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AF Medication Selection and Disparities

CE / CME

Atrial Fibrillation Case Considerations: Medication Selection in the Face of Health Disparities

Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit

Nurses: 0.50 Nursing contact hour

Physicians: maximum of 0.50 AMA PRA Category 1 Credit™

Released: January 05, 2024

Expiration: January 04, 2025

David S. Kountz
David S. Kountz, MD, MBA, MACP
CME/CE Information

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Discussion and Key Research
The decision to initiate a DOAC can be a challenging one for patients with AF. Although AF greatly increases an individual’s risk for stroke, many patients are hesitant to initiate DOACs because of the increased risk of major, clinically relevant nonmajor, and even minor bleeding. Although a disabling stroke could be disastrous for patients and their families, so could a disabling bleed. It is important that shared decision-making plays a role in the management of AF to ensure that individuals know the risks and benefits of using vs forgoing anticoagulation therapy. In the case of Mr. Ohtani, it is important to discuss his low risk of stroke, but to emphasize that we cannot anticipate the severity of a stroke should one occur. A stroke from AF could be minor, or it could be life altering. Balancing this risk with patient-specific and occupational bleeding risk factors is an important part of helping Mr. Ohtani come to a decision regarding anticoagulation therapy. 

Research suggests that cultural competence interventions targeting patient–healthcare professional (HCP) interactions—such as interpreter services, written translations, and the presence of community health workers—are one way to facilitate shared decision-making and address healthcare disparities.1,2 Results from one study demonstrated that communication with HCPs presents a problem for 20% of Americans receiving healthcare, and when looking specifically at people in certain racial and ethnic minority groups, the percentage rises to 27% among Asian Americans and 33% among individuals of Hispanic heritage.2 These barriers can have a negative impact on use, satisfaction, and adherence. In this case, we saw that it is important to meet the patient where he is rather than making assumptions, as we did in our first question, where we addressed Mr. Ohtani’s concerns regarding anticoagulation and his grandmother’s bleeding history. It is imperative to address each of these concerns to ensure that he is informed of the risks vs benefits of anticoagulation to facilitate shared decision-making.

Understanding the differences between DOACs and warfarin is key to treatment success. DOACs offer multiple advantages vs warfarin and are preferred by the guidelines for most patients with AF.3 Multiple clinical trials have demonstrated that the newer therapies are as effective as (rivaroxaban, edoxaban) or superior to (dabigatran, apixaban) warfarin for preventing stroke in AF, accompanied by specific safety advantages that include less intracranial and/or gastrointestinal bleeding risk.4-10 The decision of whether to use DOACs or warfarin must be made with the goal of optimizing outcomes, while also considering patients’ individual bleeding risk, stroke risk, comorbidities, and preferences.3,11 Determining which anticoagulant to select can be a challenge. These agents differ in their dosing, pharmacokinetic and pharmacodynamic profiles, bleeding risks, and reversal agents. Medication selection requires careful consideration of many patient factors, including renal function, bleeding risk, hypertension, drug interactions, and consistent access to food. For example, standard apixaban dosing for the treatment of AF is 5 mg twice daily. Apixaban dosing should be decreased to 2.5 mg twice daily if 2 of the 3 following criteria are met: age 80 years or older, weight ≤60 kg, and SCr ≥1.5 mg/dL, even if CrCl is within normal range. When evaluating patient-specific factors for Mr. Ohtani, there were several key concerns. Mr. Ohtani has inconsistent access to various foods—and sometimes inconsistent access to food in general. This makes warfarin and rivaroxaban poor choices for him. Edoxaban was also a poor choice, as his CrCl is above the recommended upper limit of use. Therefore, from a patient-specific factor perspective, it was best to select apixaban for Mr. Ohtani. 

To provide quality, patient-centered care and effectively address disparities, HCPs must be up to date with current evidence-based information and strategies that improve patient outcomes through interprofessional collaboration. Another common barrier to anticoagulation therapy is cost for patients, whether it is the affordability of a DOAC or the repeated lab draws and return visits for warfarin therapy. The use of the full team, including pharmacy and social work counterparts, facilitated success in Mr. Ohtani’s case when it came to obtaining anticoagulation for free. Although enrollment in patient assistance programs can be convoluted and time consuming, these programs can offer low-income patients access to therapies that otherwise would not be affordable. By using these programs, HCPs can help minimize health disparities and ensure that individuals have access to the medications they need regardless of their income. Although warfarin may have been a more affordable option for him initially, the long-term logistics may not have worked in his favor financially, given the need for frequent follow-up appointments and labs to monitor his INR, as required while taking warfarin. It is important that HCPs do all that is in their power to ensure that patients are placed on preferred agents, regardless of financial status.