Inappropriate Prescription of Direct Oral Anticoagulant Starter Packs

Am J Med. 2021 Mar;134(3):370-373.e1. doi: 10.1016/j.amjmed.2020.06.045. Epub 2020 Aug 18.


Background: The 30-day direct oral anticoagulant starter pack has simplified the treatment of acute venous thromboembolisms, but it is not appropriate for use in patients with other indications for anticoagulation.

Methods: A retrospective analysis of national outpatient pharmacy claims data between January 1, 2015 and December 31, 2018, was performed. Adult patients (ages >18 years) with continuous insurance enrollment at least 12 months prior to and 1 month following a direct oral anticoagulant starter pack prescription during the study period were included. The primary study outcome was the rate of inappropriate prescription of direct oral anticoagulant starter packs, defined as a prescription without a venous thromboembolism diagnosis within the prior 45 days or a prescription with a prior starter pack fill within the past 45 days.

Results: A total of 3711 direct oral anticoagulant starter pack prescription fills were identified, representing 3634 unique patients. The mean patient age was 62.8 years (standard deviation [SD] 15.1) and 1871 (50.4%) were females. There were 770 (20.7%) direct oral anticoagulant starter pack fills identified as potentially inappropriate. Patients prescribed inappropriate fills were likely to be older than patients with appropriate fills (64.7 years vs 62.4 years, P < 0.001). There was no significant difference in the race or geographic location between patients with inappropriate and appropriate prescriptions.

Conclusions: A significant proportion of patients using direct oral anticoagulant starter packs did not have a diagnosis of acute venous thromboembolism, raising concerns about inappropriate prescribing and potential bleeding complications. Future studies are needed to identify factors associated with inappropriate direct oral anticoagulant starter pack prescription and evaluate efforts to reduce this practice.

Keywords: Anticoagulation; Atrial fibrillation; Prescription; Starter pack; Thrombosis.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acute Disease
  • Aged
  • Factor Xa Inhibitors / therapeutic use*
  • Female
  • Humans
  • Inappropriate Prescribing / statistics & numerical data*
  • Male
  • Middle Aged
  • Retrospective Studies
  • Time Factors
  • Venous Thromboembolism / drug therapy*


  • Factor Xa Inhibitors