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Anticoagulants in non-valvular atrial fibrillation [printed text] / Hans Van Brabandt , Author ; Lorena San Miguel , Author ; Nicolas Fairon , Author ; Bert Vaes, Author ; Séverine Henrard, Author ; Anelia Boshnakova, Author ; Rob Cook, Author ; Rob Davies, Author ; Aditi Karnad, Author ; Alan Lovell, Author ; Cécile Dubois , Author . - Brussels [Belgium] : KCE = Federaal Kenniscentrum voor de Gezondheidszorg = Centre Fédéral d'Expertise des Soins de Santé = Belgian Health Care Knowledge Centre, 2016 . - 195 p. : ill., ; A4. - (KCE Reports. Health Technology Assessment (HTA); 279) .
ISSN : D/2016/10.273/101 : € 0,00
Study 2015-05
Languages : English (eng)

Descriptors:	Indexation 2015-05 ; Anticoagulants ; Atrial Fibrillation ; Belgium ; Cost-Benefit Analysis ; Physician's Practice Patterns ; Practice Guidelines as Topic ; R279 ; Secondary Prevention Classification QV 193 Anticoagulants
Contents note:	LIST OF FIGURES 6 -- LIST OF TABLES 8 -- LIST OF ABBREVIATIONS 10 -- SCIENTIFIC REPORT 12 -- 1 AIMS 12 -- 2 INTRODUCTION 13 -- 3 BACKGROUND 13 -- 3 1 ANTITHROMBOTICS13 -- 3 3 STROKE RISK ASSESSMENT IN ATRIAL FIBRILLATION 14 -- 3 4 STROKE PREVENTION IN ATRIAL FIBRILLATION 19 -- 3 4 1 Vitamin K antagonists 19 -- 3 4 2 Antiplatelets 19 -- 3 4 3 Combination therapy of anticoagulants and antiplatelets 20 -- 3 4 4 Novel Oral AntiCoagulants (NOACs) 20 -- 3 5 BLEEDING RISK INDUCED BY VITAMIN K ANTAGONISTS 21 -- 4 EFFICACY AND SAFETY OF NOACS 23 -- 4 1 SEARCH STRATEGY 23 -- 4 2 SYSTEMATIC REVIEWS 25 -- 4 3 PRIMARY STUDIES 26 -- 4 3 1 Ximelagatran 26 -- 4 3 2 Dabigatran 26 -- 4 3 3 Rivaroxaban 27 -- 4 3 4 Apixaban 28 -- 4 3 5 Edoxaban 28 -- 4 3 6 Summary table 28 -- 4 4 SAFETY OF NOACS 30 -- 4 5 RISK OF BIAS IN PIVOTAL RCTS 31 -- 4 6 INTERNATIONAL PRACTICE GUIDELINES 32 -- 5 REIMBURSEMENT OF ANTICOAGULANTS IN BELGIUM 35 -- 6 ADHERENCE TO ANTICOAGULATION GUIDELINES IN PRACTICE 37 -- 6 1 PHYSICIANS’ ADHERENCE TO GUIDELINES 37 -- 6 1 1 Literature search 37 -- 6 1 2 Systematic reviews 38 -- 6 1 3 AF patient registries 38 -- 6 2 PHYSICIANS’ ADHERENCE TO APPROPRIATE DOSE PRESCRIPTION 42 -- 6 2 1 VKA dosing 42 -- 6 2 2 NOAC dosing 42 -- 6 3 PATIENTS’ ADHERENCE TO ANTICOAGULANT PRESCRIPTION 43 -- 7 CLINICAL USE OF ANTICOAGULANTS IN NON-VALVULAR AF: DISCUSSION 45 -- 7 1 STROKE RISK ASSOCIATED WITH AF, VERSUS BLEEDING RISK ASSOCIATED WITH ANTICOAGULANTS 45 -- 7 1 1 Undertreatment in high risk populations with a CHA2DS2-VASc risk score of ≥2 (♂) or ≥3 (♀) 47 -- 7 1 2 Overtreatment in low risk populations with a CHA2DS2-VASc risk score of 0 (or 1 in ♀ with no additional risk factors)47 -- 7 1 3 Anticoagulation in patients with a CHA2DS2-VASc risk score of 1 (♂) or 2 (♀) 47 -- 7 1 4 Patients’ adherence to anticoagulants 47 -- 7 2 NEW ORAL ANTICOAGULANTS VS VITAMIN K ANTAGONISTS 48 -- 7 2 1 Effect of NOACs versus VKAs on stroke 48 -- 7 2 2 Effect of NOACs versus VKAs on bleeding 48 -- 7 2 3 Drug monitoring and compliance to treatment 49 -- 8 COST-EFFECTIVENESS OF NOACS 50 -- 8 1 INTRODUCTION 50 -- 8 2 METHODS 50 -- 8 2 1 Literature review 50 -- 8 2 2 Selection process 50 -- 8 3 RESULTS 53 -- 8 3 1 Overview of economic evaluations 53 -- 8 3 2 Type of economic evaluation 57 -- 8 3 3 Time frame and discounting 58 -- 8 3 4 Perspective 58 -- 8 3 5 Population 58 -- 8 3 6 Intervention and comparator 59 -- 8 3 7 Cost and outcome inputs 59 -- 8 3 8 Industry sponsorship 59 -- 8 3 9 Costs 60 -- 8 3 10 Incremental Cost-effectiveness Ratios (ICERs) 78 -- 8 3 11 Sensitivity Analyses 84 -- 8 3 12 Subgroup Analyses 84 -- 8 3 13 Studies in Belgium 85 -- 8 3 14 NICE Health Technology Assessments 91 -- 8 4 DISCUSSION AND CONCLUSIONS 91 -- 8 4 1 Use of adapted models 91 -- 8 4 2 Assumptions and sources of data 92 -- 8 4 3 Conflict of interests 92 -- 8 4 4 Relevance to Belgian healthcare system 92 -- 8 4 5 Conclusions 92 -- 9 FLEMISH GENERAL PRACTITIONERS’ DATA 94 -- 9 1 INTRODUCTION 94 -- 9 2 METHODOLOGY 95 -- 9 2 1 Description of the Intego database 95 -- 9 2 2 Clinical research questions 95 -- 9 2 3 Patient selection 95 -- 9 2 4 Definition of clinical variables and medications 97 -- 9 2 5 Statistical analysis 100 -- 9 3 RESULTS 101 -- 9 3 1 Prescription of oral anticoagulants in general practice in the general population and validation of proxies for the CHA2DS2-VASc and CHADS2 scores (part 1) 101 -- 9 3 2 Trends in prescriptions of OACs in general practice in people with atrial fibrillation (part 2) 107 -- 9 4 CONCLUSIONS 125 -- 9 4 1 Prescription of oral anticoagulants in general practice in the general population and validation of proxies for the CHA2DS2-VASc and CHADS2 scores (part 1) 125 -- 9 4 2 Trends in prescriptions of oral anticoagulants in general practice in people with atrial fibrillation (part 2) 125 -- 10 ANALYSIS OF BELGIAN DATA 126 -- 10 1 INTRODUCTION 126 -- 10 2 METHODS 126 -- 10 2 1 General Methodology 126 -- 10 3 DATA LIMITATIONS 128 -- 10 4 RESULTS 128 -- 10 4 1 Evolution over time 128 -- 10 4 2 Profile of the anticoagulant users 132 -- 10 5 DISCUSSION 145 -- 11 FINAL CONCLUSION147 -- 11 1 TO ANTICOAGULATE OR NOT? 147 -- 11 1 1 Risk of stroke risk associated with non-valvular AF 147 -- 11 1 2 Net clinical benefit of anticoagulants 147 -- 11 1 3 Overdiagnosis and oveartreatment 148 -- 11 1 4 Undertreatment 148 -- 11 2 VKA OR NOAC? 149 -- 11 2 1 Advantages of NOACs versus VKAs 149 -- 11 2 2 Disadvantages of NOACs versus VKAs 149 -- 11 2 3 VKA or NOAC: KCE’s conclusion 150 -- 11 3 TRENDS IN ANTICOAGULANT PRESCRIPTION 151 -- APPENDICES 152 -- APPENDIX 1 RCTS COMPARING NOACS WITH VKA IN NON-VALVULAR AF 152 -- APPENDIX 2 LITERATURE SEARCH FOR EFFICACY OF NOAC 153 -- APPENDIX 3 SUMMARY OF FINDINGS TABLES 157 -- APPENDIX 4 META-ANALYSES OF ISCHEMIC STROKE RISK BY CHA2DS2-VASC SCORE 164 -- APPENDIX 5 SYSTEMATIC REVIEWS ON INAPPROPRIATE USE OF ORAL ANTICOAGULANTS 166 -- APPENDIX 6 SEARCH STRATEGIES FOR C-E CHAPTER 172 -- APPENDIX 7 APPENDICES TO FLEMISH GPS’ DATA 174 -- APPENDIX 8 APPENDICES TO BELGIAN IMA DATA 184 -- REFERENCES 186
Link for e-copy:	https://kce.fgov.be/pdf/279C
Format of e-copy:	PDF (4,8 MB)
Record link:	https://kce.docressources.info/index.php?lvl=notice_display&id=3966