Correct dosing, adherence and persistence of DOACs in atrial fibrillation and chronic kidney disease: a systematic review and meta-analysis

Subo Emanuel; Riyaz A Kaba; Gayathri Delanerolle; Benjamin C T Field; Gregory Y H Lip; Simon de Lusignan

doi:10.1136/openhrt-2023-002340

Correct dosing, adherence and persistence of DOACs in atrial fibrillation and chronic kidney disease: a systematic review and meta-analysis

Subo Emanuel^*, Riyaz A Kaba, Gayathri Delanerolle, Benjamin C T Field, Gregory Y H Lip, Simon de Lusignan

^*Corresponding author for this work

Research output: Contribution to journal › Review article › peer-review

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Abstract

Background: Chronic kidney disease (CKD) and atrial fibrillation (AF) are increasing in prevalence globally and share common risk factors.

Our aim was to characterise real-world evidence on direct oral anticoagulant (DOAC) prescribing for people with AF and CKD, in terms of adherence, persistence and renal dose titration.

Methods: PubMed, EMBASE and CINAHL were searched from inception to June 2022. Our search terms included a combination of Medical Subject Headings (MeSH) terms and keywords including ‘atrial fibrillation’, ‘chronic kidney disease’, ‘adherence’, ‘persistence’, ‘direct oral anticoagulants’ and ‘dosing’. Data extraction and quality assessment were undertaken by two reviewers independently. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Age, sex, diabetes, hypertension and heart failure were chosen as variables of interest.

Results: From 19 studies, a total of 252 117 patients were included with CKD and AF. Meta-analysis was only possible in seven studies with 128 406 patients, five on DOAC dose titration and two on adherence. There were insufficient studies on persistence. Our meta-analysis of dosing showed that 68% of patients with CKD and AF had correct dosing. There was no evidence to show any association between correct DOAC dosing and variables of interest. Overall, 67% of patients were DOAC adherent.

Conclusion: Adherence and correct dosing of DOACs were suboptimal compared with other medications in the pooled studies with respect to CKD and AF. Thus, further research is required as the lack of generalisation of findings is a rate-limiting factor for improved DOAC management in AF and CKD.

PROSPERO registration number: CRD;42022344491.

Original language	English
Article number	002340
Number of pages	10
Journal	Open Heart
Volume	10
Issue number	2
DOIs	https://doi.org/10.1136/openhrt-2023-002340
Publication status	Published - 6 Jul 2023
Externally published	Yes

Bibliographical note

Publisher Copyright:
© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Keywords

atrial fibrillation
drug monitoring
medication adherence
meta-analysis
systematic reviews as topic

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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Cite this

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title = "Correct dosing, adherence and persistence of DOACs in atrial fibrillation and chronic kidney disease: a systematic review and meta-analysis",

abstract = "Background: Chronic kidney disease (CKD) and atrial fibrillation (AF) are increasing in prevalence globally and share common risk factors.Our aim was to characterise real-world evidence on direct oral anticoagulant (DOAC) prescribing for people with AF and CKD, in terms of adherence, persistence and renal dose titration.Methods: PubMed, EMBASE and CINAHL were searched from inception to June 2022. Our search terms included a combination of Medical Subject Headings (MeSH) terms and keywords including {\textquoteleft}atrial fibrillation{\textquoteright}, {\textquoteleft}chronic kidney disease{\textquoteright}, {\textquoteleft}adherence{\textquoteright}, {\textquoteleft}persistence{\textquoteright}, {\textquoteleft}direct oral anticoagulants{\textquoteright} and {\textquoteleft}dosing{\textquoteright}. Data extraction and quality assessment were undertaken by two reviewers independently. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Age, sex, diabetes, hypertension and heart failure were chosen as variables of interest.Results: From 19 studies, a total of 252 117 patients were included with CKD and AF. Meta-analysis was only possible in seven studies with 128 406 patients, five on DOAC dose titration and two on adherence. There were insufficient studies on persistence. Our meta-analysis of dosing showed that 68% of patients with CKD and AF had correct dosing. There was no evidence to show any association between correct DOAC dosing and variables of interest. Overall, 67% of patients were DOAC adherent.Conclusion: Adherence and correct dosing of DOACs were suboptimal compared with other medications in the pooled studies with respect to CKD and AF. Thus, further research is required as the lack of generalisation of findings is a rate-limiting factor for improved DOAC management in AF and CKD.PROSPERO registration number: CRD;42022344491.",

keywords = "atrial fibrillation, drug monitoring, medication adherence, meta-analysis, systematic reviews as topic",

author = "Subo Emanuel and Kaba, {Riyaz A} and Gayathri Delanerolle and Field, {Benjamin C T} and Lip, {Gregory Y H} and {de Lusignan}, Simon",

note = "Publisher Copyright: {\textcopyright} Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.",

year = "2023",

month = jul,

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T1 - Correct dosing, adherence and persistence of DOACs in atrial fibrillation and chronic kidney disease

T2 - a systematic review and meta-analysis

AU - Emanuel, Subo

AU - Kaba, Riyaz A

AU - Delanerolle, Gayathri

AU - Field, Benjamin C T

AU - Lip, Gregory Y H

AU - de Lusignan, Simon

PY - 2023/7/6

Y1 - 2023/7/6

N2 - Background: Chronic kidney disease (CKD) and atrial fibrillation (AF) are increasing in prevalence globally and share common risk factors.Our aim was to characterise real-world evidence on direct oral anticoagulant (DOAC) prescribing for people with AF and CKD, in terms of adherence, persistence and renal dose titration.Methods: PubMed, EMBASE and CINAHL were searched from inception to June 2022. Our search terms included a combination of Medical Subject Headings (MeSH) terms and keywords including ‘atrial fibrillation’, ‘chronic kidney disease’, ‘adherence’, ‘persistence’, ‘direct oral anticoagulants’ and ‘dosing’. Data extraction and quality assessment were undertaken by two reviewers independently. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Age, sex, diabetes, hypertension and heart failure were chosen as variables of interest.Results: From 19 studies, a total of 252 117 patients were included with CKD and AF. Meta-analysis was only possible in seven studies with 128 406 patients, five on DOAC dose titration and two on adherence. There were insufficient studies on persistence. Our meta-analysis of dosing showed that 68% of patients with CKD and AF had correct dosing. There was no evidence to show any association between correct DOAC dosing and variables of interest. Overall, 67% of patients were DOAC adherent.Conclusion: Adherence and correct dosing of DOACs were suboptimal compared with other medications in the pooled studies with respect to CKD and AF. Thus, further research is required as the lack of generalisation of findings is a rate-limiting factor for improved DOAC management in AF and CKD.PROSPERO registration number: CRD;42022344491.

AB - Background: Chronic kidney disease (CKD) and atrial fibrillation (AF) are increasing in prevalence globally and share common risk factors.Our aim was to characterise real-world evidence on direct oral anticoagulant (DOAC) prescribing for people with AF and CKD, in terms of adherence, persistence and renal dose titration.Methods: PubMed, EMBASE and CINAHL were searched from inception to June 2022. Our search terms included a combination of Medical Subject Headings (MeSH) terms and keywords including ‘atrial fibrillation’, ‘chronic kidney disease’, ‘adherence’, ‘persistence’, ‘direct oral anticoagulants’ and ‘dosing’. Data extraction and quality assessment were undertaken by two reviewers independently. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Age, sex, diabetes, hypertension and heart failure were chosen as variables of interest.Results: From 19 studies, a total of 252 117 patients were included with CKD and AF. Meta-analysis was only possible in seven studies with 128 406 patients, five on DOAC dose titration and two on adherence. There were insufficient studies on persistence. Our meta-analysis of dosing showed that 68% of patients with CKD and AF had correct dosing. There was no evidence to show any association between correct DOAC dosing and variables of interest. Overall, 67% of patients were DOAC adherent.Conclusion: Adherence and correct dosing of DOACs were suboptimal compared with other medications in the pooled studies with respect to CKD and AF. Thus, further research is required as the lack of generalisation of findings is a rate-limiting factor for improved DOAC management in AF and CKD.PROSPERO registration number: CRD;42022344491.

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KW - drug monitoring

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DO - 10.1136/openhrt-2023-002340

M3 - Review article

AN - SCOPUS:85165565893

SN - 2398-595X

VL - 10

JO - Open Heart

JF - Open Heart

IS - 2

M1 - 002340

ER -

Correct dosing, adherence and persistence of DOACs in atrial fibrillation and chronic kidney disease: a systematic review and meta-analysis

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

UN SDGs

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