1. Educational Event
23rd & 24th January 2013
West Suffolk Hospital Education Centre
New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation
WSCCG NOACs in AF Prescribing Guidelines
Linda Lord
Head of Medicines Management (GP Prescribing)
West Suffolk Clinical Commissioning Group

2. WSCCG NOAC Guidelines
Detailed advice on use of NOACs for prevention of stroke and systemic embolism in nonvalvular AF
Based on NICE TA 249 and 256
Includes expert advice of local clinicians
Core guidance: 15 pages
Appendices
Manufacturers’ Summaries of Product Characteristics

3. GP Responsibilities 1 Initiating a NOAC 2
Converting from warfarin to a NOAC 3
Prescribing a NOAC as on-going treatment 4
Referring to hospital for possible NOAC initiation

4. Please refer to WSCCG guidelines
Page number

5. Initiating a NOAC

6. 1. Ensure NICE criteria met
Dabigatran
One or more of following risk factors:
Previous stroke or TIA
Left ventricular ejection fraction <40%
Symptomatic heart failure NYHA ≥ class 2
Age ≥ 75 years
Age ≥ 65 years with one of following: diabetes mellitus, coronary artery disease, hypertension

7. 1. Ensure NICE criteria met
Rivaroxaban
One or more risk factors such as:
Congestive heart failure
Hypertension
Age ≥ 75 years
Diabetes mellitus
Prior stroke or TIA

8. 2. Consider further points (strong recommendations)
CHADS2 or CHA2DS2-VASc ≥ 2
eGFR
> 40 for dabigatran
> 25 for rivaroxaban
No history of significant peptic ulcer disease
p.3-4

9. 2. Consider further points (strong recommendations)
At least one of these:
Warfarin contraindicated
Venous access for INR not possible
Insurmountable difficulties with safe compliance of INR monitoring and dose adjustments, e.g. cognitive decline
HAS-BLED ≥ 3
Warfarin has been stopped due to intolerance, poor response or significant bleed while taking warfarin

10. 2. Consider further points (strong recommendations)
No significant ischaemic heart disease
No other contraindications
Special warnings, precautions and drug interactions have been considered (appendices 6,7,8)

11. 2. Consider further points (strong recommendations)
Informed discussion with patient has taken place: disadvantages/ advantages
p.9-10

12. 3. Record details in patients’ notes
Which NICE criteria satisfied
Why a NOAC (name and dose) has been selected rather than warfarin*
* Use of checklist 4a recommended
p.21

13. 4. Perform baseline blood tests
FBC (platelet count must be >100 x 109/L & stable)
U&Es
Clotting screen
LFTs
eGFR

14. 5. Counsel patient Indication Treatment schedules and duration
Side effects
Common interactions, including OTC medicines
Avoid pregnancy and breast feeding
Importance of compliance
More…
p.18

15. 6. Issue alert card
Available free from stores

16. 7. Provide on-going treatment and monitoring
Discussed later

17. Converting from warfarin to a NOAC

18. Converting from warfarin to a NOAC
Ensure NICE criteria met – as before
Consider further points (strong recommendations) – as before
Record details in patients’ notes:
Which NICE criteria met
Why warfarin converted to a NOAC (name and dose)*
*Use of checklist 4b recommended
p.23

19. Converting from warfarin to a NOAC
Counsel patient – as before
Issue alert card – as before

20. Converting from warfarin to a NOAC
6. Implement conversion safely: Step 1 – Stop warfarin Step 2 – Wait for 3 days Step 3 – Check INR. Dabigatran can be given as soon as INR <2. Rivaroxaban should be initiated when INR ≤ 3

21. Converting from warfarin to a NOAC
7. Inform anticoagulant services that warfarin has been stopped 8. Provide on-going treatment and monitoring (discussed later)

22. Prescribing a NOAC as on-going treatment

23. On-going treatment and monitoring
p.15
At least annual clinical review
At least annual eGFR if renal function normal, more frequent if impaired
Twice yearly FBC, LFT and U&E if renal function normal, more frequent if impaired
Close clinical surveillance (looking for signs of bleeding or anaemia)

24. On-going treatment and monitoring
p.15
Being alert to:
Risks if acute decline in renal function, e.g. due to dehydration, shock, initiation of nephrotoxic medicines such as NSAIDs, ACEIs, aminoglycosides
Possibility of discharge on extended prophylaxis to reduce risk of VTE

25. Referring to hospital for possible initiation of a NOAC

26. Referral is appropriate if:
Patient has complex co-morbidities
GP does not know what to do/ cannot weigh up pros and cons of anticoagulation in whatever form
Criteria and strong recommendations for NOAC satisfied but GP does not feel competent to prescribe a NOAC

27. Referral – further information
Referral not normally expected
No specific NOAC clinic at WSH
Referral to general medical or cardiology clinics in exceptional cases
Use of checklist 4a (initiation of NOAC) or 4b (conversion from warfarin) recommended
p.21-22

28. Summary Warfarin is suitable for most patients
and is the preferred option if:
eGFR <40
(eGFR 40-50: beware of risk of progressive/acute renal dysfunction)
History of significant peptic ulcer disease
Significant ischaemic heart disease
Please keep a vigilant eye on medication safety literature regarding NOACs. Potentially life-threatening side effects

29. Educational Event
23rd & 24th January 2013
West Suffolk Hospital Education Centre
New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation
WSCCG NOACs in AF Prescribing Guidelines
Linda Lord
Head of Medicines Management (GP Prescribing)
West Suffolk Clinical Commissioning Group