Presentation on theme: "AF and NOACs An UPDATE JULY 2014"— Presentation transcript:
1 AF and NOACs An UPDATE JULY 2014 Helen WilliamsConsultant Pharmacist for CV DiseaseSouth London
2 The prevalence of AF in 80-89 year olds is as high as 9%.1 Most people seem to agree that the prevalence figures are under-reported due to the asymptomatic nature of AF. 2As with many conditions, the more you look, the more you find.References:Kannel WB et al. Prevalence, Incidence, Prognosis, and Predisposing Conditions for Atrial Fibrillation: Population-Based Estimates. The American Journal of Cardiology. 1998; 82NHS Improvement. June Available at accessed April 2010.
3 % of strokes attributable to AF AF and stroke risk% of strokes attributable to AFAF is the leading - and most preventable - cause of embolic strokeRisk increases with ageWithout preventive treatment, approximately 1 in 20 patients (5%) with AF will have a stroke each year%HWAge (years)Kannel WB et al. Am J Cardiol 1998; 82 (8A): 2N–9N.
6 NICE Priorities (CG180) Personalised package of care Assessment of stroke and bleeding riskUse of CHA2DS2-VASc and HASBLEDAnticoagulation with warfarin or a NOACStop using aspirin for stroke prevention in AFRate and rhythm controlSpecialist referral and interventions where first line options fail to manage symptoms adequately
7 CHA2DS2-VASc Annual stroke rate, % Score 1 1.3 2 2.2 3 3.2 4 4.0 5 6.7 11.322.233.244.056.769.879.68915.2Congestive heart failure/ 1LV dysfunctionHypertensionAge Diabetes mellitus 1Stroke/TIA/TEVascular disease(CAD, CArD, PAD)AgeSex category (female) 1Score 0 – 9Validated in 1084 NVAF patients not on OAC with known TE status at 1 year in Euro Heart SurveyOR for stroke if: Female: 2.53 (1.08 – 5.92), p=0.029; Vascular disease: 2.27 (0.94 – 5.46), p=0.0637
8 Assessment of risk of bleeding - HAS-BLED ScoreBleeds per 100 patient-years1.1311.0221.8833.7448.70Hypertension (current)Abnormal renal/liver function 1/2StrokeBleedingLabile INRElderly (age > 65 years)Drugs or alcohol /2LowInter-mediateHighScore 0 – 9c-statistic 0.72Validated in 3978 NVAF patients with known TE status at 1 year in Euro Heart Surveyc-statistic 0.72 (similar to HEMORR2HAGES)0.91 vs 0.85 for patients on ASA or no therapyPisters R, et al. Chest 2010;138:88
9 Myths and Misconceptions… Aspirin is as effective as oral anticoagulationAspirin is safer than oral anticoagulationFalls are a C/I to anticoagulant therapyPrior GI bleeds are a C/I to anticoagulation
10 So, where are we now?Up to 15% of patients cannot take warfarin due to allergy, contraindication or inability to manage the monitoring requirements.Up to 40% are not controlled within therapeutic range on warfarinUp to 45% with atrial fibrillation at high stroke risk are not currently anticoagulated – see QOF!
11 Where are we now? ~4% uptake of NOACs in the UK market Data on file: Bristol-Myers Squibb Pharmaceuticals LimitedDOT = Days on therapy
12 NOACs: Prioritizing Patients …. And return on investment?Patients unable to take warfarin due to allergies / CI and patients unable to comply with monitoring of warfarin (n=207)HIGH PRIORITY= 7 strokes prevented£166k= strokes prevented£141 -£282kPatients out of range(n =252 – 501)MEDIUM PRIORITY= strokes prevented£505 - £1,010kPatients on aspirin or nothing (n= )= 3 – 5 strokes prevented£147kNew Patients (n=261)LOWER PRIORITYPatients currently stable on warfarin (n=756 – 1005)£425- £565kPlus... up to £915k for currently undetected AFWhat about costs?** Annual costs based on a CCG in South London, population 300k (prevalence = 0.9%)12
13 Novel oral anticoagulants SW London Positioning 2014/15 An alternative to warfarin for SPAF in patients with CHADS2 ≥ 1 who:have a warfarin allergy, warfarin specific-contraindication or are unable to tolerate warfarin therapyare unable to comply with the specific monitoring requirements of warfarinare unable to achieve a satisfactory INR after an adequate trial of warfarinhave had an ischaemic stroke whilst stable on warfarin therapyare unwilling to take warfarin after a full discussions of the risks and benefits
14 SWL Positioning 2014/15Warfarin is a suitable first-line option for many patientsInitiation by clinicians with ‘expertise in initiating anticoagulation’Initiating clinician responsible for at least first 3 months of therapy:Address side effectsEmphasise importance of adherenceTransfer to patients own GP when ‘stable’ and in line with approved indications
15 Prescribing NOACs Check indication – AF, VTE treatment or prophylaxis Check patient age – dose adjustment at 80 years with dabigatranCheck renal functionNot just eGFRCalculate creatinine clearanceCheck for adverse effectsDabigatran dyspepsia in up to 10% patientsRivaroxaban / apixaban: headache / dizzinessCheck adherenceNo monitoring of bloods (except annual renal function) therefore possible increased risk of non-adherence over time