Reasons for Nonadherence to Apixaban Among Patients With AF

Quick Takes

  • Anticoagulation nonadherence is common and commonly not reported to clinicians.
  • Reasons for nonadherence are heterogenous, but often include lack of education about drug efficacy and fear of bleeding.
  • Clinicians can directly discuss anticoagulant adherence and reassure patients about the availability of reversal agents to improve medication adherence.

Study Questions:

What are the patient-reported reasons for nonadherence to apixaban therapy and potential strategies to improve adherence among patients with atrial fibrillation (AF)?


The authors conducted a cross-sectional survey of patients with AF at two academic health systems. They surveyed patients who reported nonadherence to apixaban therapy. Reasons for nonadherence and level of nonadherence (using a validated 3-item measure) were assessed.


Among 419 patients surveyed, 41.5% were women and the mean age was 71.1 ± 10.9 years. The mean CHA2DS2-VASc score was 3.2 ± 1.6. Approximately two-thirds of patients reported mild nonadherence, while one-third reported poor adherence. Attitudes and beliefs associated with poor adherence include: 1) not believing apixaban was needed (odds ratio [OR], 12.24; 95% confidence interval [CI], 2.25-66.47), 2) medication cost (OR, 3.97; 95% CI, 1.67-9.42), and 3) fear of severe bleeding (OR, 3.28; 95% CI, 1.20-8.96). Strategies that patients with poor adherence selected as helping “a great deal/a lot” to increase adherence include: 1) bloodwork to evaluate efficiency (56%), physician counseling about adherence (55%), and having a reversal agent (39%). Approximately one-half of patients did not report nonadherence to their clinician.


The authors concluded that patients may not disclose apixaban nonadherence to clinicians and reasons for nonadherence are heterogeneous.


Anticoagulation therapy, including use of direct oral anticoagulation (e.g., apixaban), is critical for stroke prevention in patients with AF. However, the benefits of this therapy require that patients are highly adherent to these medications with short half-lives. This cross-sectional study highlights several important findings. First, nonadherence is both common and commonly not disclosed by patients to their clinician. So, clinicians must use nonjudgmental inquiry to uncover this common problem. Second, reasons for nonadherence are heterogeneous, but certain common reasons have potential interventions. Third, clinicians have the ability to impact medication adherence, such as re-educating about the clinical benefits of anticoagulation, providing objective evidence of therapy (e.g., anti-Xa drug levels), and reassuring patients about the broad availability of reversal strategies in the case of severe bleeding.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Cost-Benefit Analysis, Factor Xa Inhibitors, Geriatrics, Hemorrhage, Medication Adherence, Patient Compliance, Secondary Prevention, Stroke, Vascular Diseases

< Back to Listings