Direct Oral Anticoagulants (DOACs) are generally preferred for 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, United Kingdom, evaluated DOAC prescriptions for stroke and systemic embolism prophylaxis in patients >65 years old with non-valvular AF. It aimed to ensure alignment with current national guidelines, hence optimizing outcomes by minimizing thromboembolic risk and dosing-related adverse effects. Data from electronic patient records over a two-week period showed that of the 235 patients reviewed, 51 had AF, with 49 prescribed a DOAC. Only 10% of DOACs were initiated during hospital stays, indicating that most were initiated pre-admission.
The DOAC distribution was Apixaban (n=21), Dabigatran (n=2), Rivaroxaban (n=10) and Edoxaban (n=16). Results showed that only 65% received the correct DOAC choice 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 to the doctors including these findings, and educational posters with key points and dosing guidelines were placed in offices. A follow-up audit conducted three months later revealed that 72.7% of patients were prescribed the correct DOAC choice and dosage across all wards. This improvement in guideline adherence highlights the importance of continued professional education, targeted interventions such as training sessions and guideline-focused resources, and regular audits in maintaining and enhancing prescribing practices within the hospital.
