Effect of antithrombotic stewardship on the efficacy and safety of antithrombotic therapy during and after hospitalization

To analyse the appropriateness of direct oral anticoagulant (DOAC) dosing and determinants for under-and overdosing as well as acceptance and implementation rates of pharmacists' interventions. Methods: Cross-sectional study in a tertiary hospital in hospitalized patients with atrial fibrillation on DOACs in 2019 (n = 1688). Primary outcome was the proportion of patients with inappropriate DOAC prescribing with identification of determinants for under-and overdosing. Secondary outcomes included acceptance and implementation rates of pharmacists' recommendations and determination of reasons for nonacceptance/nonimplementation. Results: Inappropriate prescribing was observed in 16.9% of patients (n = 286) with underdosing (9.7%) being more prevalent than overdosing (6.9%). For all DOACs considered together, body weight<60 kg (odds ratio [OR] 0.46 [0.27-0.77]), edoxaban use (OR 0.42 [0.24-0.74]), undergoing surgery (OR 0.57 [0.37-0.87]) and being DOAC naïve (OR 0.45 [0.29-0.71]) were associated with significantly lower odds of underdosing. Bleeding history (OR 1.86 [1.24-2.80]) and narcotic use (OR 1.67[1.13-2.46]) were associated with significantly higher odds for underdosing. Determinants with a significantly higher odds of overdosing were renal impairment ) and body weight<60 kg ), whereas dabigatran use (OR 0.24 [0.08-0.71]) and apixaban (OR 0.18 [0.10-0.32]) were associated with a significantly lower odds of overdosing compared to rivaroxaban. Physicians accepted the pharmacists' advice in 179 cases (79.2%) consisting of 92 (51.4%) recommendations for underdosing, 82 (45.8%) for overdosing and 5 (2.8%) for contraindications. Conclusion:Inappropriate DOAC prescribing remains common, although there is a slight improvement compared to our study of 2016. Clinical services led by pharmacists help physicians to reduce the number of inadequate prescriptions for high-risk medications such as DOACs.

Section: Discussionmentioning

confidence: 99%

Determinants for under‐ and overdosing of direct oral anticoagulants and physicians' implementation of clinical pharmacists' recommendations

Moudallel

Cornu

Dupont

et al. 2021

“…Also with DOACs, DDIs still need to be considered and data on clinical relevance of these DDIs are often lacking. Hospital pharmacists may possibly be more aware of these concerns since they are often involved in clinical pharmacy activities and antithrombotic stewardship programmes 26,27 . Such programmes are currently lacking in primary care in Belgium, which may explain the difference in perception between hospital and community pharmacists.…”

Section: Discussionmentioning

confidence: 99%

Physicians' and pharmacists' views and experiences regarding use of direct oral anticoagulants in clinical practice

Capiau

Mehuys

Dhondt

et al. 2021

Direct oral anticoagulants (DOACs) are increasingly used compared to vitamin K antagonists (VKAs). Guidelines advocate a structured multidisciplinary approach in the management of patients treated with DOACs. The aim of this study was to assess the views and experiences of physicians and pharmacists regarding DOAC use in clinical practice.Methods: An online questionnaire was sent to both primary (general practitioners [GPs], community pharmacists) and secondary healthcare professionals (cardiologists, residents in internal medicine and hospital pharmacists) between March and July 2020. The questionnaire covered four topics: (i) current practice, (ii) prescribing behaviour (only for physicians), (iii) self-perceived knowledge about DOACs and (iv) views and opinions about DOACs versus VKAs. Results: In total, 110 physicians and 111 pharmacists completed the survey.Healthcare professionals in secondary care had more experience with DOACs and felt more confident with higher self-perceived knowledge about DOACs compared to their colleagues in primary care. Healthcare professionals' self-perceived knowledge was more or less complementary, for example physicians felt less confident in managing drug-drug interactions (DDIs) where pharmacists reported being more confident in this topic. Physicians reported uncertainties on the potential impact of risk factorssuch as older age, lower body weight and DDIson appropriate DOAC dosing. Conclusion:Complementarity in physicians' and pharmacists' self-perceived knowledge levels of DOACs may facilitate and necessitate future multidisciplinary collaboration initiatives for the management and follow-up of DOAC patients.

“…[9][10][11][12] The S-team study recently showed that implementation of hospital-based anticoagulant stewardship programmes had a significant impact on bleeding and thrombotic events and resulted in lower all-cause mortality. 12 Also, pharmacistled clinical services including reviewing all orders for NOACs can reduce the number of inappropriate prescriptions of these drugs. [13][14][15][16] Such interventions are, however, time and personnel intensive, limiting their efficacy to change hospital-wide prescribing behaviours.…”

Section: Introductionmentioning

confidence: 99%

Improving appropriate use of anticoagulants in hospitalised patients: A pharmacist‐led Check of Medication Appropriateness intervention

Quintens

Verhamme²,

Vanassche³

et al. 2022

Inappropriate anticoagulant use increases the risk of bleeding and thrombotic events. We implemented clinical decision rules to promote judicious medication use, as part of the 'Check of Medication Appropriateness' (CMA). The CMA is a pharmacistled review service, targeting potentially inappropriate prescriptions (PIPs). In this analysis, we aimed to evaluate the impact of the CMA on anticoagulant prescribing. Methods:The number of anticoagulant-related PIPs was evaluated before and after implementation of the intervention in a quasi-experimental interrupted time series analysis. The pre-implementation cohort received usual care. The anticoagulantfocused CMA, comprising 13 clinical rules pertaining to anticoagulation therapies, was implemented in the post-implementation cohort. Segmented regression analysis was used to assess the impact of the intervention on the number of residual PIPs. A residual PIP was defined as a PIP which persisted up to 48 hours after the CMA intervention. Total number of recommendations and acceptance rate were documented for the 2-year post-implementation period.Results: Pre-implementation, we observed 501 PIPs in 466 inpatients on 36 days, with a median proportion of 78.5% (range: 46.2%-100%) residual PIPs per day. Postimplementation, 538 PIPs were detected in 485 patients over the same number of days. The CMA intervention reduced the median proportion to 18.2% (range: 0-100%) per day. The effect coincided with an immediate relative reduction of 70% (95%CI 0.19-0.46) in anticoagulant-related residual PIPs. Post-implementation, 2778 recommendations were provided and 75.1% were accepted. Conclusion:Our CMA approach significantly reduced anticoagulant-related PIPs.Implementing a pharmacist-led intervention, based on clinical rules, may support safer prescribing of anticoagulants.