Leef George C, Perino Alexander C, Askari Mariam, Fan Jun, Ho P Michael, Olivier Christoph B, Longo Lisa, Mahaffey Kenneth W, Turakhia Mintu P
Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
J Pharm Pract. 2020 Oct;33(5):647-653. doi: 10.1177/0897190019828270. Epub 2019 Feb 21.
Direct oral anticoagulants (DOACs) have strict dosing guidelines, but recent studies indicate that inappropriate dosing is common, particularly in chronic kidney disease (CKD), for which it has been reported to be as high as 43%. Since 2011, the Veterans Health Administration (VA) has implemented anticoagulation management programs for DOACs, generally led by pharmacists, which has previously been shown to improve medication adherence.
We investigated the prevalence of overdosing and underdosing of DOACs in the VA.
Using data from the TREAT-AF cohort study (The Retrospective Evaluation and Assessment of Therapies in AF), we identified VA patients with newly diagnosed atrial fibrillation (AF) and receipt of a DOAC between 2003 and 2015. We classified dosing as correct, overdosed, or underdosed based on the Food and Drug Administration-approved dosing criteria.
Of 230 762 patients, 5060 received dabigatran (77.3%) or rivaroxaban (22.7%) within 90 days of AF diagnosis (age 69 [10[ years; CHADS-VASc 1.6 [1.4]), of which 1312 (25.9%) had CKD based on estimated glomerular filtration rate <60. Overall, 93.6% of patients, 83.2% with CKD, received appropriate DOAC dosing. Incorrect dosing increased with worsening renal function.
Compared to recent studies of commercial payers and health-care systems, incorrect dosing of DOACs is less common across the VA. Pharmacist-led DOAC management or similar anticoagulation management interventions may reduce the risk of incorrect dosing across health-care systems.
直接口服抗凝剂（DOACs）有严格的给药指南，但近期研究表明，给药不当情况很常见，尤其是在慢性肾脏病（CKD）患者中，据报道该比例高达43%。自2011年以来，退伍军人健康管理局（VA）已实施了由药剂师主导的DOACs抗凝管理项目，此前已证明该项目可提高用药依从性。
我们调查了VA中DOACs用药过量和用药不足的发生率。
利用TREAT-AF队列研究（房颤治疗的回顾性评估与分析）的数据，我们确定了2003年至2015年间新诊断为房颤且接受DOAC治疗的VA患者。我们根据美国食品药品监督管理局批准的给药标准将给药情况分为正确、过量或不足。
在230762例患者中，5060例在房颤诊断后90天内接受了达比加群（77.3%）或利伐沙班（22.7%）治疗（年龄69[10]岁；CHADS-VASc评分1.6[1.4]），其中1312例（25.9%）根据估算的肾小球滤过率<60被诊断为CKD。总体而言，93.6%的患者、83.2%的CKD患者接受了适当的DOAC给药。肾功能恶化时，给药错误增加。
与近期对商业医保支付方和医疗保健系统的研究相比，VA中DOACs给药错误的情况较少见。由药剂师主导的DOAC管理或类似的抗凝管理干预措施可能会降低整个医疗保健系统中给药错误的风险。
