1. Optimising Anticoagulation in the New Oral Anticoagulant Clinic for People with AF Satinder Bhandal Consultant Anticoagulation Pharmacist February 2015 Buckinghamshire Health Care NHS Trust

2. Algorithm: Stroke prevention of people with nonvalvular AF National Clinical Guideline Centre. Atrial fibrillation: the management of atrial fibrillation. June 2014. Available at: http://guidance.nice.org.uk/CG180/Guidance (accessed June 2014http://guidance.nice.org.uk/CG180/Guidance

3. The Statistics Annual data Estimate 16,100 strokes are averted including 4,400 fatal strokes by current warfarin treatment 54% of people requiring anticoagulation receive it 8.74% of people requiring anticoagulation have declined it or it is recorded it is contra-indicated Another 46% need anticoagulation Cost & Benefits of Antithrombotic Therapy in England: An Economic Analysis based on GRASF-AF (NHS Improving Quality Report – November 2014)

4. AF and NICE Dabigatran and rivaroxaban approved 2012 Apixaban approved 2013 Need to implement NICE guidance Need to ensure patients benefit from these new drugs Ensure safe prescribing Need to reduce avoidable strokes Manage the entry of these new drugs

5. Challenges Politics Lack of experience with NOACs – On job learning Lack of clarity on place of NOACs Demanding / mis-informed patients Securing funding

6. Commissioning a Specialist Anticoagulant Decision Unit Convened a meeting of all the key stakeholders Agreed criteria for NOAC use Agreed who could initiate NOACs Agreed to commission a specialist service Agreed referral pathways Agreed responsibilities of GPs and specialist clinic

7. Objectives The NOACs Bucks NOAC Care Pathways Safety checks for ALL anticoagulants Shared decision making Counselling Avoiding Pitfalls

8. Meta-analysis of stroke or systemic embolism Modified from Camm AJ. EHJ 2009;30:2554-5 Favours warfarin 00.30.60.91.21.51.82.0 Favours other Rx Category Relative Hazard Ratio (95% CI) W vs Placebo W vs W low dose W vs Aspirin W vs Aspirin + Clop W vs Ximelagatran W vs Dabigatran 110 W vs Rivaroxaban W vs Dabigatran 150 W vs Apixaban 5 Favours warfarin 00.30.60.91.21.51.82.0 Favours other Rx 00.30.60.91.21.51.82.0 W vs Dabigatran 110 W vs Rivaroxaban W vs Dabigatran 150 W vs Apixaban 5 W vs Dabigatran 110 W vs Rivaroxaban W vs Dabigatran 150 W vs Apixaban 5 Major bleeding ICH

10. GP diagnoses patient with AF and refers to NOAC service NOAC clinic risk assess patient & decides on anticoagulation option with patient in line with Bucks criteria Start warfarin Prescribe Counsel patient Alert Card Information Pack Start NOAC, Prescribe Counsel patient, Anticoagulant Alert Card Information pack If warfarin and NOAC unsuitable, consider referral to cardiologist Refer into usual A/C clinicSecond contact by phone at 2 weeks:  Address issues/concerns / compliance  Discharge to GP for continuation If switching NOAC, repeat above stages If switched to warfarin, refer to A/C clinic New AF patient from primary care

11. Patient with AF identified requiring A/C Non- urgent - refer to NOAC clinic CHA2DS2VASC>/= 6 but no TIA or stroke : refer to NOAC clinic for urgent initiation 72hours NOAC clinic risk assess patient & agrees anticoagulation with patient in line with Bucks criteria Start warfarin Prescribe Counsel patient Anticoagulation Alert Card Information pack Start/continue NOAC Prescribe Counsel patient Anticoagulant Alert Card Information Pack If warfarin and NOAC unsuitable, consider referral to Cardiologist Recent TIA or stroke Stroke Team starts A/C Refers to NOAC Clinic clinic Hospital Referral Pathway

12. The Consultation Open and welcoming Involve relative / carer Why the patient is here 30 minute structured consultation Educate on stroke risks Purpose of information gathering Shared decision making Information about anticoagulants Follow up arrangements Helpline

13. Safety Checks Age Weight BP U&Es FBC LFTs PMH Bleeding history Drug History Over the counter medicines

14. CHA 2 DS 2 -VASc criteriaScore Congestive heart failure/ left ventricular dysfunction 1 Hypertension1 Age  75 yrs 2 Diabetes mellitus1 Stroke/transient ischaemic attack/TE 2 Vascular disease (prior myocardial infarction, peripheral artery disease or aortic plaque) 1 Age 65–74 yrs1 Sex category (i.e. female gender) 1 CHA 2 DS 2 -VASc total score Rate of stroke/other TE (%/year)* 00.0 11.3 22.2 33.2 44.0 56.7 69.8 79.6 86.7 915.2 * Theoretical rates without therapy: assuming that warfarin provides a 64% relative reduction in TE risk (2.7% ARR), based on Hart et al. 1 Lip GYH et al. Stroke 2010;41:2731–2738. 2 Hart RG et al. Ann Intern Med 2007;146:857–67. TE = thromboembolism Stroke risk assessment with CHA 2 DS 2 -VASc

15. Balancing the risk – the HASBLED score One point for each of: – Hypertension is SBP >160mmHg – Abnormal renal function (Cr >200 or dialysis/transplant) – Abnormal liver function (cirrhosis or Bil*2 + ALT/ALP*3) – Stroke – Bleeding (history or predisposition e.g. bleeding diathesis or anaemia) – Labile INR (TTR<60%) – Elderly (>65yrs) – Drugs: Alcohol >8 units per week – Drugs that increase bleeding risk: NSAIDs, Aspirin, SSRI

16. The Risk of Stroke Versus Risk of Bleeding Some of the risk factors for bleeding are modifiable (which is a very good reason to do the assessment and take action prior to anticoagulation) - Hypertension - Labile INR (for some) - Drugs - Alcoholic drinks Explain risks versus benefits in plain English to patient / carer

17. The Shared Decisions First agree to anticoagulate!

18. Agree the right drug for the patient Stroke risk Bleeding risk Extreme age Extreme weight Co-morbidities Renal function Liver function Risk of ICH TTR Risk of side effects Need for MDS Lack of licensed antidotes for NOACs Mitral stenosis or mechanical heart valve Adherence with complex regimens Compliance issues

19. Locally Agreed Criteria for NOAC Use NEW PATIENTS High risk of interactions with warfarin leading to unacceptable INR fluctuations which cannot be addressed. Co-morbidities which make INR control challenging e.g. unstable severe COPD or recurrent cellulitis Regular INR monitoring is difficult or impractical after exploring all possible alternatives eg. immobile patients requiring home visits from phlebotomy Adherence to variable and complex warfarin dosage regimens is likely to be poor Secondary prevention of Af patients with recent stroke or TIA. To be referred by secondary care stroke service

20. Locally Agreed Criteria for NOAC Use (2) EXISTING WARFARIN PATIENTS Poor INR control (TTR < 65%) despite evidence of compliance Allergy to or intolerable side effects from warfarin which would require warfarin withdrawal

21. CharacteristicDrug choice Mechanical valve or valvular AF NOACs contra- indicated Severe renal impairment (CrCl <30 ml/min) NOACs not recommended Dabigatran contraindicated. Apixaban and rivaroxaban – Use with caution. Dyspepsia or upper GI symptoms Apixaban Preferred Dyspepsia occurs in 10% of patients on dabigatran Recent GI bleedApixaban Preferred. Higher rates of GI bleeding with dabigatran & rivaroxaban compared to warfarin. Recent ischaemic stroke on warfarin Dabigatran (at a dose of 150mg bd) is the only NOAC shown to be superior to warfarin in reducing ischaemic stroke Recent ACSRivaroxaban or Apixaban Preferred Moderate or severe heart failure Dabigatran Preferred. Peripheral oedema reported with rivaroxaban. No data available for apixaban. Poor compliance with twice daily dosing Rivaroxaban Preferred as only NOAC that is once daily administration Patient requiring a compliance aid e.g. dosette box Rivaroxaban or apixaban preferred. Dabigatran not stable in a compliance aid

22. Initiation of ANY anticoagulant needs full counselling

23. Doses for AF(1) (see SPC for full dosing and prescribing information) Dabigatran 150 mg BD 110 mg BD e.g. if high risk of bleeds, CrCl 30 - 50 ml/min, over 75 & considered a moderate risk of a bleed, over 80, very low body weight Do not added to Dosette box Best with or after food Rivaroxaban 20 mg OD If CrCl 15 – 49 ml/min 15 mg OD Best taken with or after food

24. Doses for AF (2) (see SPC for full dosing and prescribing information) Apixaban 5 mg BD All patients with creatinine clearance 15 - 29ml/min should receive 2.5 mg twice daily of apixaban. In addition if they meet two of the following criteria they should receive the lower dose: serum creatinine 133 micromol/L, age ≥ 80years or body weight ≤ 60kg.

25. Checking Renal function CrCl = (140 – age) x weight (kg) x 1.2 for men Serum creatinine NOTE: eGFR does not allow for weight Use IBW or actual if underweight

26. Counselling Patient explanation Condition / Purpose of medicine /Duration If NOAC, lack of antidote How to take in relation to food & regimen Monitored dosage aids – warfarin and dabigatran not in dosette Compliance Action if missed dose Alert Card Informing healthcare professionals (surgery /dental/injections/pregnancy/meds) Interactions – pain relief /OTC medicines Side-effects/ Warning signs/ Emergency Alcohol /Diet Follow up arrangements

28. Telephone Follow up Questions for Patient or Carer Have you had a chance to start taking your medicine yet? How are you getting on with it? Are you having any problems with you new medicine or concerns? Do you understand why you need anticoagulation? Do you think you are getting any side-effects or unexpected effects? Have you missed any doses or changed when you take it? Do you have anything else you would like to know or anything you would like me to go over again?

29. Anticoagulants Prescribed Anticoagulant Prior to Consultation NilWarfarinNOAC 76 (66%)33 (29%)5 (4%) Drug After Consultation NilWarfarinApixabanDabigatranRivaroxaban Patients249 (41%)5 (4%)29 (25%)33 (28%) Drugs Stopped Warfarin Due to Poor TTR / Labile INR ApixabanDabigatranRivaroxaban Patients21243

30. Patient feedback questionnaire If a friend or relative needed similar treatment, would you be happy to recommend the standard of care in the clinic?

31. Did you have confidence and trust in the pharmacist?

32. Were you involved as much as you wanted to be in decisions about your treatment?

33. Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?

34. Did a member of staff tell you about medication side effects to watch for when you went home?

35. Avoiding the Pitfalls (1) NOACs are anticoagulants - Major side effect is bleeding Omitted doses cause patient harm - Short Half Lives all about 12 hours Only ONE anticoagulant at a time - No LMWH, fondaparinux or warfarin

36. Avoiding the Pitfalls (2) Avoid antiplatelets - same rules as with warfarin - include OTC medicines Report any potential side effects to NOAC team Prescribe correct dose for renal function calculated using Cockcroft & Gault

37. Summary Specialist NOAC clinic pathways in Bucks Consultation style to facilitate patient education Patient risk assessment Shared decision making Counselling Avoiding pitfalls