linked to concerns about ICS and perceived treatment intensiveness. Patients beliefs about ICS and the concept of medication intrusiveness were key factors in non-adherence. Understanding individual patient goals, eliciting patient concerns and addressing practical barriers should help encourage adherence.

WHAT ARE THE DIFFERENCES IN ORAL ANTICOAGULANT TREATMENT PERSISTENCE IN NON-VALVULAR ATRIAL FIBRILLATION IN EUROPE? REAL-WORLD STUDIES IN THREE EUROPEAN COUNTRIES

Background: Discontinuation of oral anticoagulant (OAC) therapy in patients with non-valvular atrial fibrillation (NVAF) leaves patients unprotected from risk of stroke. We investigated OAC treatment persistence in NVAF in primary care of 3 European countries.nnMethods: Three cohorts of patients