Published date: Sep 30 2024

Journal Title: Sudan Journal of Medical Sciences

Issue title: Sudan JMS: Volume 19 (2024), Issue No. 3

Pages: 317–331

DOI: 10.18502/sjms.v19i3.14496

Toga K. Mohamedtogakhalid@gmail.comDepartment of Clinical Pharmacy, Faculty of Pharmacy, University of Medical Sciences and Technology, Khartoum, Sudan

Bashir A. Yousefbashiralsiddiq@gmail.comDepartment of Pharmacology, Faculty of Pharmacy, University of Khartoum, Sudan

Abdalla O. ElkhawadAbdallaO.Elkhawad@outlook.comDepartment of Pharmacology, Faculty of Pharmacy, University of Medical Sciences and Technology, Khartoum, Sudan

Kannan O. Ahmedomerkannan@gmail.comDepartment of Pharmacy Practice and Training, College of Pharmacy, National University of Science and Technology, Muscat, Oman

Background: During recent years, the prescription rates of direct oral anticoagulants (DOACs) have increased rapidly worldwide. Little is known about situation of DOACs in Sudan. Therefore, this study was conducted to assess prescribing doctors’ knowledge, attitude, and practice level regarding DOACs.
Methods: A cross-sectional, hospital-based study was conducted at three large hospitals in Khartoum, Sudan. The doctors were recruited from a wide range of disciplines such as cardiology, surgery, and nephrology. A four-section questionnaire consisting of questions on demographics, knowledge, attitude, and practice was designed and administered.
Results: A total of 100 doctors responded over a period of four months, 52% of them were found to correlate with a low level of knowledge. Moreover, 56% and 81% of the doctors demonstrated inappropriate attitude and practice levels, respectively. With regard to switching protocols between DOACs and warfarin, the majority of the doctors did not have sufficient information when converting from rivaroxaban to warfarin and vice versa.
Conclusion: The overall knowledge, attitudes, and practices of prescribing doctors regarding the use of the DOACs were found to be inadequate and insufficient for maintaining high therapeutic outcomes in patients necessitating anticoagulants agents. A well-structured educational program about DOACs is urgently needed.

Keywords: doctors, knowledge, attitude, practice, direct oral anticoagulant, Sudan

[1] Wong, S. L., Marshall, L. Z., & Lawson, K. A. (2018). Direct oral anticoagulant prescription trends, switching patterns, and adherence in Texas Medicaid. The American Journal of Managed Care, 24(8 Spec No.), SP309–SP314.

[2] Yu, Y. B., Liu, J., Fu, G. H., Fang, R. Y., Gao, F., & Chu, H. M. (2018). Comparison of dabigatran and warfarin used in patients with non-valvular atrial fibrillation: Meta-analysis of random control trial. Medicine, 97(46), e12841. https://doi.org/10.1097/MD.0000000000012841

[3] Chen, A., Stecker, E., & A Warden, B. (2020). Direct oral anticoagulant use: A practical guide to common clinical challenges. Journal of the American Heart Association, 9(13), e017559. https://doi.org/10.1161/JAHA.120.017559

[4] Robinson, A., McCarty, D., & Douglas, J. (2016). Novel oral anticoagulants for acute coronary syndrome. Therapeutic Advances in Cardiovascular Disease, 11(1), 4–11. https://doi.org/10.1177/1753944716671484

[5] Connolly, S. J., Ezekowitz, M. D., Yusuf, S., Eikelboom, J., Oldgren, J., Parekh, A., Pogue, J., Reilly, P. A., Themeles, E., Varrone, J., Wang, S., Alings, M., Xavier, D., Zhu, J., Diaz, R., Lewis, B. S., Darius, H., Diener, H. C., Joyner, C. D., Wallentin, L., & the RE-LY Steering Committee and Investigators. (2009). Dabigatran versus warfarin in patients with atrial fibrillation. The New England Journal of Medicine, 361(12), 1139–1151. https://doi.org/10.1056/NEJMoa0905561

[6] Patel, M. R., Mahaffey, K. W., Garg, J., Pan, G., Singer, D. E., Hacke, W., Breithardt, G., Halperin, J. L., Hankey, G. J., Piccini, J. P., Becker, R. C., Nessel, C. C., Paolini, J. F., Berkowitz, S. D., Fox, K. A., Califf, R. M., & the ROCKET AF Investigators. (2011). Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. The New England Journal of Medicine, 365(10), 883–891. https://doi.org/10.1056/NEJMoa1009638

[7] Lassen, M. R., Raskob, G. E., Gallus, A., Pineo, G., Chen, D., Hornick, P., & the ADVANCE-2 investigators. (2010). Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE- 2): A randomised double-blind trial. Lancet, 375(9717), 807–815. https://doi.org/10.1016/S0140- 6736(09)62125-5

[8] Larsen, T. B., Skjøth, F., Nielsen, P. B., Kjældgaard, J. N., & Lip, G. Y. (2016). Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: Propensity weighted nationwide cohort study. BMJ (Clinical Research Ed.), 353, i3189. https://doi.org/10.1136/bmj.i3189

[9] Eek, A. K., Øie, E., & Granas, A. G. (2018). Prescribing of NOACs has outnumbered warfarin: Exploringhow physicians choose anticoagulant treatments. European Journal of Clinical Pharmacology, 74, 323–330. https://doi.org/10.1007/s00228-017-2374-4

[10] Chan, K. E., Edelman, E. R., Wenger, J. B., Thadhani, R. I., & Maddux, F. W. (2015). Dabigatran and rivaroxaban use in atrial fibrillation patients on hemodialysis. Circulation, 131(11), 972–979. https://doi.org/10.1161/CIRCULATIONAHA.114.014113

[11] Rose, D. K., & Bar, B. (2018). Direct oral anticoagulant agents: Pharmacologic profile, indications, coagulation monitoring, and reversal agents. Journal of Stroke and Cerebrovascular Diseases, 27(8), 2049– 2058. jstrokecerebrovasdis.2018.04.004 https://doi. org/10.1016/j.jstrokecerebrovasdis.2018.04.004

[12] Paul, C., Baby, M., Anthraper, A. R., & K, K. (2020). NOACs: An emerging class of oral anticoagulantsa review article. Future Journal of Pharmaceutical Sciences, 6, 1–7. https://doi.org/10.1186/s43094-020- 00114-1

[13] Clinical Excellence Commission. (2023). Direct Oral Anticoagulant (DOAC) Guidelines. https://www.cec.health.nsw.gov.au/keeppatients- safe/medication-safety/high-riskmedicines/ anticoagulants

[14] Grześk, G., Rogowicz, D., Wołowiec, Ł., Ratajczak, A., Gilewski, W., Chudzińska, M., Sinkiewicz, A., & Banach, J. (2021, August 8). The clinical significance of drug-food interactions of direct oral anticoagulants. International Journal of Molecular Sciences, 22(16), 8531. https://doi.org/10.3390/ijms22168531

[15] Trujillo, T., & Dobesh, P. P. (2014, September). Clinical use of rivaroxaban: Pharmacokinetic and pharmacodynamic rationale for dosing regimens in different indications. Drugs, 74(14), 1587–1603. https://doi.org/10.1007/s40265-014-0278-5. Erratum in: Drugs, 74(15).

[16] Chen, A., Stecker, E., & A Warden, B. (2020, July 7). Direct oral anticoagulant use: A practical guide to common clinical challenges. Journal of the American Heart Association, 9(13), e017559. https://doi.org/10.1161/JAHA.120.017559

[17] Wigle, P., Hein, B., & Bernheisel, C. R. (2019, October 1). Anticoagulation: Updated guidelines for outpatient management. American Family Physician, 100(7), 426–434.

[18] Charan, J., & Biswas, T. (2013). How to calculate sample size for different study designs in medical research? Indian Journal of Psychological Medicine, 35(2), 121–126. https://doi.org/10.4103/0253- 7176.116232

[19] El-Bardissy, A., Elewa, H., Mohammed, S., Shible, A., Imanullah, R., & Mohammed, A. M. (2018). A survey on the awareness and attitude of physicians on direct oral anticoagulants in Qatar. Clinical and Applied Thrombosis/Hemostasis, 24(9), 255S– 260S. https://doi.org/10.1177/1076029618807575

[20] Ye, S., Wang, T., Liu, A., Yu, Y., Pan, Z., & Gu, J. (2020). A study of knowledge, attitudes, and practices of primary care physicians toward anticoagulant therapy in patients with non-valvular atrial fibrillation in Shanghai, China. BMC Family Practice, 21, 165. https://doi.org/10.1186/s12875-020-01236-4

[21] Alnemari, R., Banheem, A., Mullaniazee, N., Alghamdi, S., Rajkhan, A., Basfar, O., & Basnawi, M. (2018). Knowledge, attitude and practice of physicians towards oral anti-coagulants in Taif city, Saudi Arabia. International Journal of Advances in Medicine, 5(5), 1086–1092. https://doi.org/10.18203/2349-3933.ijam20183884

[22] Piran, S., Schulman, S., Salib, M., Delaney, J., Panju, M., & Pai, M. (2017). Direct oral anticoagulants in the real world: Insights into Canadian health care providers’ understanding of medication dosing and use. Canadian Journal of General Internal Medicine, 12(3), 23–27. https://doi.org/10.22374/cjgim.v12i3.201

[23] Wigle, P., Hein, B., & Bernheisel, C. R. (2019). Anticoagulation: Updated guidelines for outpatient management. American Family Physician, 100(7), 426–434.

[24] Zappulla, P., & Calvi, V. (2021). Gastrointestinal bleeding and direct oral anticoagulants amongpatients with atrial fibrillation: Risk, prevention, management, and quality of life. TH Open: Companion Journal to Thrombosis and Haemostasis, 5(2), e200–e210. https://doi.org/10.1055/s-0041-1730035

[25] Connell, N. T., & Butera, J. N. (2015). Attending physician attitudes toward choice of oral anticoagulant for the treatment of venous thromboembolism. Rhode Island Medical Journal, 98(7), 32–36.

[26] Aursulesei, V., & Costache, I. I. (2019). Anticoagulation in chronic kidney disease: From guidelines to clinical practice. Clinical Cardiology, 42(8), 774–782. https://doi.org/10.1002/clc.23196

[27] Dewilde, W. J., Oirbans, T., Verheugt, F. W., Kelder, J. C., De Smet, B. J., Herrman, J. P., Adriaenssens, T., Vrolix, M., Heestermans, A. A., Vis, M. M., Tijsen, J. G., van ’t Hof, A. W., ten Berg, J. M., & the WOEST study investigators. (2013). Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: An open-label, randomised, controlled trial. Lancet, 381(9872), 1107–1115. https://doi.org/10.1016/S0140- 6736(12)62177-1

[28] Gibson, C. M., Mehran, R., Bode, C., Halperin, J., Verheugt, F. W., Wildgoose, P., Birmingham, M., Ianus, J., Burton, P., van Eickels, M., Korjian, S., Daaboul, Y., Lip, G. Y., Cohen, M., Husted, S., Peterson, E. D., & Fox, K. A. (2016). Prevention of bleeding in patients with atrial fibrillation undergoing PCI. The New England Journal of Medicine, 375(25), 2423–2434. https://doi.org/10.1056/NEJMoa1611594

[29] Raval, A. N., Cigarroa, J. E., Chung, M. K., Diaz- Sandoval, L. J., Diercks, D., Piccini, J. P., Jung, H. S., Washam, J. B., Welch, B. G., Zazulia, A. R., Collins, S. P., & the American Heart Association Clinical Pharmacology Subcommittee of the Acute Cardiac Care and General Cardiology Committee of the Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; and Council on Quality of Care and Outcomes Research. (2017). Management of patients on non–vitamin K antagonist oral anticoagulants in the acute care and periprocedural setting: A scientific statement from the American Heart Association. Circulation, 135(10), e604–e633. https://doi.org/10.1161/CIR.0000000000000477