Reasons for discontinuing oral anticoagulation

13 May 2021

Investigating why patients stop taking their lifesaving medication for atrial fibrillation

A recent systematic review into oral anticoagulation therapy (OAC) for atrial fibrillation has shown that more investigation is needed into the reasons why a high number of patients stop taking their medication. Lead researcher Jackie Buck explains the new research which was supported by the Health Economics Unit (HEU) and published in British Geriatrics Society Age and Ageing Journal.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and it can lead to significant comorbidities and even death. It’s crucial that patients continue taking their oral anticoagulation therapy (OAC) to prevent stroke but research shows that rates of discontinuation are high.

I had previously worked with Andi Orlowski, director at HEU, on kidney disease before we started collaborating on AF. I have a background in cardiac care nursing and my work with the University of East Anglia (UEA) usually focuses on older people, so this was a natural area of interest for me.

It had jumped out to us that, while there is a wealth of information available on the initiation of patients taking OAC, there was very little on why people stop taking these lifesaving drugs or why doctors stop prescribing them.

The systematic review

We were funded initially by Norfolk Clinical Commissioning Group then subsequently by Imperial College Health Partners in addition, to carry out a systematic review of studies that reported factors influencing discontinuation. Our two reviewers independently screened titles, abstracts and papers across 11 databases, grey literature and backwards citations from eligible studies against the inclusion criteria and extracted the data.

Of the 6,619 sources identified by our reviewers, only 12 met the inclusion criteria. From these, we found that bleeding complications and gastrointestinal events were the most common factors associated with discontinuation, followed by frailty and risk of falling. However, we found little evidence of the researchers looking into patient perspectives or the influence of family carers in decisions regarding OAC discontinuation. There was also less data available for the newer direct oral anticoagulants than for the older medications.

A systematic review is a real art, as there are hundreds of thousands of papers published every year. Reviewers need skill and determination to search the data using key terms and references to find out all that is known on a subject to answer a specific question. Such a review is important in gaining funding for research, as commissioners need to be reassured the work hasn’t already been done before.

Sharing the learning

The paper has now been published in the British Geriatrics Society Age and Ageing journal, and Andi Orlowski and Bruno Petrungaro developed clear visualisations of the data for inclusion.

Classification of data.

The data included medical information but nothing on the patient experience and how this may affect discontinuation. For example, we know that some drugs such as warfarin require lifestyle changes from the patient including regulating certain nutrients in their diet to avoid a higher risk of bleeding.

Inter-relationship of reasons for discontinuation.

Also, with some of the older drugs people need to go to regular hospital or GP appointments for blood level checks. Newer types of drugs don’t require these kinds of intervention, but there is no research as yet to show if this makes a difference to rates of discontinuation.

As we now have strong data to show that this research hasn’t yet been done, we are putting together a research funding application to look into discontinuation and the potential strategies and interventions to reduce it. The health economics input from Andi and his team will be crucial.

PRISMA flowchart.

Andi said: “Working with Jackie is a real privilege, drawing on both her clinical background and her research role with the UEA and Addenbrooke’s Hospital. In addition, AF and its impact on so many lives is an important issue for us at HEU, so this joint research is an important part of our overall research portfolio.”

Read the full report here.

The HEU team is keen to work in collaboration with organisations across the NHS. To find out more about how you can get involved, contact us. Alternatively, follow us on Linkedin and Twitter for all of our latest news.

About the author

Jackie Buck is a Lecturer, School of Health Sciences, University of East Anglia and FMH Research Ethics Committee Chair and Lead Nurse Research – Cambridge University Hospitals NHS Foundation Trust.

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