Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Pharmacie, 75012, Paris, France.
Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP UMR-S1136, 75012, Paris, France.
Drugs Aging. 2019 Nov;36(11):1047-1055. doi: 10.1007/s40266-019-00710-8.
Direct oral anticoagulants (DOACs) were developed to overcome some of the limitations associated with vitamin K antagonists (VKAs), such as interindividual variability or the need for therapeutic drug monitoring. However, the complexity of DOAC dose regimens can still lead to dosing errors and potential bleeding-related or thromboembolic adverse events, especially in the elderly.
Our objective was to evaluate the rate of inappropriate preadmission DOAC prescriptions at hospital and to evaluate the ability of hospitals to correct them.
An observational prospective study was conducted in elderly patients (aged ≥ 65 years) hospitalized in six acute units of three Parisian university hospitals between February and July 2018. DOAC prescriptions prior to admission and at discharge were analyzed according to the guidelines in the summaries of product characteristics.
A total of 157 patients were included in the study, with a median age of 84 years (interquartile range [IQR] 77-89). The median glomerular filtration rate, determined with the Cockcroft-Gault equation, was 48 mL/min (IQR 35-61). Apixaban was the most frequently prescribed drug, mainly for atrial fibrillation. Overall, 48 (30.6%) and 34 (22.4%) prescriptions were inappropriate prior to admission and at discharge, respectively, showing a significant decrease (p < 0.001). Hospitals significantly corrected more inappropriate prescriptions (37.5%) than they generated (4.6%) (p < 0.05). The nature of the inappropriate prescribing was underdosing (68.8% and 76.5% prior to admission and at discharge, respectively), followed by overdosing (stable rate at almost 20%) and indication errors. No risk factors for inappropriate use were identified by our analysis.
One-third of DOAC preadmission prescriptions for elderly patients were inappropriate, indicating that a need remains to strengthen DOAC prescribing guidelines in ambulatory clinical practice. However, the rate of inappropriate prescriptions decreased at patient discharge. Future studies are needed to test actions to promote the proper use of DOACs.
直接口服抗凝剂（DOACs）的开发旨在克服一些与维生素 K 拮抗剂（VKAs）相关的局限性，例如个体间变异性或需要治疗药物监测。然而，DOAC 剂量方案的复杂性仍可能导致剂量错误和潜在的出血相关或血栓栓塞不良事件，尤其是在老年人中。
我们的目的是评估医院中 DOAC 预入院处方不当的发生率，并评估医院纠正这些处方的能力。
我们在 2018 年 2 月至 7 月期间，在巴黎三所大学医院的六个急症病房对 157 名年龄≥65 岁的老年患者进行了一项观察性前瞻性研究。根据产品特性摘要中的指南，分析了患者入院前和出院时的 DOAC 处方。
共纳入 157 例患者，中位年龄为 84 岁（四分位距 [IQR] 77-89）。使用 Cockcroft-Gault 方程确定的中位肾小球滤过率为 48 mL/min（IQR 35-61）。阿哌沙班是最常开的药物，主要用于治疗心房颤动。总体而言，入院前和出院时处方不当的比例分别为 48（30.6%）和 34（22.4%），显著下降（p<0.001）。医院显著纠正了更多不当处方（37.5%）而不是开具的处方（4.6%）（p<0.05）。处方不当的性质主要是剂量不足（入院前和出院时分别为 68.8%和 76.5%），其次是剂量过大（接近 20%的稳定率）和适应症错误。我们的分析未发现处方不当的危险因素。
三分之一的老年患者 DOAC 预入院处方不当，表明在门诊临床实践中仍需要加强 DOAC 处方指南。然而，患者出院时处方不当的比例有所下降。未来需要进一步研究以测试促进正确使用 DOAC 的措施。
