ADAS Anticoagulant Dosing and Advisory Service Sean O’Brien ADAS Deputy Manager Bev Straker - Bennett Senior Specialist Anticoagulation BMS August 2019

Service Provision ADAS is a Consultant led service managed by the Pathology Directorate. Provides POCT and computer assisted dosing advice to 6000 registered patients on oral anticoagulant therapy. The service is delivered by Biomedical Scientists, Medical Laboratory Assistants. All clinics are community based. Daily housebound patient service.

Community Clinic sites

Cardioversion management Comprehensive Initiation / Education for all new starters. (WARFARIN / DOAC’s) INR monitoring / warfarin dosing DOAC safety checks / 3 week follow up   ADAS Blackpool Fylde Wyre BVH Wards Point of care Team Gastro- Enterology Colonoscopy Opthalmology Cataract patients Ambulatory DVT services. GP Led Cardiology Ablation Cardioversion management Management of patients awaiting cardiovascular procedures Warfarin dosing for intermediate care units. Management of pre procedure INR levels. Direct links with DVT service. Management of pre procedure INR levels.

Anticoagulant service DOAC concerns Variation in initiation in both primary and secondary care. Inconsistent education for patients. Patients presenting to ADAS clinics for advice and confused. Patients prescribed a DOAC with contraindications. Patients on both warfarin and a DOAC ! Patient not on either anticoagulant ! Switches done without renal bloods or INR checks. NICE guidance not followed. Switches done when INR is above recommended level (bleeding risks). Patients on the wrong doses of DOACs / no follow up checks. Phone calls to ADAS for DOAC advice and switch assistance.

Scenarios Worrying Scenarios Patient admitted to CAT unit at BVH as her INR was >10. Discharged a day later with an INR of 7.3 following vitamin K ADAS had no update referral / no follow up check / no E discharge letter to GP ADAS performed a home visit 3 days later INR still >3 Patient had been sent home and started on Apixaban on discharge with an INR of 7.3!! No follow up in place, no education for patient / carers.

Worrying Scenarios Clinic patient attended confused about her anticoagulation. Started on rivaroxaban 3 days previously. INR performed just for safety and a closing INR for records INR was >8 Patient previously on 3mg warfarin daily and had been Rx’d 15mg rivaroxaban. She had taken 15mg of Warfarin and Rivaroxaban Oral Vit K administered Consulted with GP re stopping and restarting Riva when INR<2 She and her carer had not received any information the drug switch or counselling on DOAC

Secondary Care Pathway for all Anticoagulants Patient requires Anticoagulation Secondary Care Pathway for all Anticoagulants Medics to discuss options with patient following trust guidelines and prescribe appropriate Anticoagulant. NEXUS referral made to Adas. DOAC or Warfarin Anticoagulation Initiated by Medic Anticoagulation Initiated / switched by Adas Education on chosen Anticoagulant. Safety Checks performed. Patient registered on centralised database Warfarin INR checked. Dosed amended/initiated. Follow up appointments in clinics arranged. DOAC Patient seen for three week follow up appointment to discuss issues/side effects Regular monitoring TTR/VGR review. Reports sent to GP Discharged to GP care. All carers informed of medication changes if a switch of Anticoagulant has occurred

E Discharge Flag

Common DOAC issues No clotting screen at initiation (INR / PTT) Liver enzymes not assessed or raised above safe limits according to product data sheets Patient weight < 40kg or >120kg – no data on efficacy Renal function not appropriate for DOAC use <15 ml/min Apix / Riva / Edox and <30ml/min Dabigatran E GFR being used instead of Cock Croft Gault assessment for dosage, using actual body weight Patients switched who are higher range 3-4 warfarin – APA / Clot whilst on warfarin / mechanical valve Apixaban patients on 2.5 mg BD instead of 5 mg BD, using 1 instead of 2 of the dose reduction criteria Rivaroxaban prescribed at 20mg OD when Cr Cl 15-49ml/min

Common DOAC issues Patients not taking Rivaroxaban with largest meal BD doses not taken at appropriate intervals Renal function regular checks and care / action if renal function is declining Reviews of dosage if patients weight or renal function or age indicate a change in dose VTE patients - end of acute treatment duration review, discussions re prophylaxis or switch down to prophylactic dose for recurrent VTE Confused / vulnerable patients - ? Risk with no monitoring and switches should be carefully implemented Switches to DOAC can be assisted by ADAS – checks to ensure safe INR levels / appropriate starts ADAS switches back to warfarin closely monitored

Benefits of the pathway Centralisation of all anticoagulant patients (universal anticoagulant database). Auditable, consistent, comprehensive education for all patients/carers. Less Medic time/confusion on who is educating patients. Safe medication switches. Secondary safety check to ensure: no contraindications (drugs or conditions) bloodwork is done and results appropriate correct dosage appropriate treatment duration 3 week DOAC review Compliance for NRLS (NPSA) / NICE recommendations.