scholarly journals OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England

2020 ◽  
Author(s):  
◽  
Helen J Curtis ◽  
Brian MacKenna ◽  
Alex J Walker ◽  
Richard Croker ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Care Home ◽  
Direct Oral Anticoagulants ◽  
Test Results ◽  
Factors Associated ◽  
Safety Alert ◽  
National Guidance ◽  
Function Test ◽  
Home Residency ◽  
Direct Acting

BackgroundEarly in the COVID-19 pandemic the NHS recommended that appropriate patients anticoagulated with warfarin should be switched to direct acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately co-prescribed two anticoagulants following a medication change, and associated monitoring.ObjectiveTo describe which people were switched from warfarin to DOACs; identify potentially unsafe co-prescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.MethodsWorking on behalf of NHS England we conducted a population cohort based study using routine clinical data from >17 million adults in England.Results20,000 of 164,000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in co-prescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. INR testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).ConclusionsIncreased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people co-prescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

scholarly journals OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic

Open Heart ◽  
2021 ◽  
Vol 8 (2) ◽  
pp. e001784
Author(s):  
◽  
Helen J Curtis ◽  
Brian MacKenna ◽  
Alex J Walker ◽  
Richard Croker ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Care Home ◽  
Test Results ◽  
Sharp Rise ◽  
Factors Associated ◽  
Safety Alert ◽  
National Guidance ◽  
Function Test ◽  
Home Residency ◽  
Direct Acting

BackgroundEarly in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring.ObjectiveTo describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.MethodsWith the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England.Results20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50–100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).ConclusionsIncreased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

scholarly journals Treatment Patterns and Clinical Outcomes in Korean Cancer Patients With Venous Thromboembolism: A Retrospective Cohort Study

2021 ◽  
Vol 27 ◽  
pp. 107602962097957
Author(s):  
Soo-Mee Bang ◽  
Jin-Hyoung Kang ◽  
Min Hee Hong ◽  
Jin-Seok Ahn ◽  
So Yeon Oh ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Clinical Outcomes ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Events ◽  
Factors Associated ◽  
Vein Thrombosis ◽  
Medical Chart Review ◽  
Deep Vein

This study assessed epidemiologic data and clinical outcomes, including venous thromboembolism (VTE) recurrence and bleeding events, in patients with cancer-associated VTE, and assessed factors associated with clinical outcomes. Data were extracted from retrospective medical-chart review of adult patients diagnosed with cancer-associated deep vein thrombosis or pulmonary embolism who received anticoagulation treatment for ≥3 months. Patients were classified by: low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and other anticoagulants. First VTE recurrence and bleeding events, and factors associated with their occurrence, were assessed during the initial 6 months of treatment. Overall, 623 patients (age: 63.7 ± 11.3 years, 49.3% male) were included (119, 132, and 372 patients in LMWH, DOACs and other anticoagulants groups, respectively). The cumulative 6-month incidence of VTE recurrence was 16.6% (total), 8.3% (LMWH), 16.7% (DOACs), and 20.7% (other); respective bleeding events were 22.5%, 11.0%, 12.3%, and 30.7%). VTE recurrence and bleeding rates differed only between LMWH and other anticoagulants (HR 2.4, 95% CI: 1.2-5.0 and 3.6, 1.9-6.8, respectively). These results highlight the importance of initial VTE treatment choice for preventing VTE recurrence and bleeding events. LMWH or DOACs for ≥3 months can be considered for effective VTE management in cancer patients.

A Review of Direct Oral Anticoagulants in Patients With Stage 5 or End-Stage Kidney Disease

2021 ◽  
pp. 106002802110400
Author(s):  
Jessica A. Starr ◽  
Nathan A. Pinner ◽  
Melanie Mannis ◽  
Mary Katherine Stuart
Keyword(s):  
Kidney Disease ◽  
Data Extraction ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cochrane Library ◽  
End Stage Kidney Disease ◽  
Vein Thrombosis ◽  
Study Selection ◽  
Direct Acting ◽  
End Stage

Objective: To evaluate the role of oral anticoagulation in patients with stage 5 chronic kidney disease (CKD-5) or end-stage kidney disease (ESKD). Data Sources: A literature search of PubMed (January 2000 to July 1, 2021), the Cochrane Library, and Google Scholar databases (through April 1, 2021) was performed with keywords DOAC (direct-acting oral anticoagulant) OR NOAC or dabigatran OR rivaroxaban OR apixaban OR edoxaban AND end-stage kidney disease combined with atrial fibrillation (AF) or venous thromboembolism (VTE) OR pulmonary embolism OR deep-vein thrombosis. Study Selection and Data Extraction: Case-control, cohort, and randomized controlled trials comparing DOACs to an active control for AF or VTE in patients with CKD-5 or ESKD and reporting outcomes of stroke, recurrent thromboembolism, or major bleeding were included. Data Synthesis: Nine studies were included. Efficacy data supporting routine use of warfarin or DOACs in CKD-5 or ESKD are limited. Rivaroxaban and apixaban may provide enhanced safety compared to warfarin in patients with AF. Data for VTE are limited to 1 retrospective study. Relevance to Patient Care and Clinical Practice: Because of the paucity of rigorous, prospective studies in CKD-5 or ESKD, OACs should not be broadly used in this population. It is clear that data regarding efficacy of DOACs cannot be reliably and safely extrapolated from the non-ESKD population. Therefore, use of OACs in this population should be individualized. Conclusions: If OACs for stroke prevention with AF are deemed necessary, apixaban or rivaroxaban can be considered. DOACs cannot currently be recommended over warfarin in patients with CKD-5 or ESKD and VTE.

scholarly journals 109Accuracy of test results for Direct Oral Anticoagulants (DOACs) and Warfarin- importance of External Quality Assessment (EQA)

EP Europace ◽  
2017 ◽  
Vol 19 (suppl_1) ◽  
pp. i46-i46
Author(s):  
DP Kitchen ◽  
A W-C Chow ◽  
S Munroe-Peart ◽  
L Brown ◽  
I Jennings ◽  
...  
Keyword(s):  
Quality Assessment ◽  
External Quality Assessment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Test Results ◽  
External Quality

scholarly journals The Quality of Advice Provided by Pharmacists to Patients Taking Direct Oral Anticoagulants: A Mystery Shopper Study

Pharmacy ◽  
2020 ◽  
Vol 8 (3) ◽  
pp. 164
Author(s):  
Jonathon Ertl ◽  
Leanne Chalmers ◽  
Luke Bereznicki
Keyword(s):  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Patient Characteristics ◽  
Study Patient ◽  
Optimal Care ◽  
Over The Counter ◽  
Mystery Shopper ◽  
Direct Acting

Pharmacists report being less confident in their knowledge of direct acting oral anticoagulants (DOACs) than of vitamin K antagonists, which may influence their ability to detect and manage complications arising from DOAC use. In a mystery shopper study, patient agents were sent into community pharmacies with symptom or product-related requests related to common complications that might arise during treatment with oral anticoagulants, with each visit being assessed for the preferred outcome. Only 10/41 (24.4%) visits resulted in the preferred outcome. A complete history-taking process, obtaining a medical history, patient characteristics and pharmacist involvement were strong predictors of the preferred outcome being achieved. The preferred outcome was not consistently achieved without pharmacist involvement. The potential for strategies that support comprehensive pharmacist involvement in over-the-counter requests should be considered to ensure the provision of optimal care to patients taking high-risk medications such as DOACs.

scholarly journals Efficacy and Safety of Direct-Acting Oral Anticoagulants (DOACs) in the Overweight and Obese

2020 ◽  
Vol 2020 ◽  
pp. 1-7
Author(s):  
Kimberley Doucette ◽  
Hira Latif ◽  
Anusha Vakiti ◽  
Eshetu Tefera ◽  
Bhavisha Patel ◽  
...  
Keyword(s):  
Care Center ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Tertiary Care ◽  
Primary Prophylaxis ◽  
Normal Weight ◽  
Phase Iii ◽  
Large Tertiary Care ◽  
Phase Iii Trials ◽  
Direct Acting

Obesity plays an essential role in the safety of pharmacologic drugs. There is paucity of data for direct oral anticoagulants (DOACs) in the obese, despite these agents becoming more widely used. The primary and secondary objectives of this study were to assess the safety and efficacy of DOACs in the overweight and obese populations when used for primary prophylaxis in the setting of non-valvular atrial fibrillation (NVAF) and for treatment of venous thromboembolisms (VTE). We conducted a retrospective cohort study in a large tertiary care center and obtained data through review of electronic health records. Among patients with NVAF and VTE on apixaban, there were no differences in rates of major bleeding (MB) and clinically relevant nonmajor bleeding (CRNMB) in the overweight and obese populations when compared to normal weight and underweight individuals. The multivariate adjusted analysis for rivaroxaban found that the odds of CRNMB for patients with BMI <25 was 5.37 (95% CI 1.50–19.32) times higher than that of BMI ≥25. Moreover, patients on medications that had known interactions with DOACs had 6.40 times higher odds of CRNMB than patients without such interactions (95% CI 1.49–27.57), which was not accounted for by the effects of aspirin and plavix alone. Efficacy was similar between all weight groups, for both apixaban and rivaroxaban. These results support previous analyses preformed in the large phase III trials and confirm that apixaban and rivaroxaban are safe in the overweight and obese.

Factors Associated With the Choice of Oral Anticoagulant Class in the Older Patients: An Observational Study

2020 ◽  
Vol 25 (4) ◽  
pp. 332-337
Author(s):  
Arnaud Pagès ◽  
Rémi Sabatier ◽  
Brigitte Sallerin
Keyword(s):  
Vitamin K ◽  
Oral Anticoagulant ◽  
Older Patients ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Female Gender ◽  
Vitamin K Antagonist ◽  
Factors Associated ◽  
Stage 4

Aim: Oral anticoagulants are the first-line drugs for treating thrombotic disorders related to nonvalvular atrial fibrillation and for treating deep vein thrombosis, diseases that increase in prevalence with age. Older patients have a greater risk of thrombotic and hemorrhagic events and are more prone to drug interactions. Given this backdrop, we wanted to determine the factors associated with the prescription of direct oral anticoagulants and vitamin K antagonists in older patients. Methods: We performed a cross-sectional observational study using a hospital prescription database. The study population consists of 405 older patients who were given oral anticoagulants. The 2 variables of interest were the prescription of 1 of the 2 classes of oral anticoagulants (direct oral anticoagulants vs vitamin K antagonists) and appropriateness of oral anticoagulant prescribing according to Summary of Product Characteristics (potentially inappropriate vs appropriate). Results: The factors associated with direct oral anticoagulant prescribing were the female gender (odds ratio [OR]: 1.87, 95% confidence interval [CI]: 1.22-2.88) and initiation during hospital stay (OR: 2.56, 95% CI: [1.52-4.32]). Stage 4 and 5 chronic kidney diseases (OR: 0.39, 95% CI: [0.19-0.79] and OR: 0.07, 95% CI: [0.01-0.53]) were factors favoring vitamin K antagonist prescription. Being 90 years of age or more (OR: 2.05, 95% CI: [1.06-3.98]) was a factor for potentially inappropriate anticoagulant prescribing. The gastroenterology department (OR: 2.91, 95% CI: [1.05-8.11]) was associated with potentially inappropriate anticoagulant prescribing. Conclusions: Direct oral anticoagulants are the drugs of choice for anticoagulant treatment, including in older adults. The female gender and the initiation during hospital stay increased the chances of being prescribed a direct oral anticoagulant in older adults. Stage 4 and 5 chronic kidney disease increased the likelihood of having a vitamin K antagonist prescribed. Our study also revealed a persistence of potentially inappropriate oral anticoagulant prescriptions in older patients.

scholarly journals Potentially inappropriate prescribing of DOACs to patients with mechanical heart valves: a federated analysis of 57.9 million patients' primary care records in situ using OpenSAFELY

2021 ◽  
Author(s):  
◽  
Louis Fisher ◽  
Victoria Speed ◽  
Helen J Curtis ◽  
Christopher T Rentsch ◽  
...  
Keyword(s):  
Heart Valve ◽  
Heart Valves ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Inappropriate Prescribing ◽  
Mechanical Heart Valve ◽  
Mechanical Heart Valves ◽  
Audit And Feedback ◽  
National Guidance

National guidance was issued during the COVID-19 pandemic to switch patients on warfarin to direct oral anticoagulants (DOACs) where appropriate as these require less frequent blood testing. DOACs are not recommended for patients with mechanical heart valves. We conducted a retrospective cohort study of DOAC prescribing in people with a record of a mechanical heart valve between September 2019 and May 2021, and describe the characteristics of this population. We identified 15,457 individuals with a mechanical heart valve recorded in their records, of whom 1058 (6.8%) had been prescribed a DOAC during the study period. 767 individuals with a record of a mechanical heart valve were currently prescribed a DOAC as of May 31st 2020. This is suggestive of inappropriate prescribing of DOACs in individuals with mechanical heart valves. Direct alerts have been issued to clinicians through their EHR software informing the issue. We show that the OpenSAFELY platform can be used for rapid audit and feedback to mitigate the indirect health impacts of COVID-19 on the NHS. We will monitor changes in prescribing for this risk group over the following months.

Sign in / Sign up

Export Citation Format

Share Document