Prescriptive appropriateness of direct oral anticoagulants in older subjects with atrial fibrillation discharged from acute medical wards.

Abstract Background. Knowledge on the prescriptive practice of direct oral anticoagulants (DOACs) in older subjects with atrial fibrillation (AF) hospitalized in acute medical wards is limited. Objective. To evaluate the prevalence and appropriateness of DOAC prescriptions in hospitalized older subjects with AF, discharged from acute medical wards. Methods. We analyzed a cohort of 609 subjects with AF, aged 65 years or more (mean age 85 years) and enrolled in 39 geriatric and nephrology acute wards in Italy. DOAC prescriptive appropriateness was evaluated according to the summary of product characteristics (smPC), 2019 Beers and STOPP criteria, and drug-drug interactions (DDIs). Results. At hospital discharge, 33% of patients with AF were prescribed with DOAC, 26% with vitamin-K antagonist, while 41% didn’t receive any anticoagulant. Among subject on DOAC therapy, 31% presented a violation of the smPC criteria (mainly leading to an underdosage -17%-), while 48% and 18% presented a Beers/STOPP inappropriate prescription, or a DDI, respectively. Older age, lower body mass index (BMI), cancer and higher estimated glomerular filtration rate (eGFR) were independently associated with DOAC underdosage or missed prescription (age: aOR 1.06, 95%CI 1.00-1.12 for underdosage; eGFR: aOR 1.04, 95%CI 1.02-1.07 for underdosage; BMI: aOR 0.95, 95%CI 0.91-0.99 for missed prescription; cancer: aOR 1.93, 95%CI 1.19-3.13 for missed prescription). Conclusions. This study showed a suboptimal DOAC prescriptive practice in older in-patients, with frequent missed prescription and DOAC underdosage. In apparent contrast with current recommendation, treating physicians seem to be over-concerned by bleeding risk in real-life older and frailer subject. Strategies should be developed to promote appropriate DOAC prescription in the hospital setting.