(144) A scoping Review of Factors Associated with the Prescribing of Direct Oral Anticoagulant Drugs (DOACs)

Background: In the last decade, with the substantial increase in direct oral anticoagulant (DOAC) usage, prescribers encounter complex decisions regarding the appropriate agent to be prescribed.

Objectives: This scoping review aims to identify factors that impact anticoagulant choice in real world practice over time.

Methods: Four databases (Medline, Embase, Scopus, Web of Science) were searched using the synonyms of each concept (patients prescribed DOACs for any indication, factors affecting the choice of oral anticoagulant (OAC), quantitative observational studies in any health care setting) in both free text and Medical Subject Heading (MeSH terms). Studies among adults, published between January 2010 and March 2023, were included. Quality assessment was performed using the Johanna Briggs Institute’s critical appraisal tools. At all steps, a second researcher validated 10% of included studies.

Results: Of 4659 identified studies, 60 met the selection criteria. 96% (n=58) examined factors influencing the choice between DOACs and vitamin K antagonists (VKA); 15% (n=9) evaluated factors affecting the choice amongst DOACs. Of the 60 studies, 77% (n=46) and 70% (n=42) studies included age and gender, respectively, while 58% (n=35) studies examined renal impairment, followed by heart failure 48% (n=29), previous stroke 43% (n=26), and thromboembolic risk 43% (n=26). Most of the studies were of good quality and rated as low (62%) or moderate (36%) risk of bias. Older age had a significant negative association with DOAC prescribing in 50% (22/44) and a positive association in 18% (8/44) of studies, while 32% (14/44) found no association compared to VKA. Compared to other DOACs, there was a significant positive association between apixaban use and increasing age in 85% (6/7 studies). In 51% (20/39) of studies, gender was not a significant predictor of DOAC initiation compared to VKA. Renal impairment ( < 60 ml/min GFR) reduces DOAC initiation, favouring warfarin in 94% (31/33 studies). Other comorbidities such as heart failure in 60% (17/28), ischaemic heart disease or myocardial infarction in 57% (11/19), or liver disease in 46% (6/13) of studies were negatively associated with using DOACs. Specialist prescriptions were associated with DOAC initiation significantly in 92% (12/13 studies).

Conclusions: Several significant key factors were identified as being associated with OAC choice, including demographic factors such as age, and clinical factors such as kidney function, prior stroke, and other comorbidities. In addition, studies documented considerable impact of physician specialty on the prescribing choice. Significant predictors for the choice among DOACs were advanced age, renal impairment, and those with a high risk of bleeding and higher thromboembolic risk.