1 Institute for Pharmaceutical Outcomes & Policy, Department of Pharmacy Practice & Science, University of Kentucky College of Pharmacy, Lexington, and Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville.
2 Division of Pharmaceutical Evaluation & Policy, University of Arkansas for Medical Sciences, Little Rock.
J Manag Care Spec Pharm. 2017 Sep;23(9):958-967. doi: 10.18553/jmcp.2017.23.9.958.
Few studies have assessed adherence to non-vitamin K antagonist oral anticoagulants (NOACs), especially using contemporary data now that multiple NOACs are available.
To compare adherence and treatment patterns among NOACs for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF).
Incident and treatment-naive NVAF patients were identified during 2013-2014 from a large claims database in this retrospective cohort study. Patients were included who initiated rivaroxaban, dabigatran, or apixaban within 30 days after diagnosis. Adherence to the index medication and adherence to any oral anticoagulant was assessed using the proportion of days covered (PDC) at 3, 6, and 9 months. The number of switches and gaps in therapy were also evaluated. Analyses were stratified by stroke risk scores, and a logistic regression model was used to control for factors that may predict high adherence.
Dabigatran had lower adherence (PDC = 0.76, 0.64, 0.57) compared with rivaroxaban (PDC = 0.83, 0.73, 0.66; P < 0.001) and apixaban (PDC = 0.82, 0.72, 0.66; P < 0.001) at 3, 6, and 9 months of follow-up and twice the number of switches to either other anticoagulants or antiplatelet therapy. Adherence was higher overall as stroke risk increased, and dabigatran had consistently lower adherence compared with the other NOACs. Multivariable logistic regression predicting PDC ≥ 0.80 showed rivaroxaban users with higher odds of high adherence compared with dabigatran or rivaroxaban across all time periods. Adjusted analyses showed that increasing age and comorbid hypertension and diabetes were associated with higher adherence.
In this real-world analysis of adherence to NOACs, rivaroxaban and apixaban had favorable unadjusted adherence profiles compared with dabigatran, while rivaroxaban users had higher odds of high adherence (PDC ≥ 0.80) among the NOACs in adjusted analyses. Clinicians and managed care organizations should consider the implications of lower adherence on clinical outcomes and quality assessment.
This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1TR000117. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have nothing to disclose. Study concept and design were contributed by Brown and Shewale. Brown and Talbert collected the data, and data analysis was performed primarily by Brown, along with Shewale and Talbert. The manuscript was written primarily by Brown, along with Shewale, and revised by all the authors.
目前有多种新型口服抗凝药物（NOAC）可供使用，鲜有研究评估这些药物的用药依从性，尤其是使用当代数据进行评估的研究。
本研究旨在比较非瓣膜性心房颤动（NVAF）患者中不同 NOAC 用于卒中预防的用药依从性和治疗模式。
本回顾性队列研究从大型理赔数据库中于 2013-2014 年识别出新发和治疗初治的 NVAF 患者，在诊断后 30 天内开始使用利伐沙班、达比加群或阿哌沙班的患者纳入研究。采用覆盖天数（PDC）评估指数药物和任何口服抗凝药的用药依从性，分别在第 3、6 和 9 个月评估。还评估了药物转换和治疗中断的数量。根据卒中风险评分对分析进行分层，并使用逻辑回归模型控制可能预测高用药依从性的因素。
与利伐沙班（PDC=0.83、0.73、0.66；P＜0.001）和阿哌沙班（PDC=0.82、0.72、0.66；P＜0.001）相比，达比加群在随访第 3、6 和 9 个月时的用药依从性较低（PDC=0.76、0.64、0.57），且达比加群的药物转换数量是其他抗凝药或抗血小板治疗的两倍。随着卒中风险的增加，总体用药依从性更高，而达比加群的用药依从性始终低于其他 NOAC。多变量逻辑回归预测 PDC≥0.80 显示，与达比加群或利伐沙班相比，利伐沙班使用者具有更高的高用药依从性（PDC≥0.80）的可能性。调整分析显示，年龄增加以及合并症高血压和糖尿病与更高的用药依从性相关。
在这项对 NOAC 用药依从性的真实世界分析中，与达比加群相比，利伐沙班和阿哌沙班具有更有利的未调整用药依从性，而在调整分析中，利伐沙班使用者具有更高的高用药依从性（PDC≥0.80）的可能性。临床医生和管理式医疗组织应考虑用药依从性较低对临床结局和质量评估的影响。
本项目由美国国立卫生研究院国家转化医学科学中心通过拨款号 UL1TR000117 提供支持。内容仅由作者负责，不一定代表 NIH 的官方观点。作者无其他应披露内容。Brown 和 Shewale 提出了研究概念和设计。Brown 和 Talbert 收集了数据，Brown 与 Shewale 和 Talbert 共同进行了数据分析。Brown 主要撰写了手稿，Shewale 也参与了手稿的修订，所有作者都对其进行了审阅。
