New practice tool to improve anticoagulant management globally
With a new generation of novel direct oral anticoagulant drugs (NOACs or DOACs) now being prescribed to millions of patients around the world, Canadian experts call for careful patient monitoring — guided by a new evidence-based practice tool — to ensure that these drugs are used properly to maximize stroke prevention and minimize bleeding complications.
The authors describe their recommended monitoring approach in the June 30, 2015 issue of the Annals of Internal Medicine, where they introduce a new anticoagulant monitoring checklist that clinicians can use whenever patients receiving DOACs are seen for follow-up. It is designed as a knowledge-translation tool to promote standardized patient assessments, safety monitoring, medication adherence, and counseling.
“Anticoagulation for atrial fibrillation is one of the most powerful stroke prevention interventions, but it entails potential risks for patients and clinicians,” says Dr. David Gladstone, lead author of the paper and Medical Director of the Regional Stroke Prevention Clinic at Sunnybrook. “We hope that practice tools like this, if used regularly, will help to reduce the incidence of preventable strokes and preventable bleeding.”
The checklist distills the essentials of published recommendations into a practical one-page worksheet to streamline assessments for busy clinicians.
An accompanying page of quick-reference tables summarizes dosing, drug interactions, and instructions on how many doses to hold before a surgical procedure. The checklist reminds clinicians to be on the lookout for the common reversible risk factors for bleeding in anticoagulated patients, and to ensure correct DOAC dosing and renal function monitoring.
The checklist places special emphasis on adherence to treatment and provides tips for how to counsel patients. “Medication adherence is important for all drugs, but is especially critical for DOACs because they are short-acting anticoagulants. If one or more doses are missed, patients will no longer be maximally protected against stroke,” says Dr. Gladstone. “Physicians, nurses, and pharmacists have an important role to play in helping patients achieve and maintain optimal daily medication adherence and avoid prolonged or unnecessary interruptions in therapy.”
“DOACs are being used increasingly in patients with atrial fibrillation to prevent stroke,” says Dr. James Douketis, President of Thrombosis Canada and a co-author of the paper. “The DOAC monitoring tool will provide a user-friendly roadmap for healthcare professionals on how to monitor patients who are receiving the newer anticoagulants so that their risks of both stroke and bleeding are minimized.”
Given the wide variability in current DOAC monitoring practices, the checklist is poised to set a new standard for anticoagulant follow-up care. The checklist is intended for use by any clinician caring for patients taking these anticoagulants, including primary care physicians, specialists, pharmacists, nurses, physician assistants, and trainees.