Implementation of a Direct Oral Anticoagulation Screening Service at a Large Academic Medical Center Provided by a Pharmacist-managed Antithrombosis Clinic as a Method to Expand Antithrombotic Stewardship Efforts

Uppuluri, Ellen M; McComb, Meghan N.; Shapiro, Nancy L.

doi:10.1177/0897190018799200

Cited by 21 publications

(34 citation statements)

References 16 publications

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“…The patient received routine phone follow-up by a new primary care provider 5 days after discharge and by the medical center’s direct oral anticoagulant (DOAC) screening service 6 days after discharge. 8 During these follow-up phone calls, he reported adherence to the prescribed apixaban regimen and continued to complain of chest pain but reported an improvement in pain severity. The patient also reported occasionally coughing up a small amount of blood-tinged sputum and denied any other signs or symptoms of bleeding.…”

Section: Case Reportmentioning

confidence: 99%

Development of pulmonary embolism in a nonhospitalized patient with COVID-19 who did not receive venous thromboembolism prophylaxis

Uppuluri

Shapiro

2020

American Journal of Health-System Pharmacy

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Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Coronavirus disease 2019 (COVID-19) has been associated with thrombotic complications such as stroke and venous thromboembolism (VTE), and VTE prophylaxis for hospitalized patients with COVID-19 is recommended. However, extended postdischarge VTE prophylaxis and VTE prophylaxis for nonhospitalized patients with COVID-19 are not routinely recommended due to uncertain benefit in these populations. Summary Here we report development of a pulmonary embolism (PE) in a young patient without other VTE risk factors who was treated for COVID-19 in an emergency department (ED) and discharged home without VTE prophylaxis, which was consistent with current recommendations. The patient presented to the ED 12 days later with complaints of chest pain for 1 day and was found to have a PE within the segmental and subsegmental branches of the left lower lobe. Conclusion This case suggests that nonhospitalized patients with COVID-19 may be at higher risk for VTE than patients with other medical illnesses and warrants further research into the risk of VTE in outpatients with COVID-19.

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Section: Case Reportmentioning

confidence: 99%

Development of pulmonary embolism in a nonhospitalized patient with COVID-19 who did not receive venous thromboembolism prophylaxis

Uppuluri

Shapiro

2020

American Journal of Health-System Pharmacy

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“…3 As DOAC management became more common, several organizations have published outcomes of pharmacist involvement in various DOAC management models. 4,5 To date, there are few publications describing anticoagulation management during the pandemic. Kow and colleagues provided an algorithm to use during COVID-19 which suggests re-evaluation of anticoagulation need, followed by consideration for change to DOAC, change to parenteral agent, or self-monitoring of INRs to limit health care exposure.…”

Section: Introductionmentioning

confidence: 99%

Implementation of warfarin to direct oral anticoagulant conversion initiative in pharmacist‐run anticoagulation clinics during COVID‐19 pandemic

Kish

Lekic

2021

J Am Coll Clin Pharm

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Due to community transmission of coronavirus disease 2019 (COVID‐19), social distancing and stay‐at‐home orders were implemented statewide in an effort to limit the spread of disease. This posed unique challenges for patients on medications requiring close and continued monitoring by clinic staff, such as anticoagulation clinics. Thus, innovative measures were implemented at Cleveland Clinic Health System (CCHS) to maintain the health and care of ambulatory patients. An initiative to evaluate patients for warfarin to direct oral anticoagulants (DOAC) conversion was used in the pharmacist‐run anticoagulation clinics. This article describes how patients were screened for eligibility, the education to pharmacists, the utilization of student learners in the process, and the workflow for provider notification of conversion. Follow up monitoring, challenges encountered, and future directions are also described.

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“…Implementation of pharmacist-managed anticoagulation clinics has been shown to identify and resolve dosing errors and offer additional benefits such as medication access, patient counseling, adverse effect monitoring and peri-procedural planning. [26][27][28]…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Direct Oral Anticoagulant Prescribing in Patients With Moderate to Severe Renal Impairment

Ting

Rhoten

Dempsey

et al. 2021

Clin Appl Thromb Hemost

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Patients with renal impairment require dose adjustments for direct oral anticoagulants (DOACs), though there is uncertainty regarding their use in severe chronic kidney disease. Inappropriately dosed DOACs may increase risk of ischemic events when under-dosed, or risk of bleeding when over-dosed. The purpose of this study was to describe DOAC selection, dosing strategies, and associated clinical outcomes in patients with moderate to severe renal impairment at our institution. This was a single-center retrospective analysis of adult outpatients with moderate to severe renal impairment (estimated creatinine clearance <50 mL/min, including need for hemodialysis) who were prescribed a DOAC by a cardiologist between June 1, 2015 and December 1, 2018. Outcomes evaluated included the percentage of patients who received appropriate and inappropriate DOAC dosing, prescriber reasons for inappropriate DOAC dosing if documented, and incidence of thrombotic and bleeding events. A total of 207 patients were included. Overall, 61 (29.5%) patients received inappropriate dosing, with 43 (70.5%) being under-dosed and 18 (29.5%) being over-dosed as compared to FDA-labeled dosing recommendations for atrial fibrillation or venous thromboembolism (VTE). By a median follow-up duration of 20 months, stroke occurred in 6 (3.3%) patients receiving DOACs for atrial fibrillation, and VTE occurred in 1 (4.3%) patient receiving a DOAC for VTE. International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding occurred in 25 (12.1%) patients. Direct oral anticoagulants were frequently prescribed at off-label doses in patients with moderate to severe renal impairment, with a tendency toward under-dosing.

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Implementation of a Direct Oral Anticoagulation Screening Service at a Large Academic Medical Center Provided by a Pharmacist-managed Antithrombosis Clinic as a Method to Expand Antithrombotic Stewardship Efforts

Abstract: Implementation of a DOAC screening service identified and resolved dosing errors, improved medication access, provided patient education, and improved follow-up.

Cited by 21 publications

References 16 publications

Development of pulmonary embolism in a nonhospitalized patient with COVID-19 who did not receive venous thromboembolism prophylaxis

Development of pulmonary embolism in a nonhospitalized patient with COVID-19 who did not receive venous thromboembolism prophylaxis

Implementation of warfarin to direct oral anticoagulant conversion initiative in pharmacist‐run anticoagulation clinics during COVID‐19 pandemic

Evaluation of Direct Oral Anticoagulant Prescribing in Patients With Moderate to Severe Renal Impairment

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