Switching of oral anticoagulants and associated clinical outcomes in
patients with non-valvular atrial fibrillation: A narrative review
Abstract
Approval of direct-acting oral anticoagulants (DOACs) for stroke
prevention in atrial fibrillation (AF) was an important milestone,
providing widened treatment choices along with the possibility for
inter-drug switching after initiation. In addition to improved
utilisation of oral anticoagulants (OACs) for stroke prevention, reports
of switching among OACs are growing in the literature. Switching may
influence clinical outcomes, healthcare costs and patient satisfaction.
This review aimed to summarise the current literature on the pattern of
OAC switching in patients with AF, including reasons for switching and
clinical consequences following switching. We included articles
published after 2013, following the introduction of apixaban; searched
on June 27, 2020 from PubMed, Scopus and Embase. The review found that
switching among OACs was common in clinical practice, significantly
varying with the type of OAC. Studies reporting the reason for switching
and clinical outcomes were comparatively limited. The reasons were often
related to safety issues, poor anticoagulation control and ease of use.
Factors that can increase the risk of bleeding and stroke were found to
be associated with switching from vitamin K antagonists, but less for
DOAC switching. Findings regarding bleeding outcomes following switching
were inconsistent, possibly confounded with the type of OAC, reasons for
switching and switching protocol. Despite the limited number of studies
included and their relatively short follow-up periods, our review
revealed that switching had minimal impact on stroke and other related
thrombotic outcomes. Further prospective studies are needed to better
understand possible reasons for switching and its influence on clinical
outcomes.