1b) This is the third in a series; you can still earn 🆓CE/#CMEcredit for the first two tweetorials at https://t.co/mHOQVw4mlC and https://t.co/orYQvmXHu9. What a deal! pic.twitter.com/BEW3Vi0BCe
— cardio-met (@cardiomet_CE) March 30, 2023
2a) Your co-hosts are Dr Jackevicius @UofT @ICESOntario @WesternUPharm 🇨🇦 and🩸clot, #antithrombotic therapy, & #atrialfib aficionado Charles Pollack MD @md_pollack from @UMMCnews 🇺🇸. Earn 0.5hr 🆓CE/#CME by following this 🧵. pic.twitter.com/Afc9Z32emn
— cardio-met (@cardiomet_CE) March 30, 2023
3a) Our discussion article for #JournalClub is entitled “Real-World Adherence and Persistence to Direct Oral #Anticoagulants in Patients With Atrial Fibrillation: A Systematic Review & Meta-Analysis”
— cardio-met (@cardiomet_CE) March 30, 2023
That ref again: 🔓 https://t.co/q93f5CM3SK
👏@netta_doc @denniskomd @_ayaOzk
4a) The 🔑issue in our featured article: Although it is convenient that #DOACs do not require laboratory monitoring, that does not necessarily lead to good #adherence and #persistence ➡️ the desired success in #SPAF may not be achieved.
— cardio-met (@cardiomet_CE) March 30, 2023
5a) So, let's review the background here.
— cardio-met (@cardiomet_CE) March 30, 2023
🫀 #AFib is the most common chronic arrhythmia, affecting 33.5 million 🌎🌍🌏2010, projected to 2⃣x ⬆️by 2030.
🫀 AFib is assoc'd w/ a 5⃣x ⬆️in the risk of stroke 🧠& requires #anticoagulant tx for pts w/ moderate to high-stroke risk.
6a) But . . . are there ⬆️consequences of poor #DOAC #adherence? Their shorter half-lives (vs #warfarin) & consequent short duration of #anticoagulant effect means that even brief periods of DOAC #nonadherence may rapidly result in #subtherapeutic anticoagulant levels. pic.twitter.com/ACwDoUHvY0
— cardio-met (@cardiomet_CE) March 30, 2023
6c) In fact, NOT needing ongoing monitoring for DOAC tx may actually predispose pts, knowing ⤵️#clinician oversight, to #nonadherence. They know there's no #INR check looming!
— cardio-met (@cardiomet_CE) March 30, 2023
8a) To address the ❓, they conducted a systematic review and meta-analysis of studies that assessed real-world #DOAC adherence/persistence in patients with #AF through 6/25/2018 ➡️1148 unique articles, ultimately including 48 suitable studies included in this analysis. pic.twitter.com/4pknAGlyUM
— cardio-met (@cardiomet_CE) March 30, 2023
8c) They systematically assessed study quality and potential biases. Subgroup analyses were conducted by #DOAC agent, region, observation time period, and #persistence definition. Post hoc analyses comparing adherence/persistence between DOACs and #VKA were performed.
— cardio-met (@cardiomet_CE) March 30, 2023
9a) So what about these studies?
— cardio-met (@cardiomet_CE) March 30, 2023
👉The 48 included studies comprised a total of 594,784 pts with #AFib taking #DOACs & 283,182 patients taking #VKA.
👉Study n's ranged 159-66,090.
👉generally these were observational studies published between 2016 and 2018.
9c)
— cardio-met (@cardiomet_CE) March 30, 2023
👉52% reported a comparison between #DOACs and #VKA
👉Duration of observation time ranged from 3 months to 3 years, with the 12-month period being most commonly reported
👉Persistence gap definitions varied from 14 to 90 days.
11a)
— cardio-met (@cardiomet_CE) March 30, 2023
🔑The 12-month overall pooled proportion of days covered/medication possession ratio was 77% (95% CI, 75%–80%).
🗝️The proportion of patients with good adherence was 66% (95% CI, 63%–70%).
🔑The proportion persistent was 69% (95% CI, 65%–72%).
12a) The up💉? These data show suboptimal adherence to #DOACs, with patients not taking their 💊1 out of every 4 days, and one-third of patients showing poor adherence. The patient population of the included studies is similar to the general AF population & landmark DOAC #RCTs.
— cardio-met (@cardiomet_CE) March 30, 2023
13a) What were the consequences of suboptimal persistence?
— cardio-met (@cardiomet_CE) March 30, 2023
🧠The pooled HR ➡️ #DOAC nonadherence was assoc'd with ⬆️ risk of #stroke (HR 1.39, [95% CI, 1.06–1.81], P=0.016])
🧠DOAC nonpersistence was assoc'd with ⬆️ risk of stroke/#TIA (HR, 4.55 [95% CI, 2.80–7.39], P<0.0001])
14) And a scary thought😱: the included studies primarily used Rx claims data, which records prescriptions dispensed, not necessarily taken.
— cardio-met (@cardiomet_CE) March 30, 2023
👉😱it is possible that #adherence & #persistence rates are even LOWER than the summary estimates reported in this meta-analysis!
16a) So what can we do?
— cardio-met (@cardiomet_CE) March 30, 2023
1⃣⬆️patient ed & monitoring. Replace #INR monitoring with #DOAC management by pharmacists or anticoagulation clinics, and extend monitoring after DOAC initiation to potentially achieve higher DOAC adherence.
See 🔓https://t.co/mw4k1G1ddo.
16c)
— cardio-met (@cardiomet_CE) March 30, 2023
3⃣ Periodic lab monitoring as would be done for #lipid levels or hemoglobin #A1c may be another strategy in managing #DOAC nonadherence . . . tho blood levels of DOACs are often not readily available, especially outside the hospital.
18a) Though not addressed in our #journalclub article, prior #tweetorials in this series have also suggested an emerging alternative approach to #SPAF that has the potential to substantially ⤵️#nonadherence:
— cardio-met (@cardiomet_CE) March 30, 2023
18c) @darae_ko et al point out that if these novel anticoagulation strategies are proven to reduce bleeding risks compared with #FXa inhibitors, they may address this large unmet clinical need.
— cardio-met (@cardiomet_CE) March 30, 2023
See https://t.co/w396TRfPMw.
19b) It's c that is false . . . an anticoagulant on board, even at doses < recommended for full #SPAF protection, causes largely the same degree of 🩸whether fully or partially adherent!
— cardio-met (@cardiomet_CE) March 30, 2023
20b) It's b, 1 in 3, which is a pretty dismal result, especially for a drug class #DOACs that are supposed to foster better adherence!
— cardio-met (@cardiomet_CE) March 30, 2023
Suboptimal persistence of 69% with DOAC therapy has clinical consequences & remains a great concern for patients with AF.
21) You just earned 0.5hr 🆓CE/#CME! Grab your certificate for credit at https://t.co/LmVfYMNLuZ, and follow us here on @cardiomet_ce for more education on this & other topics related to #thrombosis & #antithrombotic therapy! @HeartRPh & @md_pollack 🙏for joining!
— cardio-met (@cardiomet_CE) March 30, 2023