Abstract 257: Adherence and Persistence to Direct Oral Anticoagulants in Patients with Atrial Fibrillation

Abstract

Background: Direct oral anticoagulants (DOACs) are increasing in popularity for stroke prevention in atrial fibrillation (AF) due to ease of use. However, varying levels of DOAC adherence and persistence has been reported, which may result in poor clinical outcomes. We undertook a systematic review to characterize the real-world observational evidence for DOAC adherence and persistence. Methods: We searched MEDLINE, EMBASE, and CINAHL from inception to June 2018. We included studies that reported DOAC adherence and/or persistence rates in patients with AF. Two investigators independently screened abstracts and full text articles for inclusion, abstracted data from eligible studies, and assessed risk of bias using the Newcastle-Ottawa Scale. Prevalence rates of nonadherence were pooled using a DerSimonian and Laird random-effects model. Heterogeneity was assessed using I 2 . Results: We identified 48 studies including 576,360 patients in 40 countries. Seventeen studies (35%) reported proportion of days covered (PDC) as the adherence measure, 5 (10%) reported medication possession ratio (MPR), 36 (75%) reported persistence, and 6 (13%) evaluated clinical outcomes associated with DOAC adherence/persistence. Seventeen studies (35%) evaluated DOACs as a class, 11 (23%) evaluated apixaban, 35 (73%) evaluated dabigatran, and 28 (58%) evaluated rivaroxaban. The overall pooled proportion of patients who had good adherence (PDC/MPR≥80%) at all times was 66% (CI: 63%-70%) and at 1 year was 69% (CI: 63%-74%). There was wide variation in persistence definitions used in individual studies, with permissible gaps varying from 14 to 365 days. The overall pooled persistence rate was 71% (CI: 69%-74%) at all times and was 63% (CI: 58%-68%) at 1 year. Heterogeneity was high for all analyses. In subgroup analyses by agent, the pooled 1-year persistence rate was 72% (CI: 60%-83%) for apixaban, 54% (CI: 46%-62%) for dabigatran, and 67% (CI: 59%-75%) for rivaroxaban. Similar patterns were found for pooled adherence rates by agent. Conclusions: We found that DOAC adherence and persistence is low among patients with AF, with 1 in 3 patients not taking a DOAC after initiation. Clinicians need to be aware of the low real-world adherence and persistence rates when using DOACs in AF. High heterogeneity warrants further subgroup analyses.