Factors associated with anticoagulation discontinuation in palliative care patients

1. The decision to discontinue anticoagulation in palliative care patients was not strongly associated with patient factors and comorbidities, except recent knee or hip arthroplasty.

2. Discontinuation was associated with lower rates of bleeding, similar rates of thrombosis, and increased rates of mortality.

Evidence Rating Level: 2 (Good)

Patients in palliative care are often on anticoagulation medication due to a medical history that increases the risk of stroke and venous thromboembolism. However, it is a goal in palliative care to minimize medication burden, only taking those that are compatible with patient goals. As such, the use of anticoagulants in palliative care has not been well-studied. This current retrospective cohort study examined the rates of anticoagulation discontinuation in palliative care, as well as compared factors and outcomes for discontinued and continued anticoagulation patients. The study population consisted of all individuals in Ontario, Canada 66 years and older, who had their first physician home palliative care visit (index date) between 2010 and 2018. Discontinuation was primarily defined as not having a claim within 1.5 times the day’s supply, or within 7 days of the previous supply’s expiry. In total, 8687 patients were on anticoagulation at the index date, 24.4% of whom discontinued therapy by the study’s primary definition. The only patient factors and comorbidities that strongly predicted discontinuation were recent knee or hip arthroplasty (odds ratio 13.71, 95% CI 5.69-33.03). After adjusting for patient and physician factors, the use of a direct oral anticoagulant (DOAC) and low molecular weight heparin (LMWH) were less likely to be discontinued (OR 0.49, 95% CI 0.43-0.56 and OR 0.56, 95% CI 0.47-0.66 respectively). Furthermore, at a median follow-up of 111 (IQR 32-400) days, discontinuation was associated with decreased bleeding rates (adjusted hazards ratio 0.75, 95% CI 0.62-0.90), comparable rates of thrombosis (adjusted HR 1.06, 95% CI 0.81-1.39), and increased mortality (adjusted HR 1.35, 95% CI 1.28-1.42). Overall, this study demonstrated that the decision to continue anticoagulation in palliative care is not necessarily associated with patient factors and that there are risks and benefits when it comes to the outcomes of continuing or discontinuing anticoagulation.

Click to read the study in CMAJ

Image: PD

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