Thesis

Oral anticoagulant prescribing in Scotland, 2010–2020 : a population-based multi-study analysis

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Awarding institution
  • University of Strathclyde
Date of award
  • 2026
Thesis identifier
  • T18012
Person Identifier (Local)
  • 202276209
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Abstract
  • Introduction: Direct oral anticoagulants (DOACs) have largely replaced vitamin Kantagonists (VKAs) such as warfarin for the prevention and treatment ofthromboembolic disorders. Despite guideline recommendations for DOACs as firstline therapy, uncertainty remains regarding optimal agent selection in routinepractice, particularly among patients with complex comorbidities, renal impairment,or varying risk profiles. Real-world prescribing may also be influenced by non-clinicalfactors and external pressures such as the COVID-19 pandemic.Methods: This thesis comprised complementary studies using linked, populationbased healthcare data from Scotland. A scoping review (2010–2023) identifiedfactors influencing anticoagulant prescribing choice. Retrospective cohort analysesexamined trends in oral anticoagulant (OAC) prescribing between 2010 and 2020,stratified by age, sex, and geographic region. The impact of the COVID-19pandemic on OAC initiation, prevalence, and switching from VKAs to DOACs wasassessed using time-series and segmented regression analyses (2018–2021).Factors associated with switching were evaluated using Cox regression models, andclinical outcomes following switching were analysed using time-to-event and survivalmethods. Additional analyses explored the role of renal function in anticoagulantselection among incident OAC users.Results: The scoping review identified anticoagulant choice as multifactorial,influenced by demographic factors such as age and sex, and clinical factorsincluding renal impairment, prior stroke, heart failure, and thromboembolic risk. OACinitiation increased 72% between 2011 and 2019, followed by a modest decline in2020. DOACs progressively replaced VKAs, accounting for over 90% of new OACinitiations by 2020. Early variation in prescribing by age group and geographicregion diminished over time. Apixaban and edoxaban became most commonlyprescribed. COVID-19 pandemic was associated with a temporary reduction inincident OAC prescribing and a marked increase in switching from warfarin toDOACs. Switching was associated with lower rates of intracranial haemorrhage, buthigher rates of ischaemic stroke, myocardial infarction, and mortality compared withcontinued warfarin use. DOAC prescribing increased across all levels of renalfunction, with apixaban most commonly used among patients with impaired kidneyfunction.Conclusion: OAC prescribing in Scotland underwent substantial transformationbetween 2010 and 2020, driven by evolving evidence, guidelines, and externalpressures. COVID-19 accelerated this transition, revealing how external factors canrapidly reshape prescribing practices.
Advisor / supervisor
  • Mueller, Tanja
  • Kurdi, Amanj
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DOI

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