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As pharmacists, it is our duty to ensure that our patients receive the most appropriate medications, at the correct doses, at the right time. Anticoagulant prescribing in nonvalvular atrial fibrillation (NVAF) is no exception. In 2019, the American Heart Association (AHA) along with the American College of Cardiology (ACC) published a focused update to the 2014 Guidelines for the Management of Patients with Atrial Fibrillation (AFib). These guidelines provided new recommendations, including the preference for Direct Acting Oral Anticoagulants (DOACs) over Vitamin K Antagonists, such as warfarin, for anticoagulation in those with NVAF.1 This recommendation stems from several clinical trials whose results showed that the DOACs were at least as efficacious in reducing the risk of stroke and at least as safe or safer in reducing the risk of major bleeds when compared to warfarin.2-5 Despite this new recommendation and data, there are some populations, specifically underserved populations and women, who are not prescribed DOACs as often as they should.
Prescribing Trends by Race
Essien and colleagues have published several studies examining the prescribing of DOACs. The first study was published in 2018 in JAMA Cardiology examining the findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II. This registry is US-based, consisting of approximately 12,000 outpatients with AFib. Essien found that Black individuals were less likely to be prescribed a DOAC when compared to white and Hispanic individuals. They also found that when treated with a DOAC, Black and Hispanic individuals were more likely to receive inappropriate dosing than white individuals.6
The second study by Essien and colleagues, published in 2020 in the Journal of the National Medical Association, set out to examine racial/ethnic differences in DOAC initiation in newly diagnosed AFib. This study was conducted retrospectively using a 5% sample of Medicare beneficiaries from 2012-2014 with AFib. Based on the data, it was concluded that Black individuals were less likely to be prescribed DOACs when compared to white and Hispanic individuals.7
The third study by Essien and colleagues published in 2021 was a retrospective review of approximately 111,000 Veteran’s Health Administration patients from 2014-2018 newly diagnosed with AFib. They determined that the odds of initiating any anticoagulant were lower for Black and Asian individuals when compared to others. Also, the likelihood of initiating a DOAC were significantly lower for Hispanic, Black, and American Indian/Alaska Native individuals when compared to white individuals.8
There is considerable evidence to suggest that underserved populations are less likely to receive the preferred medications, DOACs, at the correct doses for anticoagulation when compared to their white counterparts. As pharmacists, we should strive to intervene in these areas to improve care for all our patients.
Prescribing Trends by Sex
Women with AFib have a lower rate of oral anticoagulant use compared to men, despite having a higher thromboembolic risk.9 The reasons for this difference in anticoagulant use is thought to be due to under recognition of women’s higher thromboembolic risk and/or concern for bleeding risk.9 A study published in 2017 by Thompson and colleagues in the Journal of the American Heart Association utilized the PINNACLE National Cardiovascular Data Registry from 2008-2014. Thompson found that, compared to men, women were less likely to receive anticoagulation at all CHA2DS2-VASc levels and despite the increasing use of DOACs, women continued to have them prescribed at a lower rate than men.9
Bhave and colleagues found comparable results as well. They conducted a review of Medicare beneficiary encounter data for newly diagnosed AFib from 2010-2011. After analysis of the encounter information, Bhave determined that women were less likely to be prescribed oral anticoagulation compared to their male counterparts at 45 and 90 days (about 3 months) after diagnosis.10
The 2020 study by Essien and colleagues that examined Medicare beneficiaries also sought to determine if there were sex-related differences in the initiation of DOACs in those newly diagnosed with AFib. They found that women were less likely to be initiated on any anticoagulation than men, but when anticoagulation was initiated, there were no differences in the likelihood of DOAC initiation between men and women.7
This data highlights the gap that exists in initiation of oral anticoagulants, specifically DOACs, between men and women despite their increased utilization over the last several years. As pharmacists, we can take a leading role in this area to ensure that all our patients are treated equitably.
What can pharmacists do to help?
It is our duty to make sure that our patients receive the right medication, at the right dose, at the right time. The data above clearly shows that underserved populations and women are at a disadvantage when it comes to the prescribing of oral anticoagulants and specifically DOACs. As pharmacists, we can:
- Proactively screen these populations to determine if DOAC therapy would be more appropriate than warfarin.
- Work closely with the patient’s provider to obtain the most appropriate therapy.
- Use patient assistance programs to obtain the DOAC, if financial barriers exist.
Remember, the Time Is Now, to ensure equity in the prescribing of DOACs for afib given their similar efficacy and preferable safety profile compared to warfarin.
- January CT, Wann LS, Calkins H, et al. AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019; 140: e125–e151.
- Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. New England Journal of Medicine. 2009; 361(12): 1139-1151.
- Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. New England Journal of Medicine. 2011; 365(10): 883-891.
- Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. New England Journal of Medicine. 2011; 365(11): 981-992.
- Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus Warfarin in Patients with Atrial Fibrillation. New England Journal of Medicine. 2013; 369(22): 2093-2104.
- Essien UR, Holmes DN, Jackson LR, et al. Association of Race/Ethnicity with Oral Anticoagulant Use in Patients with Atrial Fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II. JAMA cardiology. 2018; 3(12): 1174-1182.
- Essien UR, Magnani JW, Chen N, et al. Race/Ethnicity and Sex-Related Differences in Direct Oral Anticoagulant Initiation in Newly Diagnosed Atrial Fibrillation: A Retrospective Study of Medicare Data. Journal of the National Medical Association. 2020; 112(1): 103-108.
- Essien UR, Kim N, Hausmann LRM. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA network open. 2021; 4(7): e2114234-e2114234.
- Thompson LE, Maddox TM, Lei L, et al. Sex Differences in the Use of Oral Anticoagulants for Atrial Fibrillation: A Report From the National Cardiovascular Data Registry (NCDR(®)) PINNACLE Registry. Journal of the American Heart Association. 2017; 6(7): e005801.
- Bhave PD, Lui X, Girotra S, et al. Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation. Heart Rhythm. 2015; 12(7): 1406-1412.