Prescribing Trends of Oral Anticoagulants in US Patients With Cirrhosis and Nonvalvular Atrial Fibrillation.
Prescribing Trends of Oral Anticoagulants in US Patients With Cirrhosis and Nonvalvular Atrial Fibrillation.
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DOI：
10.1161/jaha.122.026863
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发表时间：
2023-02-07
影响因子：
5.4
通讯作者：
Lin, Kueiyu Joshua
中科院分区：
文献类型：
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作者：
Simon, Tracey G.;Schneeweiss, Sebastian;Singer, Daniel E.;Sreedhara, Sushama Kattinakere;Lin, Kueiyu Joshua
许多肝硬化患者并发非瓣膜性房颤（NVAF）。缺乏关于美国肝硬化和NVAF患者近期口服抗凝剂（OAC）使用趋势的数据。使用MarketScan索赔数据（2012-2019年），我们确定了符合OAC条件的肝硬化和NVAF患者（CHA 2DS 2-VASc评分≥2 [男性]或≥3 [女性]）。我们计算了每年直接开口服抗凝剂（DOAC）、华法林或不开口服抗凝剂的患者比例。我们根据高风险特征（失代偿性肝硬化、血小板减少症、凝血功能障碍、慢性肾脏疾病或终末期肾脏疾病）进行分层。在32487例患者中（平均年龄=71.6岁，38.5%为女性，15.1%为失代偿性肝硬化，平均CHA 2DS 2-VASc=4.2），44.6%在NVAF诊断后180天内使用OAC，包括DOAC（20.2%）或华法林（24.4%）。与OAC非使用者相比，OAC使用者不太可能患有失代偿性肝硬化（18.6% vs 10.7%）、血小板减少症（19.5% vs 12.5%）或慢性肾病/终末期肾病（15.5% vs 14.0%）。在2012年至2019年期间，华法林的使用减少了21.0%（32.0%至11.0%），而DOAC的使用增加了30.6%（7.4%至38.0%），在2012年至2019年期间的所有DOAC中，阿哌沙班是最常用的处方药（46.1%）。在所有亚组中，华法林的使用减少，DOAC的使用增加，包括代偿性和失代偿性肝硬化、血小板减少症、凝血病、慢性肾脏疾病/终末期肾脏疾病以及各CHA 2DS 2 ‐VASc类别。在OAC用户中（2012-2019年），DOAC使用率增加了58.9%（18.7%至77.6%）。在DOAC使用者中，阿哌沙班的比例增加最大（61.2%; P<0.001）。在美国肝硬化和NVAF患者中，DOAC的使用大幅增加，超过了华法林，包括失代偿性肝硬化。然而，超过55%的患者仍未得到治疗，这突出表明需要更明确的治疗指导。
Many patients with cirrhosis have concurrent nonvalvular atrial fibrillation (NVAF). Data are lacking regarding recent oral anticoagulant (OAC) usage trends among US patients with cirrhosis and NVAF. Using MarketScan claims data (2012–2019), we identified patients with cirrhosis and NVAF eligible for OACs (CHA2DS2‐VASc score ≥2 [men] or ≥3 [women]). We calculated the yearly proportion of patients prescribed a direct OAC (DOAC), warfarin, or no OAC. We stratified by high‐risk features (decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease, or end‐stage renal disease). Among 32 487 patients (mean age=71.6 years, 38.5% women, 15.1% with decompensated cirrhosis, mean CHA2DS2‐VASc=4.2), 44.6% used OACs within 180 days of NVAF diagnosis, including DOACs (20.2%) or warfarin (24.4%). Compared with OAC nonusers, OAC users were less likely to have decompensated cirrhosis (18.6% versus 10.7%), thrombocytopenia (19.5% versus 12.5%), or chronic kidney disease/end‐stage renal disease (15.5% versus 14.0%). Between 2012 and 2019, warfarin use decreased by 21.0% (32.0% to 11.0%), whereas DOAC use increased by 30.6% (7.4% to 38.0%), and among all DOACs between 2012 and 2019, apixaban was the most commonly prescribed (46.1%). Warfarin use decreased and DOAC use increased in all subgroups, including in compensated and decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease/end‐stage renal disease, and across CHA2DS2‐VASc categories. Among OAC users (2012–2019), DOAC use increased by 58.9% (18.7% to 77.6%). Among DOAC users, the greatest proportional increase was with apixaban (61.2%; P<0.001). Among US patients with cirrhosis and NVAF, DOAC use has increased substantially and surpassed warfarin, including in decompensated cirrhosis. Nevertheless, >55% of patients remain untreated, underscoring the need for clearer treatment guidance.