Trends and Prescription Patterns of Medications for Secondary Stroke Prevention in Denmark, 2013—2018

Background: Describing trends in the utilization of evidence-based medications for secondary stroke prevention is important for evaluating clinical practice and identify potential targets for improvement. Data on trends from Denmark are scarce.

Objectives: To examine the use of anticoagulants, antiplatelets, lipid-lowering, antihypertensive, and antidiabetic drugs after a stroke hospitalization between 2013 and 2018.

Methods: Using nationwide registries in Denmark, we identified a cohort of patients discharged from hospital with a primary inpatient diagnosis of ischemic stroke. For each medication class, we ascertained the 90-day probability of filling a prescription after discharge, stratified by calendar year, considering death as a competing event. For the assessment of trends in use of anticoagulant, antiplatelet, and antidiabetic drugs, we restricted to patients with atrial fibrillation, without atrial fibrillation, and with diabetes, respectively. We examined trends by sex, age, stroke severity, and burden of comorbidity in secondary analyses.

Results: We identified 46,575 patients (median age 72, 56% men) discharged alive with an ischemic stroke. The use of anticoagulants increased by 21% over time (90-day probability: 61% in 2013, 74% in 2018), with an increasing use of apixaban and rivaroxaban, but a decreasing use of warfarin. The use of antiplatelets remained consistently high (~88%), with clopidogrel being the most commonly dispensed antiplatelet. Similarly, the use of lipid-lowering drugs (~68%), antihypertensives (~63%), and antidiabetics (~72%) remained largely constant over time. Of note, the use of atorvastatin dramatically increased while use of simvastatin decreased. The use of antidiabetics with proven cardiovascular benefit (SGLT2-inhibitors or GLP-1 receptor agonists) remained low (overall ~10% in 2018). In subgroup analyses, the use and trends were similar for all drug classes in men and women. Use of anticoagulants increased most dramatically in patients over the age of 65. For all drug classes, the use decreased with increasing stroke severity and burden of comorbidity although trends remained consistent. For example, use of antiplatelets was ~93% for mild stroke, ~88% for moderate stroke, and ~74% for severe stroke.

Conclusions: Overall, the use of medications for secondary stroke prevention was high in Denmark during 2013—2018, though targets for improvement were identified, e.g., lower than optimal use of anticoagulants and antidiabetics with cardiovascular benefits. Noticeably, the probability of filling a prescription decreased with increasing stroke severity and burden of comorbidity, likely explained by a higher mortality or treatment barriers in sicker patients.