1. Introduction

Thrombosis (VTE) is a prevalent pathological condition that underlies ischemic heart disease, ischemic stroke, and venous thromboembolism. Ischemic heart disease and stroke collectively contribute to almost 25% of global mortality. The utilization of anticoagulant medication has experienced a surge in popularity in recent decades, mostly attributed to its well-documented effectiveness and extensive application across various diseases [1].

Warfarin, an oral anticoagulant, is the most widely utilized vitamin K antagonist globally. Although cost-effective, the use of this treatment is restricted in numerous individuals due to the unpredictable nature of anticoagulation levels, hence heightening the potential for thromboembolic or hemorrhagic consequences. Additionally, it requires frequent blood tests and modifications to the dosage. Nonvitamin K antagonist oral anticoagulants (NOACs), also referred to as Direct OACs (DOACs), are a novel category of medications that are currently being evaluated as potential substitutes for warfarin [2].

Novel OACs (NOACs) exhibit a more focused mechanism of action that specifically targets a single clotting factor. By inhibiting factor Xa and direct thrombin (factor IIa), these medications generate a more reliable and stable anticoagulant effect. This effect is less prone to being influenced by interactions with other drugs or food, and does not require frequent monitoring [1].

The safety and effectiveness of warfarin therapy rely on maintaining the International Normalized Ratio (INR) within the specified target range for the specific indication. Upon initiation of oral anticoagulant therapy, it is necessary to do daily INR monitoring until the INR falls into the therapeutic range for a minimum of two consecutive days. Perturbations in the INR levels of a patient who is otherwise medically stable may arise due to alterations in dietary habits, nonadherence to prescribed treatments, unreported substance abuse, alcohol ingestion, or self-administration of medications. When encountering unexpected values, it is important to additionally consider the possibility of laboratory error. Hemorrhaging is a significant hazard associated with warfarin treatment, and it is strongly linked to INR values [2].

There are multiple reasons that support the use of a switching strategy when there are no randomized comparison studies available to compare switching to NOACs with continuing VKA medication. There is irrefutable evidence that NOACs result in significantly fewer cases of hemorrhagic strokes and cerebral bleeding compared to warfarin. NOACS significantly decreases the likelihood of cerebral bleeding by 52% in comparison to warfarin, with a range of 33%–70%. This advantage is valid for many NOACs and is not influenced by warfarin’s duration spent inside the therapeutic range. Furthermore, NOACs exhibit a lower incidence of drug-drug and drug-food interactions in comparison to warfarin. With the exception of patients with mild renal impairment, who should have regular serum creatinine monitoring, NOACs do not require frequent blood tests. The elevated expense of NOACs remains a hindrance to their extensive use, especially in low-income environments [3].

Drug-related issues are well recognised as a major contributor to mortality and a decline in quality of life on a global scale. It has been estimated that between 5% and 10% of hospital admissions can be attributed to drug-related problems, with over half of these cases being preventable. Sudan has a significant population of patients who are prescribed anticoagulant medications, particularly warfarin as the primary choice, along with NOAC. Consequently, enhancing the available treatment alternatives is a key priority [4].

The drawbacks of warfarin, such as the rising mortality rate, declining quality of life from side effects, increased hospitalisations, and the issue of drug interactions with specific foods, highlight the need to thoroughly investigate the potential benefits of NOAC. Understanding the obstacles that hinder the widespread use of NOAC is crucial in order to find solutions and enhance anticoagulation treatment in Sudan.

2. Research Methods

3. Results

The main reason why clinicians abide the utilization of NOACs over VKA was their lack of knowledge about the recent guidelines.

A total of 144 participants were included in this study, the most common department comprised the population was medicine department comprising (45.8%) as in Table 1. The most prevalent medical degree of the total number of doctors involved in this study was registrars (25%) and medical doctors (25%), specialists (22.9%), consultants (11.8%) and then house officers (15.3%), as shown in Table 2. Table 3 shows the experience level within the participants and the most frequent experience level reported was less than 5 years (51.4%).

Out of all 144 participants, 50.7% were not aware about 2021 new guidelines recommendations regarding DOACs usage. While 49.3% did have knowledge as demonstrated in Table 4.

There was a significant association between the type of the drug prescribed for prevention of thromboembolic events and department as DOACs was mostly prescribed by ER department (40%) heparin by orthopedics department (48.6%) and warfarin was evenly distributed (25%) (p < 0.001) as shown in Table 5.

There was a significant association between the first line prescribed for the prevention of thromboembolic events nonvalvular atrial fibrillation. DOACs were prescribed mostly by medicine department (77.1%) and warfarin was also prescribed mostly by medicine department (58.5%) (p < 0.001) Table 6.

There was a significant association between the type of drug and department for using it as a first line medication for the prevention of thromboembolic events in patients with atrial fibrillation due to moderate to severe mitral stenosis caused by rheumatic heart disease. DOACs were prescribed mostly by medicine department (63.2%) followed by warfarin (71.9%) also by medicine department (p < 0.001) as shown in Table 7.

Table 8 shows association between different variables for instant Medical degree correlated positively with the years of experience (r = 0.650) (p < 0.001). The level of the rank of medical degree (r = −0.219) (p < 0.01) (r = −0.211) (p < 0.05), respectively. The prescription of DOACs positively correlated with the rank of medical degree (r = 0.371) (p < 0.001). The years of experience inversely correlated with the level of perception about barriers related to doctors (r = −0.194) (p < 0.05). Perception towards barriers related to doctors, and thoughts related to DOACs inversely correlated with Medical degree rank (r = −0.219) (r = −0.211) (p < 0.001).

Perception about barriers related to doctors inversely correlated with direct oral anticoagulant prescription (r = −0.266) (p < 0.05).

Perception about barriers related to doctors positively correlated with perception about barriers related to thoughts about the drug (r = 0.341) (p < 0.001), barriers about the resources (r = 0.366) (p < 0.001), and barriers related to insufficient reporting (r = 0.195) (p < 0.05). Perception about barriers related to patient doctor relationship positively correlated with barriers perception related to thoughts about DOACs (r = 0.393) (p < 0.001).

Perception about barriers related to patient doctor relationship correlated positively with perception of barriers related to thoughts about DOACs (r = 0.393) (p < 0.001) and to perception of insufficient reporting as a barrier (r = 0.176) (p < 0.05).

Perception of barriers related to thoughts about DOACs inversely correlated with DOAC prescription (r = −0.229) (p < 0.001). It positively correlated with perception of insufficient reporting as a barrier (r = 0.166) (p < 0.05) and resources as a barrier (r = 0.284) (p < 0.001). As illustrated in Table 8.

4. Discussion

The objective of our study was to gather comprehensive and interdisciplinary perspectives from physicians regarding the perceived obstacles to the widespread adoption of DOACs. We intentionally selected individuals from various disciplines and medical degrees, representing diverse sorts of health care delivery zones within Khartoum state. This study had a total of 144 participants, with the majority of the participating doctors being from the medicine department. The most common medical degrees among the doctors participating in this survey were registrars (25%) and medical doctors (25%). Specialists accounted for 22.9% of the total, while consultants made up 11.8%. House officers represented 15.3% of the doctors engaged.

Concerning the obstacles pertaining to doctors, the findings indicate that 85% of them acknowledged the high effectiveness of NOACs. However, only 49.3% of the doctors were aware of the recommendations outlined in the 2021 guidelines. This lack of awareness is not uncommon among doctors, as evidenced by a study conducted by Murphy et al. [5] which focused on their knowledge. 34.8% of respondents concurred with the assertion that patients with renal impairment should abstain from taking NOACs, even though the Murphy study is limited to Irish population and does not constitute a comparable group. Similarly, 34.8% of the medical professionals surveyed held the belief that patients with renal impairments should refrain from using NOACs. Only 17% of the respondents opined that all patients with valvular rheumatic heart disease should avoid NOACs. The responses indicate a significant lack of understanding on the 2021 guidelines among the clinicians participating in the survey. In regards to the preference of doctors for warfarin over NOAC, 34.7% expressed a greater level of comfort with warfarin. Conversely, 68.9% reported being hindered from prescribing NOAC due to their supervisor’s preference. This indicates the prevalence of traditional practices over more modern ones, which is unfortunately a common phenomenon among Sudanese medical professionals. They tend to adhere to familiar and proven methods rather than adopting recent updates in practice. This can be attributed to the widely held belief of “if something is effective, there is no need to alter it.”

When it comes to the obstacles of using NOAC in various medical departments, physicians or individuals in the medical field had the lowest average score (12.89) compared to the surgical department, specifically orthopedics (14.83). This suggests that there is a wider variation in the use of NOAC among physicians compared to orthopedic surgeons. This difference can be partially attributed to the fact that physicians rely more on guidelines and updates in their practice, rather than solely relying.

Conversely, the patient-doctor relationship barriers had a lower average score in the surgical department [6] compared to the medicine department (10.21). This may indicates that physicians in the medicine department engage in more detailed discussions about their patients’ treatment and management plans than surgeons. This difference can be attributed to the reduced interaction between patients and surgeons, as well as the specific practices of physicians.

The consultants had the lowest mean score (27.29) while the house officers had the highest mean score (32.73) when it came to barriers of thinking on the drug in relation to medical degree. This disparity in scores highlights the knowledge gap between these two groups.

The study found a strong correlation between the type of drug prescribed for preventing thromboembolic events and the departments in which they were prescribed. The emergency department mostly prescribed NOACs (40%), while the orthopedic department mostly prescribed Heparin (48.6%). Warfarin was distributed evenly among departments, with a statistically significant difference (p < 0.001). However, it is important to note that NOACs are known to be more effective than LMWH in preventing VTE, as stated by Shakespeare et al. This finding suggests a lack of appropriate knowledge among orthopedic surgeons [6].

We discovered a noteworthy correlation between the initial medications prescribed for preventing thromboembolic events in nonvalvular atrial fibrillation. Our findings indicate that NOACs were predominantly prescribed by the medicine department (77.1%), while warfarin was also predominantly prescribed by the medicine department (58.5%) with a statistically significant difference (p < 0.001). This outcome is not unexpected, as physicians are primarily responsible for managing cases of thromboembolic events and atrial fibrillation.

NOACs were predominantly prescribed by the medicine department (63.2%) as the primary line of medication for preventing thromboembolic events in patients with atrial fibrillation resulting from moderate or severe mitral stenosis caused by rheumatic heart disease. Warfarin (71.9%) was also prescribed by the medicine department for the same purpose. The medicine department’s preference for prescribing warfarin over NOACs is mostly influenced by comorbidities that may occasionally prevent the commencement of therapy that adheres to guidelines, as indicated by the research conducted by Farinha et al. [7] These findings regarding the prescription of DOAC over VKA in mitral stenosis associated atrial fibrillation is in line the recent trial conducted by Ghamrawy et al. where they found that among patients with mitral stenosis related atrial fibrillation VKA therapy led to a lower rates of cardiovascular events or death than DOAC (Rivaroxaban) therapy [8].

Cost is a significant consideration, with 73.2% of doctors identifying the price of DOACs as a significant obstacle to their use. This figure is comprehensible given the prevalent low socioeconomic level of most Sudanese individuals. Another prevalent practice is for doctors to make assumptions about their patients′ poverty and give them the most affordable and readily accessible drugs, such as Warfarin.

5. Conclusion

The study examined the obstacles that hinder the widespread use of NOACs for the prevention of thromboembolic events among clinicians in Sudan. The primary obstacle to prescribing NOACs is the absence of a dedicated antidote and the absence of a multidisciplinary approach to their prescription. Another significant barrier is the limited understanding of international guidelines, with many participants preferring to seek specialist advice. Personal experience with the efficacy of NOACs also contributes to a noteworthy proportion of the barriers. Additionally, the high cost of NOACs is a considerable factor. Physicians appear to possess the highest level of expertise among all specialties in the survey.

6. Recommendations

Disclosure

A preprint has previously been punished on Reasarch Square (Elaf Sabri Khalil, Asmaa Elfatih Husain, Waddaha Mohammed Nouh et al. 2024) [9].

Conflicts of Interest

The authors declare no conflicts of interest.

Funding

This project was not funded, it was conducted as part of fulfillment of Bachelor of Medicine (MBBS) from Al-Neelain University.