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Improve your MURs on new oral anticoagulants

Improve your knowledge of apixaban, dabigatran and rivaroxaban ahead of your next consultation

Warfarin has been prescribed as an oral anticoagulant for a number of years in the UK. More recently, Nice has approved the use of a further three oral anticoagulants for use in the UK, as a potential alternative to warfarin, for patients with non-valvular atrial fibrillation to prevent stroke and systemic embolism:1

  • Apixaban
  • Dabigatran
  • Rivaroxaban

The advice provided below will be of particular use when conducting MURs with patients on the newer anticoagulants.

1. Check that the patient understands why they are taking the oral anticoagulant

Using language that you judge to be appropriate to the patient’s level of understanding, it is important to highlight that the oral anticoagulant has been prescribed to prevent a blood clot in their circulation from forming (which may in turn lead to a stroke or heart attack). This is because they have atrial fibrillation, which means they have an abnormal heart rhythm. Because of the abnormal heart rhythm, they are at increased risk of blood clots forming in the heart and travelling to the brain, increasing the possibility of stroke. You should reassure the patient that their doctor will have assessed whether or not they are at risk of this happening to them and, with that in mind, they have made the decision to prescribe them an oral anticoagulant.2,3

2. Check adherence to the dose prescribed

Ask the patient when they usually take their medication and if they are adhering to the prescribed dose. Adherence is important for the effectiveness of this medication as the anticoagulant effect is reduced 12 to 24 hours after the last dose is taken, therefore increasing the risk of thromboembolic problems.1 The table below summarises the dosage guidelines for the new oral anticoagulants when prescribed for patients with non-valvular atrial fibrillation to prevent stroke and systemic embolism (patients must be over 18 years old).1

 

Name of oral anticoagulant

Dose

Apixaban

5mg twice daily

2.5mg twice daily if:

· over 80 years of age and weighing less than 60kg

 

Dabigatran

150mg twice daily

110mg twice daily if:

· over 80 years 

· patients at high risk of bleeding

· receiving concomitant treatment with verapamil or amiodorane

Rivaroxaban

20mg once daily with food

15mg once daily if:

· glomerular filtration rate (eGFR) has been estimated to be between 15-49mL/minute/1.73m2

3. Counselling points

A key point to note with the new oral anticoagulants is that regular monitoring of the patient’s international normalized ratio (INR) is not required. However it is key to ensure the patient understands the importance of regular follow-up appointments and to understand the importance of checking for signs of bleeding.

The following points should be discussed with patients during the course of the MUR:1

  • Treatment is usually reviewed every three months
  • Annual blood tests monitor how well the kidney and liver are working
  • Immediate medical advice should be sought if:
    • spontaneous bleeding occurs and the bleeding does not stop or recurs (includes bruising, bleeding gums, nosebleeds, prolonged bleeding from cuts, blood in the urine or stools, coughing up blood, a completely bloodshot eye, and vaginal bleeding in a postmenopausal woman)
    • sudden severe back pain develops
  • Before purchasing over-the-counter medicines, patients should inform the pharmacist they are taking an oral anticoagulant
  • Before having a dental procedure, the patient should inform their dentist they are taking an oral anticoagulant

 

In addition, the patient could be reminded to carry their alert card at all times (see below)1

Name of oral anticoagulant

Alert card required by the patient

Apixaban

Eliquis Alert Card

 

Dabigatran

Pradaxa Patient Alert Card

Rivaroxaban

Xarelto Patient Alert Card

4. Lifestyle advice for patients taking oral anticoagulants

As well as general healthy lifestyle advice, you should remind patients to inform doctors if they are making changes to their lifestyle with regard to a change in alcohol consumption, or if they lose weight, as the dosage may need to be reviewed.

References:

CKS Summaries Oral Anticoagulation

NHS Conditions Atrial fibrillation introduction

NHS Conditions Atrial fibrillation treatment

 

Harsha Parmar is a lecturer in pharmacy practice in the School of Pharmacy at the University of Manchester

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