Transitions of care in anticoagulated patients

Abstract

Anticoagulation is an effective therapeutic means of reducing thrombotic risk in patients with various conditions, including atrial fibrillation, mechanical heart valves, and major surgery. By its nature, anticoagulation increases the risk of bleeding; this risk is particularly high during transitions of care. Established anticoagulants are not ideal, due to requirements for parenteral administration, narrow therapeutic indices, and/or a need for frequent therapeutic monitoring. The development of effective oral anticoagulants that are administered as a fixed dose, have low potential for drug-drug and drug-food interactions, do not require regular anticoagulation monitoring, and are suitable for both inpatient and outpatient use is to be welcomed. Three new oral anticoagulants, the direct thrombin inhibitor, dabigatran etexilate, and the factor Xa inhibitors, rivaroxaban and apixaban, have been approved in the US for reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation; rivaroxaban is also approved for prophylaxis and treatment of deep vein thrombosis, which may lead to pulmonary embolism in patients undergoing knee or hip replacement surgery. This review examines current options for anticoagulant therapy, with a focus on maintaining efficacy and safety during transitions of care. The characteristics of dabigatran etexilate, rivaroxaban, and apixaban are discussed in the context of traditional anticoagulant therapy.

Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment

“…The patient erroneously took both the 15 mg tablets and the 20 mg tablets for several days before the error was discovered. This underscores the importance of clinician familiarity with dosing strategies combined with strong infrastructures, educational processes and thorough handoffs that support accurate and timely implementation of these changes to avoid adverse events [ 109 , 110 ].…”

The WHF Roadmap for Reducing CV Morbidity and Mortality Through Prevention and Control of RHD

“…In the context of a developing country, it may be reasonable to include tertiary medical and surgical services within the remit of RHD control programmes where capacity and resources permit [45]. Valve repair has been shown to be preferable to replacement as patient survival is better and anticoagulation is not needed; however, repeat operations are often required [48,49].…”

A methodology pathway to develop a Computer Drug Safety program in Primary health care setting based on clinical audit

“…Major bleeding, in particular that of intracranial and upper gastrointestinal tract localisations, is the most important complication that largely compromises the efficacy of warfarin therapy. [19,20] Many clinical conditions and disease diagnoses have been identified to increase this risk, leading to another group of international guidelines, that based on the risk for bleeding quantification. [20] Current research focus, in patients with FA, is oriented towards information integration on the risk for stroke and the risk for bleeding, in order to provide the net clinical benefit of oral anticoagulant therapy.…”

“…[19,20] Many clinical conditions and disease diagnoses have been identified to increase this risk, leading to another group of international guidelines, that based on the risk for bleeding quantification. [20] Current research focus, in patients with FA, is oriented towards information integration on the risk for stroke and the risk for bleeding, in order to provide the net clinical benefit of oral anticoagulant therapy. [21] Efforts are also put on clinical trials results translation into clinical practice, by addressing the clinical context complexity of patients in real life setting taking this therapy.…”

“…[22] That the need for designing such programs is not the matter of past, because of the appearance in the market of new oral anticoagulant drugs which do not require regular INR monitoring and don't have high potential for drug-drug and drug-food interactions, it is supported by the evidence showing that, in older patients, well-controlled therapy with warfarin continuous to be the gold standard for oral anticoagulant treatment. [20] Patients on usual long-term oral anticoagulant care, in PHC and GP setting, are mostly older people with the diagnosis of FA, or with conditions which predispose them to deep venous thromboembolism. [33,34] Characteristics of patients with FA are that they usually possess one or more risk factors for thromboembolic stroke and at the same time have increased risk for bleeding.…”