Appropriateness of prescribing dabigatran etexilate and rivaroxaban in patients with nonvalvular atrial fibrillation: a prospective study

Background: Direct oral anticoagulants have been developed to address some of the drawbacks of vitamin-K antagonists. However, special attention should be given when using these drugs, especially in patients with renal insufficiency, questionable compliance, and those at high risk of bleeding.

Objective: To evaluate the appropriateness of prescribing dabigatran etexilate (DE) and rivaroxaban in patients with nonvalvular atrial fibrillation (NVAF) in real-life clinical practice.

Methods: This was a prospective study that included patients presenting to a teaching hospital from April to mid-October 2013, who were taking rivaroxaban or DE for NVAF. Appropriateness of prescribing was evaluated using 9 of the 10 criteria of the Medication Appropriateness Index. The primary outcome measure was the prevalence of inappropriate prescribing. Secondary outcome measures included (a) categories of inappropriateness, (b) prevalence of adverse drug events, and (c) interventions made by a clinical pharmacist to optimize prescribing.

Results: A total of 69 patients were evaluated; 16 patients (23%) had 1 inappropriate criterion, and an additional 18 (26%) had more than 1 inappropriate criterion. The most frequent inappropriate criteria were inappropriate choice (28% of patients), wrong dosage (26%), and impractical modalities of administration (26%). An adverse event (AE) was found in 51% of patients (including 8 patients with transient ischemic attack/stroke). The clinical pharmacists performed 48 interventions, and 94% were accepted by the physician.

Conclusions: Inappropriate use of DE and rivaroxaban in patients with NVAF is frequent and possibly leads to AEs. Reinforcing education of health care professionals and patients is needed. Collaboration with clinical pharmacists can contribute to better use.