European Journal of Clinical Pharmacology

, Volume 74, Issue 3, pp 323–330 | Cite as

Prescribing of NOACs has outnumbered warfarin: exploring how physicians choose anticoagulant treatments

  • Anne Katrine EekEmail author
  • Erik Øie
  • Anne Gerd Granas
Pharmacoepidemiology and Prescription



The development of non-vitamin K-dependent oral anticoagulants (NOACs) is a new alternative to treatment with warfarin. The purpose of this study was to explore drug prescription decisions of NOACs or warfarin from hospital physicians in cardiovascular departments.


A qualitative study with focus group interviews was conducted in three different hospitals. The interview guide explored the background of prescribing anticoagulants (warfarin, dabigatran, rivaroxaban, and apixaban) and experiences with effect and side-effects they had observed in patients.


The systematic text condensation eluded four main themes: when to prescribe NOACs, concern about side-effects, pharmaceutical properties and patient adherence, and prescribing policy and intra-professional communication. All available anticoagulants were prescribed. However, no specific NOAC was preferred. Factors perceived as contraindications for NOACs varied among the doctors. Most had observed side-effects of NOACs; however, these rarely influenced prescribing decisions due to small differences in safety profiles. Few drug-drug interactions and fixed daily doses made NOACs easy to prescribe; but some doctors had experienced lack of drug effect for some patients. Non-adherence with NOACs was harder to spot. Some different prescribing cultures had evolved between the different hospitals and between general practitioners.


The hospital physicians chose anticoagulants based on patient conditions as renal function, bleeding risks, and drug interactions being the most common taken into account. They could not say which NOAC was best, and wish that future studies could compare the different NOACs, and not just compare with warfarin.


Anticoagulants Warfarin NOAC Hospital physicians Drug prescriptions Drug-related side-effects Adverse reactions 


Contributions of authors

AKE and AGG contributed to the conception or design of the work and to the acquisition and analysis of the data, and all authors to interpretation of data for the work. All drafted the manuscript and critically revised the manuscript. All gave final approval and AKE and AGG agree to be accountable for all aspects of work ensuring integrity and accuracy.

Compliance with ethical standards

This study was approved by the Norwegian Social Science Data Services (NSD). Physicians signed consent forms.

Conflict of interest

The authors declare they have no conflicts of interest.

Supplementary material

228_2017_2374_MOESM1_ESM.pdf (242 kb)
ESM 1 (PDF 241 kb)


  1. 1.
    Yeh CH, Hogg K, Weitz JI (2015) Overview of the new oral anticoagulants: opportunities and challenges. Arterioscler Thromb Vasc Biol 35(5):1056–1065. CrossRefPubMedGoogle Scholar
  2. 2.
    Harrington AR, Armstrong EP, Nolan PE Jr, Malone DC (2013) Cost-effectiveness of apixaban, dabigatran, rivaroxaban, and warfarin for stroke prevention in atrial fibrillation. Stroke 44(6):1676–1681. CrossRefPubMedGoogle Scholar
  3. 3.
    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Alexandru Popescu B, Schotten U, Van Putte B, Vardas P (2017) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Rev Esp Cardiol (Engl Ed) 70(1):50. Google Scholar
  4. 4.
    Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM (2014) Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 383(9921):955–962. CrossRefPubMedGoogle Scholar
  5. 5.
    Camm AJ, Accetta G, Ambrosio G, Atar D, Bassand JP, Berge E, Cools F, Fitzmaurice DA, Goldhaber SZ, Goto S, Haas S, Kayani G, Koretsune Y, Mantovani LG, Misselwitz F, Oh S, Turpie AG, Verheugt FW, Kakkar AK (2017) Evolving antithrombotic treatment patterns for patients with newly diagnosed atrial fibrillation. Heart 103(4):307–314. CrossRefPubMedGoogle Scholar
  6. 6.
    The Norwegian Institute of Public Health. The Norwegian Prescription Database. Available from:
  7. 7.
    Ten Cate H (2013) New oral anticoagulants: discussion on monitoring and adherence should start now! Thromb J 11(1):8. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Stalmeijer RE, McNaughton N, Van Mook WN (2014) Using focus groups in medical education research: AMEE Guide No. 91. Med Teach 36(11):923–939. CrossRefPubMedGoogle Scholar
  9. 9.
    Malterud K (2012) Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health 40(8):795–805. CrossRefPubMedGoogle Scholar
  10. 10.
    Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361(12):1139–1151. CrossRefPubMedGoogle Scholar
  11. 11.
    Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L (2011) Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 365(11):981–992. CrossRefPubMedGoogle Scholar
  12. 12.
    Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM (2011) Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 365(10):883–891. CrossRefPubMedGoogle Scholar
  13. 13.
    Lip GY, Windecker S, Huber K, Kirchhof P, Marin F, Ten Berg JM, Haeusler KG, Boriani G, Capodanno D, Gilard M, Zeymer U, Lane D, Storey RF, Bueno H, Collet JP, Fauchier L, Halvorsen S, Lettino M, Morais J, Mueller C, Potpara TS, Rasmussen LH, Rubboli A, Tamargo J, Valgimigli M, Zamorano JL (2014) Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 35(45):3155–3179. CrossRefPubMedGoogle Scholar
  14. 14.
    Kundu A, Sardar P, Chatterjee S, Aronow WS, Owan T, Ryan JJ (2016) Minimizing the risk of bleeding with NOACs in the elderly. Drugs Aging 33(7):491–500. CrossRefPubMedGoogle Scholar
  15. 15.
    Al-Khalili F, Lindstrom C, Benson L (2016) The safety and persistence of non-vitamin-K-antagonist oral anticoagulants in atrial fibrillation patients treated in a well structured atrial fibrillation clinic. Curr Med Res Opin 32(4):779–785. CrossRefPubMedGoogle Scholar
  16. 16.
    Alexander JH, Lopes RD, Thomas L, Alings M, Atar D, Aylward P, Goto S, Hanna M, Huber K, Husted S, Lewis BS, McMurray JJ, Pais P, Pouleur H, Steg PG, Verheugt FW, Wojdyla DM, Granger CB, Wallentin L (2014) Apixaban vs. warfarin with concomitant aspirin in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J 35(4):224–232. CrossRefPubMedGoogle Scholar
  17. 17.
    Dans AL, Connolly SJ, Wallentin L, Yang S, Nakamya J, Brueckmann M, Ezekowitz M, Oldgren J, Eikelboom JW, Reilly PA, Yusuf S (2013) Concomitant use of antiplatelet therapy with dabigatran or warfarin in the randomized evaluation of long-term anticoagulation therapy (RE-LY) trial. Circulation 127(5):634–640. CrossRefPubMedGoogle Scholar
  18. 18.
    Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, Birmingham M, Ianus J, Burton P, van Eickels M, Korjian S, Daaboul Y, Lip GY, Cohen M, Husted S, Peterson ED, Fox KA (2016) Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 375(25):2423–2434. CrossRefPubMedGoogle Scholar
  19. 19.
    Ellis MH, Neuman T, Bitterman H, Dotan SG, Hammerman A, Battat E, Eikelboom JW, Ginsberg JS, Hirsh J (2016) Bleeding in patients with atrial fibrillation treated with dabigatran, rivaroxaban or warfarin: a retrospective population-based cohort study. Eur J Intern Med 33:55–59. CrossRefPubMedGoogle Scholar
  20. 20.
    Moe L. Doctors must get their act together [Legene må skjerpe seg]. Legemidler - Dagens Medisin. Available from:
  21. 21.
    Steinberg BA, Shrader P, Thomas L, Ansell J, Fonarow GC, Gersh BJ, Kowey PR, Mahaffey KW, Naccarelli G, Reiffel J, Singer DE, Peterson ED, Piccini JP (2016) Off-label dosing of non-vitamin K antagonist oral anticoagulants and adverse outcomes: the ORBIT-AF II Registry. J Am Coll Cardiol 68(24):2597–2604. CrossRefPubMedGoogle Scholar
  22. 22.
    Moore TJ, Cohen MR, Mattison DR (2014) Dabigatran, bleeding, and the regulators. BMJ 349(jul23 17):g4517. CrossRefPubMedGoogle Scholar
  23. 23.
    Douxfils J, Lessire S, Dincq AS, Hjemdahl P, Ronquist-Nii Y, Pohanka A, Gourdin M, Chatelain B, Dogne JM, Mullier F (2015) Estimation of dabigatran plasma concentrations in the perioperative setting. An ex vivo study using dedicated coagulation assays. Thromb Haemost 113(4):862–869. CrossRefPubMedGoogle Scholar
  24. 24.
    Mani H, Rohde G, Stratmann G, Hesse C, Herth N, Schwers S, Perzborn E, Lindhoff-Last E (2012) Accurate determination of rivaroxaban levels requires different calibrator sets but not addition of antithrombin. Thromb Haemost 108(1):191–198. CrossRefPubMedGoogle Scholar
  25. 25.
    Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P (2016) Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 38(27):2137–2149.
  26. 26.
    Altena R, van Roon E, Folkeringa R, de Wit H, Hoogendoorn M (2014) Clinical challenges related to novel oral anticoagulants: drug-drug interactions and monitoring. Haematologica 99(2):e26–e27. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Norwegian Medicines Agency (NoMA). Drug Interaction Database. Available from:
  28. 28.
    Martinez C, Katholing A, Wallenhorst C, Freedman SB (2016) Therapy persistence in newly diagnosed non-valvular atrial fibrillation treated with warfarin or NOAC. A cohort study. Thromb Haemost 115(1):31–39. CrossRefPubMedGoogle Scholar
  29. 29.
    Gorst-Rasmussen A, Skjoth F, Larsen TB, Rasmussen LH, Lip GY, Lane DA (2015) Dabigatran adherence in atrial fibrillation patients during the first year after diagnosis: a nationwide cohort study. J Thromb Haemost 13(4):495–504. CrossRefPubMedGoogle Scholar
  30. 30.
    Rodriguez RA, Carrier M, Wells PS (2013) Non-adherence to new oral anticoagulants: a reason for concern during long-term anticoagulation? J Thromb Haemost 11(2):390–394. CrossRefPubMedGoogle Scholar
  31. 31.
    Ghanima W, Atar D, Sandset PM (2013) New oral anticoagulants--a review. Tidsskr Nor Laegeforen 133(18):1940–1945. CrossRefPubMedGoogle Scholar
  32. 32.
    Martinussen PE (2013) Hospital physicians’ assessments of their interaction with GPs: the role of physician and community characteristics. Health Policy 110(1):14–21. CrossRefPubMedGoogle Scholar
  33. 33.
    Thorsen O, Hartveit M, Baerheim A (2012) General practitioners’ reflections on referring: an asymmetric or non-dialogical process? Scand J Prim Health Care 30(4):241–246. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Berendsen AJ, Benneker WH, Meyboom-de Jong B, Klazinga NS, Schuling J (2007) Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study. BMC Health Serv Res 7(1):4. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Regional Medicines Information & Pharmacovigilance Centre (RELIS)Oslo University Hospital HF RikshospitaletOsloNorway
  2. 2.Diakonhjemmet HospitalOsloNorway
  3. 3.School of PharmacyUniversity of OsloOsloNorway

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