1. Non-vitamin K antagonist oral anticoagulants (NOACs)
YOUR FACILITY
Presenter
Month YYYY
Presenter: add your facility, name and month / year

2. This session will provide an:
Introduction to high-risk medicines
Overview of NOACs (also known as ‘DOACs’ – Direct Oral Anticoagulant), including:
NOACs available
Indications
Contraindications
Adverse effects
Prescribing, administering and supply
Specific NOAC risks

3. ‘A-PINCH’
A – Anti-infectives P – Potassium & other concentrated electrolytes I – Insulins N – Narcotics and other sedatives C – Cytotoxic agents H – Heparins and other anticoagulants
‘A-PINCH’ is an acronym used as a starting point to identify high-risk medicines. As anticoagulant medicines, NOACs are part of this acronym.

4. Features of High-Risk Medicines:
More likely to cause harm if involved in an error
Narrow therapeutic window
Multiple interactions with other medications
Potent medications
Complex dosage and monitoring schedules
Wide variation in effect
All anticoagulants can cause harm if involved in an error

5. Anticoagulant medicines:
Are used extensively in clinical practice
Act through targeting a number of different proteins that may limit or prevent thrombus formation
Have a narrow therapeutic index and over or under anticoagulation can result in significant adverse patient outcomes
Choice of anticoagulant will be based on a variety of patient factors and indication for treatment
Until introduction of NOACs, warfarin was the only oral anticoagulant available
All anticoagulants can cause harm if involved in an error

6. There are currently three NOACs registered in Australia:
One direct thrombin inhibitor: Dabigatran (Pradaxa®)
Three NOACs are registered in Australia. They work on different parts of the clotting cascade.

7. Two Factor Xa inhibitors:
Apixaban (Eliquis®) Rivaroxaban (Xarelto®)

8. NOAC indications include:
Reduces risk of stroke in non-valvular atrial fibrillation
Prevention of VTE following hip or knee replacement
Treatment and ongoing prevention of VTE
Important to note: there is currently no reversal agent registered in Australia for these medicines

9. Contraindications to NOAC therapy include:
Renal impairment
a reduced dose may be used in moderate renal impairment, depending on renal function, NOAC and indication
Disorders of haemostasis
Clinically significant active bleeding
Prosthetic heart valve
Liver disease
Pregnant and breastfeeding women
Children under 18 years

10. NOAC adverse effects Dabigatran Apixaban Rivaroxaban Common bleeding
anaemia
nausea
dyspepsia
gastritis
abdominal pain
GI bleeding
peripheral oedema itch, skin blisters
muscle spasm
Infrequent
increased liver enzymes
thrombocytopenia
Rare
allergic reactions

11. NOAC dosing Unlike warfarin:
NOAC doses are fixed based upon patient factors, such as renal function and indication of therapy
Dose frequency is either daily, or twice daily depending on indication
Duration of therapy is dependent on the indication for therapy

12. NOAC monitoring Unlike warfarin:
There is no need to routinely measure patient blood levels and make dose adjustments according to a ‘therapeutic range’
However:
NOACs are excreted renally. Renal function should be monitored:
at least annually
if the patients condition changes
Patients should also be routinely assessed for signs of bleeding and for other bleeding risk factors (e.g. persistent hypotension; other medicines; platelet counts)
Point one: provide an example: monitoring International Normalised Ration (INR) for patients on warfarin

13. Prescribing NOACs on the National Inpatient Medication Chart (NIMC)
Check all charts in case an anticoagulant medicine has already been ordered
The NOAC should be prescribed in either a ‘Regular Medication’ order space, or following VTE risk assessment, on the ‘VTE prophylaxis section’
NIMC Regular medicine order space
NIMC VTE prophylaxis section

14. Prescribing therapeutic dose NOACs on the NIMC
Use a NIMC ‘regular medicine’ order space
Include the ‘Indication’ in the order:
allows the medicine to be reviewed in terms of why it was ordered
reduces the risk of misinterpretation of the order e.g. medicines with look-a-like names or incorrect doses and for medicines which have different doses for different indications
Remove this slide if the relevant NOAC chart is not in use in your facility

15. Prescribing VTE prophylaxis dose NOACs on the NIMC
Use the NIMC VTE prophylaxis section
The ‘Indication’ is preprinted in this section
If VTE therapy is required e.g. for a pre-existing DVT, it should be charted in a regular medicines order space
Remove this slide if the relevant NOAC chart is not in use in your facility

16. Documenting NOAC education on the NIMC
NOAC education can be documented on the NIMC in the ‘Warfarin Education Section’
Warfarin should be crossed out and the name of the NOAC inserted.
Remove this slide if the relevant NOAC chart is not in use in your facility

17. NOAC administration instructions:
Dabigatran (Pradaxa®)
Swallow whole with or without food
Do not chew or open capsule
Keep in original packaging
Do not transfer capsule to a dose administration aid
Apixaban (Eliquis®)
Can be used in dose administration aids
Rivaroxaban (Xarelto®)
10 mg tablet may be taken with or without food
15 mg and 20 mg tablet should be taken with food
Images courtesy of MIMS Australia
PRESENTATION NAME –
PRESENTER NAME

18. Accessing NOAC supplies
NOACs are short-acting medicines. Dose omission may put the patient at risk of thrombosis
Inform the ward pharmacist when a patient is admitted or commenced on a NOAC
If the prescribed NOAC is not available as imprest supply, and the Pharmacy Department, is closed the NOAC should be sourced by:
Contacting the After-Hours Pharmacist
Sourcing it through the After-Hours Supply
Contact the relevant medical officer if a dose is still not available
The chart shouldn’t simply be marked as ‘N’ (not available)
The presenter should adjust this slide according to facility procedures

19. General NOAC safety considerations:
For all patients receiving anticoagulants clinicians should be alert to signs of bleeding
Patients taking anticoagulants are at increased risk of bleeding if they fall (refer to local fall protocol)
All patients (and/ or their carer) receiving or going home on an anticoagulant require education on their medicines
The presenter should adjust this slide according to facility procedures

20. Specific NOAC risks
Specific incidents that have been identified associated with NOAC use:
Failure to recognise these medicines as anticoagulants
For example, venous thromboembolism (VTE) prophylaxis (enoxaparin) prescribed along with a NOAC
Anticoagulants prescribed on different charts
Intravenous heparin is prescribed on an IV heparin chart and a NOAC is prescribed on the NIMC

21. Specific NOAC risks Failure to realise clinical significance of NOACs
For example, doses omitted and documented ‘N’ (not available)
If there is any doubt whether a dose has been given, contact the medical officer, don’t simply omit
Mismanaged during the perioperative period
For example, the NOAC is ceased too early prior to a procedure
Risk of drug interactions
Specific interactions and medicines that increase bleeding risk

22. In summary: NOACs (anticoagulants) are a high-risk medicine
As with all medicines, if the patient’s condition changes NOAC use may need to be reviewed
NOACs need to be sourced, or the medical officer notified if not available
For all anticoagulants, check that duplicate anticoagulant therapy hasn’t inadvertently been prescribed

23. References
Australian Commission on Safety and Quality in Health Care. NIMC User Guide
MIMS Australia. Pradaxa Full Product Information
MIMS Australia. Xarelto Full Product Information
Therapeutic Goods Administration. Approved Product Information. Apixaban (Eliquis) 2015
Presenter can include additional local resources on this slide

24. Policy and resources:
Australian Commission on Quality and Safety in Health Care, NIMC User Guide Government of Western Australia. Living with a New Oral Anticoagulant (NOAC) NSW Clinical Excellence Commission High-Risk Medicines Webpage NSW Health Policy on High-Risk Medicine Management National Prescribing Service (NPS)
Presenter can include additional local resources on this slide

25. Thank you Questions
For further information: