Incorporating Comprehensive Management of Direct Oral Anticoagulants into Anticoagulation Clinics

Abstract

Anticoagulation clinics emerged as a means to optimize warfarin effectiveness and minimize bleeding risks. Anticoagulation clinics have traditionally been warfarin-based models due to the need for frequent blood-level monitoring, drug interactions, dietary considerations, and periprocedural management with warfarin. These models have demonstrated improved anticoagulation control and reduced bleeding complications for patients taking warfarin. Direct oral anticoagulants (DOACs) emerged with the perception of improved convenience due to the lack of blood-level monitoring and lack of dietary considerations. Despite the advantages of DOAC therapy, new challenges exist with their management, warranting ongoing monitoring. Such challenges include prescribing and dosing issues, drug adherence, drug interactions, and high drug cost. Comprehensive anticoagulation centers are needed to manage and monitor all oral anticoagulants including DOACs. The objectives of this review are to describe the challenges and opportunities that exist in the management of DOACs and to describe a practice model that integrates a DOAC management service into the traditional anticoagulation clinic.

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

“…This hypothesis has also been generated and published by other clinicians who have integrated DOAC management into their anticoagulation clinics. 8 To meet this expected patient need, a clinical service through the pharmacist-led antithrombosis clinic (ATC) was initiated to provide oversight for all prescribed DOACs at the institution, regardless of referral to the ATC, in an effort to expand antithrombotic stewardship efforts across the institution.…”

Adverse Drug Reactions, Power, Harm Reduction, Regulation and the ADRe Profiles

“…Additional regulatory requirements may encourage switching to (more expensive) medicines where patient monitoring is not mandated. For example, the prescription of factor Xa inhibitors increased between 2010 and 2014 [ 104 ], due, in part, to the reduced need to attend anticoagulation clinics [ 105 ]. Substitution of diclofenac for coxibs increased the use of diclofenac, until the recognition of the dose–response association of this medicine with cardiovascular events [ 106 ], and subsequent withdrawal from pharmacy sale [ 107 ].…”

Targeted Therapeutic Drug Monitoring for Direct Oral Anticoagulants: What Is Its Potential Place and Can It Limit Black Swan Events?

“…We need to build on the experience and success in many centres of specialized multidisciplinary anticoagulation clinics that improved monitoring of the use of vitamin K antagonists. 9 However, we also need to refamiliarize physicians with some of the principles of pharmacokinetics. It is ironic that among those physicians treating atrial fibrillation, many of these principles are prominent in the judicious use of antiarrhythmic pharmacotherapy 10 and yet remain underappreciated and underused: redistribution and elimination phases and their half-lives (lidocaine, amiodarone), volume of distribution (amiodarone), active metabolites (procainamide, amiodarone), drug interactions (most of them), and protein binding.…”