DOACs dose adherence during initial and long term VTE management. Practical implications, findings from the RIETE registry.
E. Papadakis1, J. Trujillo-Santos2, P. Di Micco3, F. Dentali4, J.-A. Diaz-Peromingo5, M.-J. Nunez6, I. Canas7, D. Mastroiacovo8, M.-S. De Sousa9, A. Banti1, M. Monreal10 (1Thessaloniki, Greece, 2Murcia, Spain, 3Naples, Italy, 4Varese, Italy, 5Santiago de Compostela, Spain, 6Pontevedra, Spain, 7Barcelona, Spain, 8Avezzano, Italy, 9Vila Nova de Gaia, Portugal, 10Badalona, Spain)
Time: 08:00 - 09:15
Objective: Direct oral anticoagulants (DOACs) are available as alternatives to vitamin K anticoagulants (VKAs) for VTE management. Recently updated ACCP guidelines (February 2016) suggest using DOACs over VKAs for VTE treatment in non-cancer patients. Warfarin’s long half-life is an advantage for patients who occasionally miss doses compared with DOACs. Twice-daily dosing schedules may be more difficult for patients to adhere on the other hand the impact of a missed dose may be greater with DOACS. Medication adherence is important to attain good clinical outcomes with DOACs, especially in long term management asymptomatic patients. RIETE is a multicenter International Registry of VTE (more than 65000 patients enrolled from 245 centers) providing real life data on VTE presentation and management
Methods: From 17194 patients enrolled in RIETE registry between 2013-16, 1445(8.4%) received rivaroxaban and 81(0.47%) apixaban as initial VTE treatment. Among 16123 patients, 2.403(15%) received rivaroxaban and 315(2%) apixaban as long term therapy. Patients receiving DOACs were usually younger than 50 years, without cancer and renal impairment and with normal body weight (Tables 1&2)
Results: 81.7% of the patients received the recommended daily dose and 78% the recommended twice daily schedule. When receiving DOACs active cancer patients and patients with renal insufficiency tend to receive lower doses. As far as long term treatment for VTE 87% received the recommended daily dose, 6% lower, and 6.8% higher. Regarding daily regimen 90.4% of patients received appropriate schedule. Patients that did not receive recommended doses were usually older, presented cancer and renal insufficiency. Patients that received DOACs in lower than recommended doses did not less bleeding. Interestingly patients that received DOACs in non recommended schedule or dose presented statistically more VTE recurrences Table 3 (HR 10.7, p<0.05)
Conclusion: When starting DOACs, physicians need to be aware of the various dosing and monitoring requirements for each agent, while patients need to be counselled regarding appropriate use of their medication. Inappropriate prescribing, monitoring and administration of DOACs occur frequently and expose patients to greater risk for VTE recurrence.