Implementation of non-vitamin K antagonist oral anticoagulants in daily practice: the need for comprehensive education for professionals and patients

Abstract

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for the prevention and treatment of venous thromboembolism and for stroke prevention in patients with atrial fibrillation. NOACs do not require routine coagulation monitoring, creating a challenge to established systems for patient follow-up based on regular blood tests. Healthcare professionals (HCPs) are required to cope with a mixture of patients receiving either a vitamin K antagonist or a NOAC for the same indications, and both professionals and patients require education about the newer drugs. A European working group convened to consider the challenges facing HCPs and healthcare systems in different countries and the educational gaps that hinder optimal patient management. Group members emphasised the need for regular follow-up and noted national, regional and local variations in set-up and resources for follow-up. Practical incorporation of NOACs into healthcare systems must adapt to these differences, and practical follow-up that works in some systems may not be able to be implemented in others. The initial prescriber of a NOAC should preferably be a true anticoagulation specialist, who can provide initial patient education and coordinate the follow-up. The long-term follow-up care of patients can be managed through specialist coagulation nurses, in a dedicated anticoagulation clinic or by general practitioners trained in NOAC use. The initial prescriber should be involved in educating those who perform the follow-up. Specialist nurses require access to tools, potentially including specific software, to guide systematic patient assessment and workflow. Problem cases should be referred for specialist advice, whereas in cases for which minimal specialist attention is required, the general practitioner could take responsibility for patient follow-up. Hospital departments and anticoagulation clinics should proactively engage with all downstream HCPs (including pharmacists) to ensure their participation in patient management and reinforcement of patient education at every opportunity. Ideally, (transmural) protocols for emergency situations should be developed. Last but not least, patients should be well-informed about their condition, the treatment, possible risk scenarios, including the consequences of non-adherence to prescribed therapy, and the organisation of follow-up care.

Is there a correlation between late re-exploration after cardiac surgery and removal of epicardial pacemaker wires?

“…In order to minimize the risk of serious bleeding, we initiate the oral anticoagulation regimen – VKA or NOAC – after the EPW have been taken out. Although none of the eight patients were on NOACs, we believe that it is prudent to commence these regimens after pulling out the EPW, as no standard screening for NOACs is routinely used [14]. On the other hand, patients who have a strong indication for DAPT, for example by coronary intervention with drug eluting stent implantation in the short-time perioperative period, still have their EPW removed under this medication.…”

Drug therapy in anticoagulation: which drug for which patient?

“…It is unlikely that plasma drug levels will be available within the approved time frame for thrombolysis so for FXa inhibitors, judgement relies on timing of most recent dose together with patient characteristics; in the absence of available evidence, it has been suggested that thrombolytic therapy not be given within 24-48 hours following last NOAC dose. 82 …”

Clinical use and laboratory testing of oral anticoagulation therapy: experience from Finland

“…In renal impairment, apixaban is currently preferred, with the lower dose of 2.5 mg BID recommended in case of creatinine >133 mmol/L, elderly patients (>80 yrs) and small weight (<60 kg) (59). Finally, renal patients are subjected to the most severe complications of drug interactions, which tend to be increasingly identified (8).…”

“…DOACs are gaining new indications, rivaroxaban for prevention of atherothrombosis in coronary artery disease, and several DOACs are being considered in cancer patients as well (5)(6)(7). While the use of DOACs is increasing, clinicians will encounter many patients switching from traditional vitamin K antagonists (VKAs) to DOACs, and broad education is required (8). To respond to the challenge of increased repertoire of anticoagulants in patients with risk factors for both thrombosis and bleeding, e.g., elderly patients undergoing vascular surgery, a special anticoagulation clinic was launched in conjunction with the Coagulation Disorders Unit in 2015.…”