Understanding reasons for nonadherence to the direct oral anticoagulant (DOAC) apixaban for atrial fibrillation

Context: Direct oral anticoagulants (DOACs) are proven to reduce the risk of strokes in patients with nonvalvular atrial fibrillation (NVAF), yet up to 50% of patients with NVAF are nonadherent to DOACs. Reasons for nonadherence have not been well characterized.

Objective: To describe the reasons for nonadherence to anticoagulation in patients with NVAF who received prescriptions for apixaban.

Study Design: Semi-structured interviews conducted between August 2020 and January 2021.

Setting: Two large academic health centers in Northern and Southern California.

Participants: 42 participants with NVAF who were prescribed chronic anticoagulation, and self-reported nonadherence to apixaban.

Outcome measures: Themes for nonadherence to apixaban described by participants during interviews.

Results: Interviewees had a mean age of 69.6 years (SD=12.4) and 38% were female. Thirty-two (76%) reported intentional nonadherence to apixaban, the others reported forgetting to take medication. Major themes regarding nonadherence included: 1) cost; 2) bleeding (both feared and experienced); 3) lack of atrial fibrillation symptoms; 4) believing it was safe to skip doses; 5) inability to measure or assess the effect of the medication; and 6) poor and conflicting physician and patient communication. Infrequently mentioned issues included preferences for alternative or natural treatments.

Conclusions: Potentially mutable obstacles to adherence to apixaban relate to affordability; strategies to minimize or address bleeding events; and patient misperceptions regarding reasons for and expected benefits of anticoagulation for NVAF, and the need for constant anticoagulation despite intermittent or lack of atrial fibrillation symptoms. Findings suggest the need for proactive physician queries about nonadherence and affordability of anticoagulation, and for education about common misperceptions about DOAC use.