Oral anticoagulation in emergency department patients: high rates of off-label doses,no difference in bleeding rates.
Am J Med. 2019 Oct 24;:
Authors: Eschler CM, Woitok BK, Funk GC, Walter P, Maier V, Exadaktylos AK, Lindner G
BACKGROUND: Empirically, a significant proportion of patients using Direct Oral AntiCoagulation (DOAC) take off-label reduced doses. We aimed to investigate: the prevalence, indications, doages and bleeding complications of oral anticoagulants on admission to the emergency department METHODS: In this retrospective analysis patients presenting to our emergency department between January 1st and December 31st 2018 with therapeutic oral anticoagulation were included (vitamin-K antagonists, rivaroxaban, apixaban, edoxaban, dabigatran). A detailed chart review was performed for each case concerning characteristics, indication and bleeding complications.
RESULTS: 19.662 consecutive emergency department cases were reported. 1.721 (9%) had therapeutic oral anticoagulation. Vitamin-K antagonists (41%), rivaroxaban (36%) and apixaban (19%) were the most common. Stroke prophylaxis in patients with atrial fibrillation (63.2%) and venous thromboembolism (24.1%) were the most common indications. In 27 cases (1.6%) no indication could be identified. 32% of patients were classified to have either off label-doses of DOACs or an INR out of range (in vitamin-K antagonists), while 20% were classified as off-label under-dosed and 12% as over-dosed. No difference in likelihood of bleeding on admission could be found between the respective drugs. Only concomitant use of aspirin was significantly associated with presence and higher severity of bleeding.
CONCLUSIONS: Vitamin-K antagonists are still the most widely used drug followed by rivaroxaban. A significant proportion of patients are being prescribed off label-doses. While no difference was found for the respective anticoagulants with respect to bleeding, concomitant aspirin use was a significant predictor for bleeding in our collective.
PMID: 31668901 [PubMed - as supplied by publisher]