Low prescription of NOACs criticised

The low number of non-vitamin k oral anti-coagulants prescribed for people with atrial fibrillation and the stark difference in prescribing rates across the country ‘make a mockery’ of the concept of a national health service, according to the Atrial Fibrillation Association.

In a new report, the Atrial Fibrillation Association (AFA) examines the prescribing rate of non-vitamin k oral anti-coagulants (NOACs) across the country and the role they play in reducing the risk of ischaemic stroke in people with atrial fibrillation (AF).

Over 12,500 cases of stroke each year are thought to be directly related to the heart condition.

According to the report, more than half of the clinical commissioning groups in England (56%) are at or below the national prescribing average for NOAC use compared to warfarin. Within this 56%, 25% of CCGs have NOAC prescribing rate of 10% or less.

Only seven CCGs have reached or exceeded the recommended level of 35% NOAC use set out by the National Institute for Health and Care Excellence (NICE) in June 2014, the report claims – a fact that is branded as ‘unacceptable’ by the charity’s CEO.

“It makes a mockery of the concept of a National Health Service that patients with the same condition living just miles apart receive such dramatically different rates of the newer therapies,” said Trudie Lobban MBE, Founder and CEO, AFA.

The data shows large variations in NOAC use between neighbouring CCGs, as well as different regions of the country. For example, Havering CCG in East London has 43% of atrial fibrillation patients receiving the newer treatments, whereas the neighbouring CCG of Thurrock in Essex, prescribes only 4.2% of patients new AF therapies.

“We need better understanding and information for both healthcare professionals and patients,” said Mrs Loban.

NICE guidance, updated in 2014 for the first time in 8 years, recommends anticoagulants, including NOACs to be offered where appropriate for patients with atrial fibrillation. There are currently four different NOACs recommended as options for the prevention of AF related stroke: apixaban, dabigatran etexilate, rivaroxaban and edoxaban. The use of aspirin for the prevention of AF related stroke is not recommended.

NICE estimated that as a result of the updated guideline, the number of AF patients on anti-coagulants has increased by 82%, with those on NOACs rising to 35%, while the number of people taking aspirin has fallen to just 2.5%, the report says.

Findings from the Sentinel Stroke National Audit Programme show that 59% of patients with diagnosed AF who were admitted to hospital with a stroke were not on an anticoagulant, and only 15% had a ‘justifiable reason’ for this.

Considerable variation was reflected across CCGs, in the percentage of AF patients admitted with a stroke who were on an anticoagulant, the report says.

However, NOACs are not necessarily suitable for everyone and there are prescribing concerns for clinicians. The NICE Implementation Collaborative Consensus, published last year alongside the new guidance for AF described some of the issues surrounding the prescription of NOACs. Currently, there is no specific antidote for NOACs in the event of a major bleed and it is this ‘lack of reversibility’ that proves to be a point of objection for many clinicians – although there are steps that can be taken if a major bleed was to occur.

Other prescribing barriers are the high cost of NOACs in comparison to warfarin and the concern around patient adherence.

Unlike warfarin, NOACs do not need regular blood tests (INR monitoring). There is concern that the lack of monitoring could lead to low patient adherence. NICE Consensus says that good adherence is even more important with NOACs due to the drug’s relatively short half-life. After missing a dose, the anti-coagulant effect fades after 12-24 hours, compared to 48-72 hours with warfarin.

Some patients may be concerned about the lack of reversibility and feel reassured to have regular monitoring – in cases such as these warfarin may be more suitable.

Kay Elliott, one of the clinical development coordinator’s at the British Heart Foundation said “Anti-coagulation treatment usually continues throughout a person’s lifetime in order to address their increased risk of stroke, caused by atrial fibrillation.

“These new classes of anticoagulants [NOACs] have been shown to be at least as effective as warfarin and they carry a lower risk for intracranial haemorrhage. 

“They do not require INR monitoring but individuals taking them do need close monitoring to detect problems, such as concordance, bleeding and renal function issues.”

Around 835,000 people in England have diagnosed atrial fibrillation, but there may be a further 250,000 people living with the condition undiagnosed.

 

NOAC prescribing across the country

The map shows the use of NOACs compared to warfarin across England. 

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