The effective, safe and appropriate use of anticoagulation medicines: A systematic overview of reviews

Ginny Brunton, Michelle Richardson, Gillian Stokes, Laurence Blanchard, Helen Burchett, Meena Khatwa, Claire Louise Khouja, Ruth Alice Elizabeth Walker, Kath Wright, Amanda Jayne Sowden, James Thomas

Research output: Book/ReportCommissioned report


Current NICE guidelines recommend the use of both warfarin and novel oral anticoagulants (NOACs) for the prevention and treatment of stroke related to atrial fibrillation (AF), and for venous thromboembolism (VTE). This review was commissioned to assess uncertainties about the evidence on the efficacy, safety and patient/clinician experience in adults with AF or VTE.
We undertook a rapid overview of systematic reviews, searching four databases for systematic reviews published from 2014 and using a comprehensive review on oral anticoagulants (OACs) efficacy and safety by Sterne et al. (2017). Data extraction frameworks were developed for each dimension examined. The quality of reviews was assessed using criteria for quantitative, mixed-methods or qualitative evidence syntheses, as appropriate. Results were synthesised narratively and thematically.
Twenty-three reviews were included in this overview. In relation to efficacy and safety, the findings of Sterne’s review indicate that NOACs show advantages over warfarin for the prevention of AF-related stroke for most efficacy and safety outcomes, especially apixaban (5mg bd). There is no strong evidence to support the use of NOACs for VTE for primary prevention, acute treatment and secondary prevention. Ten genotyping reviews were assessed, however, none provided evidence specific to AF and VTE populations. There was limited, low-quality evidence, from six reviews of self-management, indicating that education, or education plus patient decision aids, were beneficial for AF populations.
Results were mixed among mixed-diagnoses groups. Pharmacist-managed anticoagulation may be beneficial, compared with usual care, among mixed-diagnoses groups. No review evaluated pharmacist-managed anticoagulation services exclusively among populations with AF and no interventions exclusively targeted a VTE population. Evidence from nine reviews of stakeholder experiences suggests that patients and most clinicians value drug efficacy first, followed by safety. There were no clear patterns regarding which factors are most important for patients’ decisions around OACs or OAC adherence.
This overview of reviews informs policy decisions in the choice of OACs for the prevention and treatment of AF-related stroke and VTE. It also identifies dimensions for clinicians to consider when prescribing and monitoring OACs in terms of their and patients’ needs and preferences.
PROSPERO Registration: CRD42017084263
Original languageEnglish
Place of PublicationLondon
PublisherEPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London.
Commissioning bodyNIHR Policy Research Programme
Number of pages189
ISBN (Print)978-1-911605-07-2
Publication statusPublished - May 2018

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