How do practitioners and older patients with non-valvular atrial fibrillation perceive medicines optimisation of oral anticoagulants? A literature Review

Problem

Warfarin has been effective at reducing stroke risk in patients with non valvular atrial fibrillation (NVAF). However, NICE updated its guideline in 2012 to reflect current evidence for the effectiveness and safety of direct oral anticoagulants (DOACs) in treating NVAF. Since then there has been an upward trend in the uptake of DOACs (dabigatran, rivaroxaban, apixaban and edoxaban) for NVAF in primary care. The challenges surrounding warfarin management such as frequent INR checks, drug and food interactions and variable dosing are not encountered as often with DOACs thus these newer drugs may be perceived as safer and more convenient to use. Therefore, more patients, especially those aged 65 years and over with non valvular atrial fibrillation are prescribed DOACs during hospital admission, to be continued and monitored in primary care. More GPs are also initiating patients on DOACs. However, complexities such as multi-morbidity, poor renal function and polypharmacy are associated with increasing age and DOACs can cause serious harm such as life threatening bleeds if not prescribed, consumed or monitored properly. Increased use of DOACs may translate to less contact time with health professionals resulting in reduced opportunities for healthcare professional intervention. Elderly patients have high stroke and bleeding risk therefore optimising safe and effective use of DOACs will promote adherence leading to lower incidence of stroke and lower adverse events in this patient group.AimTo undertake a systematic literature search and a narrative meta-synthesis of qualitative research relevant to the prescribing and management of oral anticoagulants (OAC) in patients over 65 years, with non-valvular atrial fibrillation (NVAF) and one or more co-morbidities. The review will summarise patient and practitioner perspectives on the primary care prescribing, monitoring and consumption of oral anticoagulants including direct oral anticoagulants by older adults with NVAF and other co-morbidities.

Approach

Five databases (CINAHL, Medline, Embase, PubMed and Web of Science) will be searched applying pre-defined inclusion and exclusion criteria to titles. ‘Covidence’ software will be used to organize independent abstract, full publication screening and quality assurance of the papers by the research team.

Findings

This literature meta-synthesis will provide new insights into the reasons behind the choice of prescribed oral anticoagulants and how patients and practitioners perceive medicines optimisation of DOACs within routine care, beyond CHA2DS2-VASC and HAS-BLED scoring systems.

Consequences

The conclusions from the literature review will contribute to knowledge on how patients and healthcare practitioners view oral anticoagulation in the elderly. Barriers and facilitators to innovation such as the newer oral anticoagulants will inform ways to provide patient centred care whilst working closely with patients to choose the most appropriate medication for those with complex care needs to improve patient safety and minimise harm.