Prescribing trends of Direct Oral Anticoagulant Drugs (DOACs) across Scotland from 2011 to 2020: a population-based, retrospective study

Introduction: This study aimed to report real-world oral anticoagulation prescription patterns in Scotland and to highlight changes in prescribing practice over time.
Methods: Retrospective cohort study using linked administrative data from Scotland to identify adults prescribed a first DOAC (dabigatran, rivaroxaban, apixaban, edoxaban) or warfarin in primary care for any indication from Jan 2011 to Dec 2020. Incidence rates were calculated and stratified by age, gender, geography, and socio-demographic factors.
Results: During the study period, 196,924 patients initiated oral anticoagulation (OAC). The incidence of OAC initiation increased significantly by 72.3%, from 250.6 per 100,000 population in 2011 to 431.8 in 2019, before slightly declining by 7.9 % to 397.6 in 2020. Prescribing patterns shifted markedly, with DOAC use rising and VKA initiation declining. In 2011, 98.9% (n=13,133) of patients started on VKA and 1.1% (n=148) on DOAC. By 2015, more patients initiated DOACs (n=11,889; 57%) than VKA (n=8,987; 43.1%), with rivaroxaban being the most prescribed DOAC. By 2020, DOAC use increased to 94.3% (n=20,282) of incident users, with apixaban (n=9,630; 44.8%) and edoxaban (n=6,472; 30%) as the most commonly prescribed. Warfarin initiation declined to 5.7% (n=1,232). Between 2012 and 2017, OAC initiation patterns varied substantially by age group and geographical area, including differences in the choice between DOACs and warfarin and the DOACs prescribed. From 2018 to 2020, these variations diminished significantly.
Conclusion: OAC prescribing patterns have shifted significantly over the study period with DOACs replacing VKAs as the preferred choice across all age groups, geographic areas, and socioeconomic levels