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. 2024 Aug;124(8):778-790.
doi: 10.1055/a-2168-9378. Epub 2023 Sep 6.

Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC

Tessa Elling  1 , Eelko Hak  2 , Jens H Bos  2 , Vladimir Y I G Tichelaar  1   3 , Nic J G M Veeger  4 , Karina Meijer  1
Affiliations

Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC

Tessa Elling et al. Thromb Haemost. 2024 Aug.

Abstract

Introduction: Current guideline suggests a switch from vitamin K antagonist (VKA) to direct oral anticoagulant (DOAC) in patients with low time in therapeutic range (TTR < 70%). Poor international normalized ratio (INR) control may be the result of poor compliance, and might therefore be associated with subsequent DOAC intake. Therefore, this study evaluates the effect of previous TTR and other measures of INR control on DOAC nonadherence and nonpersistence, in patients who switched from VKA to DOAC.

Methods: A total of 437 patients who switched from VKA to DOAC between 2012 and 2019 were included using data from Certe Thrombosis Service, IADB.nl pharmacy community database University Groningen, and Statistics Netherlands. DOAC prescriptions were used to determine nonadherence and nonpersistence. INR control (i.e., TTR, time under therapeutic range [TUR], and INR variability) was assessed during the last 180 days of VKA use. Multivariable regression models were applied to determine the association between INR control and DOAC nonpersistence/nonadherence.

Results: On VKA, 67.7% of the patients had a TTR below 70%. DOAC nonpersistence was 39.8% (95% confidence interval [CI]: 33.4-45.5%) during a median follow-up of 34.4 months (interquartile range: 19.1-49.2). Approximately 80% of persistent patients were DOAC-adherent. Low TTR was not associated with DOAC nonpersistence (hazard ratio: 1.14, 95% CI: 0.69-1.87) and DOAC nonadherence (odds ratio: 1.38, 95% CI: 0.67-2.84), nor were TUR and INR variability.

Conclusion: Previous INR control during VKA therapy is not associated with subsequent DOAC nonadherence and nonpersistence. This study suggests that INR control on VKA cannot, and therefore should not, be used for predicting DOAC adherence or persistence.

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Conflict of interest statement

K.M. reports speaker fees from Alexion, Bayer, and CSL Behring, participation in trial steering committees for Bayer and Astra Zeneca, consulting fees from Uniqure, participation in data monitoring and endpoint adjudication committee for Octapharma. T.E., E.H., J.H.J.B., V.Y.I.G.V.T., and N.J.G.M.V. have nothing to disclose.

Figures

Fig. 1
Fig. 1
Flowchart. DOAC, direct oral anticoagulant; INR, international normalized ratio; VKA, vitamin K anticoagulant. 1 Patients with less than three INR values during the study period or patients with a time interval between INR values larger than 56 days.
Fig. 2
Fig. 2
DOAC nonpersistence. DOAC nonpersistence evaluated in all patients ( A ) and stratified by TTR ( B ), INR variability ( C ), and TUR ( D ). DOAC, direct oral anticoagulant; INR, international normalized ratio; TTR, time in therapeutic range; TUR, time under therapeutic range.
Fig. 3
Fig. 3
DOAC adherence. DOAC adherence evaluated during different time intervals after index date. Adherence was dichotomized into nonadherent (PDC < 90%) and adherent (PDC ≥ 90%). DOAC, direct oral anticoagulant; PDC, proportion of days covered.
See this image and copyright information in PMC

Comment in

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