Abstract
Direct Oral Anticoagulants (DOACs) have revolutionized the management of stroke prevention in non-valvular atrial fibrillation (AF), particularly in patients >65 years old who are at higher risk of thromboembolic events and bleeding complications. DOACs offer efficacy comparable to warfarin with a better safety profile and fewer dietary interactions making them suitable for elderly patients. However, challenges remain in patients with renal impairment, polypharmacy, poor nutrition or elevated bleeding risk.
An audit at Derriford Hospital, Plymouth, evaluated DOAC prescriptions for stroke and systemic embolism prophylaxis in elderly patients with non-valvular AF. It aimed to ensure alignment with current guidelines, thus optimizing outcomes by minimizing thromboembolic risk and dosing-related adverse effects. Data from electronic patient records over a two-week period showed that of 235 patients reviewed, 51 had AF, with 49 prescribed a DOAC. Only 10% of DOACs were initiated during hospital stays, indicating most were initiated pre-admission.
The DOAC distribution was Apixaban (n=21), Dabigatran (n=2), Rivaroxaban (n=10) and Edoxaban (n=16). Results showed only 65% received the correct DOAC and dosage based on their clinical needs. Contributing factors included sub-therapeutic doses, clinical scenarios where Apixaban should have been the preferred DOAC and inadequate dose adjustments for weight, age and renal function. These findings highlight the need for individualized DOAC therapy. To improve practice, a teaching session was provided on these findings and educational posters with key points and dosing guidelines have been distributed to healthcare of the elderly prescribers. A follow-up audit is planned to assess the impact of these interventions.