How to Improve Very Low Adherence to Anticoagulation Therapy in Elderly Patients with Non-Valvular Atrial Fibrillation [Letter]

Dear editor

Enhancing medication adherence, especially among individuals with non-valvular atrial fibrillation receiving anticoagulation therapy, stands as a pivotal factor in averting adverse events. Cao et al undertook a comprehensive exploration into the causes behind discontinuation of oral anticoagulation treatment among elderly patients with atrial fibrillation, aiming to elucidate the factors influencing such behavior.¹ Their investigation revealed a high rate of non-adherence to oral anticoagulants among this demographic, primarily manifesting shortly after initial discharge. This behavioral pattern predominantly stemmed from demographic aspects and individual patient inclinations. However, it has raised several pertinent concerns.

The ELDERCARE-AF study, a Phase 3 randomized double-blind placebo-controlled trial, sought to compare low-dose edoxaban with placebo among very elderly patients, aged 80 years or older, afflicted with non-valvular atrial fibrillation and at high risk of bleeding.² Notably, while this study reported a 30% discontinuation rate of anticoagulants, the authors’ study documented a higher termination rate of 57%.¹ Could the authors provide clarification regarding the discrepancy between their findings and those of previous studies? Previous literature has predominantly concentrated on bleeding risk during anticoagulation therapy in elderly cohorts,² yet the authors shed light on the pivotal aspect of patient preferences.¹ Might patient education contribute to ameliorating this low adherence?

One of the primary reasons for warfarin termination lay in perceiving anticoagulation therapy as excessively burdensome.¹ Dietary restrictions and frequent blood tests posed considerable inconvenience, particularly for elderly patients. When feasible, transitioning from warfarin to direct oral anticoagulants (DOACs) is recommended. Conversely, the major impetus for DOAC cessation revolved around the exorbitant costs associated with this treatment,¹ an issue anticipated to abate with the forthcoming introduction of generic medications. Thus, can it be posited that the low adherence to anticoagulants will witness improvement in the foreseeable future?