New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic...
-
Upload
heather-wallett -
Category
Documents
-
view
216 -
download
4
Transcript of New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic...
![Page 1: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/1.jpg)
New Oral Anticoagulants (NOACs)Dabigatran and Rivaroxaban
for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation
Educational Event23rd & 24th January 2013
West Suffolk Hospital Education Centre
WSCCG NOACs in AF Prescribing Guidelines
Linda LordHead of Medicines Management (GP Prescribing)
West Suffolk Clinical Commissioning Group
![Page 2: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/2.jpg)
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
![Page 3: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/3.jpg)
GP Responsibilities1 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
![Page 4: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/4.jpg)
Please refer to WSCCG guidelines
Page number
![Page 5: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/5.jpg)
Initiating a NOAC
![Page 6: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/6.jpg)
1. Ensure NICE criteria metDabigatran
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
![Page 7: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/7.jpg)
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
![Page 8: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/8.jpg)
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
![Page 9: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/9.jpg)
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
![Page 10: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/10.jpg)
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)
p.4-5
![Page 11: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/11.jpg)
2. Consider further points (strong recommendations)
• Informed discussion with patient has taken place: disadvantages/ advantages
p.9-10
![Page 12: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/12.jpg)
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
![Page 13: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/13.jpg)
4. Perform baseline blood tests
• FBC (platelet count must be >100 x 109/L & stable)
• U&Es
• Clotting screen
• LFTs
• eGFR
![Page 14: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/14.jpg)
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
![Page 15: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/15.jpg)
6. Issue alert card
Available free from stores
![Page 16: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/16.jpg)
7. Provide on-going treatment and monitoring
Discussed later
![Page 17: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/17.jpg)
Converting from warfarin to a NOAC
![Page 18: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/18.jpg)
Converting from warfarin to a NOAC
1. Ensure NICE criteria met – as before
2. Consider further points (strong recommendations) – as before
3. Record details in patients’ notes: Which NICE criteria met Why warfarin converted to a NOAC
(name and dose)*
*Use of checklist 4b recommendedp.23
![Page 19: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/19.jpg)
Converting from warfarin to a NOAC
4. Counsel patient – as before
5. Issue alert card – as before
![Page 20: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/20.jpg)
Converting from warfarin to a NOAC
6. Implement conversion safely:
Step 1 – Stop warfarinStep 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
![Page 21: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/21.jpg)
Converting from warfarin to a NOAC
7. Inform anticoagulant services that warfarin has been stopped
8. Provide on-going treatment and monitoring (discussed later)
![Page 22: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/22.jpg)
Prescribing a NOAC as on-going treatment
![Page 23: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/23.jpg)
On-going treatment and monitoring
• 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)
p.15
![Page 24: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/24.jpg)
On-going treatment and monitoring
• 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
p.15
![Page 25: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/25.jpg)
Referring to hospital for possible initiation of a
NOAC
![Page 26: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/26.jpg)
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
![Page 27: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/27.jpg)
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
![Page 28: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/28.jpg)
SummaryWarfarin 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
![Page 29: New Oral Anticoagulants (NOACs) Dabigatran and Rivaroxaban for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Educational.](https://reader034.fdocuments.us/reader034/viewer/2022051819/551ac2bd550346b2288b548b/html5/thumbnails/29.jpg)
New Oral Anticoagulants (NOACs)Dabigatran and Rivaroxaban
for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation
Educational Event23rd & 24th January 2013
West Suffolk Hospital Education Centre
WSCCG NOACs in AF Prescribing Guidelines
Linda LordHead of Medicines Management (GP Prescribing)
West Suffolk Clinical Commissioning Group