Oral Anticoagulation in Patients in the Emergency Department: High Rates of Off-Label Doses, No Difference in Bleeding Rates - Eschler, C. M.; Woitok, B. K.; Funk, G. C.; Walter, P.; Maier, V.; Exadaktylos, A. K.; Lindner, G. (Am J Med, 2019)
BACKGROUND: Empirically, a significant proportion of patients using direct oral anticoagulation (DOAC) take off-label reduced doses. We aimed to investigate the prevalence, indications, dosages, 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 1 and December 31, 2018, with therapeutic oral anticoagulation were included (ie, vitamin-K antagonists, rivaroxaban, apixaban, edoxaban, and dabigatran). A detailed chart review was performed for each case concerning characteristics, indication, and bleeding complications. RESULTS: A total of 19,662 consecutive cases in the emergency department were reported: 1721 (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; further, 32% of patients were classified to have either off-label doses of DOACs or an international normalized ratio (INR) out of range (in vitamin-K antagonists), whereas 20% were classified as off-label underdosed and 12% as overdosed. No difference in the 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.
Keywords: journalArticle; Administration, Oral; Aged; Anticoagulants/administration & dosage/*adverse effects/therapeutic use; Anticoagulation; Atrial Fibrillation/drug therapy; Bleeding; Dabigatran/administration & dosage/adverse effects; Dosage; Emergency; Emergency Service, Hospital/*statistics & numerical data; Female; Hemorrhage/*chemically induced/epidemiology; Humans; Male; Off-Label Use/*statistics & numerical data; Pyrazoles/administration & dosage/adverse effects; Pyridines/administration & dosage/adverse effects; Pyridones/administration & dosage/adverse effects; Retrospective Studies; Rivaroxaban/administration & dosage/adverse effects; Stroke/prevention & control; Thiazoles/administration & dosage/adverse effects; Vitamin K/antagonists & inhibitors