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Enhancing Anticoagulant Monitoring in Family Medicine Clinic

Implementing a monitoring service for Direct Oral Anticoagulants (DOACs) in a family medicine clinic to ensure safe usage. The service includes patient education, provider flow chart, and regular follow-ups. Results show improved adherence and patient safety. Pharmacy students play a key role in monitoring DOACs.

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Enhancing Anticoagulant Monitoring in Family Medicine Clinic

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  1. Development of a Direct Oral Anticoagulant Monitoring Service in a Family Medicine Clinic CaprisseHonsbruch, Leah Mouw, Zachary Mulford, Jay Tieri, Sara Wiedenfeld PharmD

  2. Introduction

  3. Practice Site • Siouxland Medical Education Foundation • 18 family medicine residents • 8 faculty physicians • 2 physician assistants • 2 clinical pharmacists • ~14 Iowa pharmacy students per year • Care for over 40,000 patient visits annually • Pharmacist’s are responsible for 100% of anticoagulated ambulatory and nursing home patients • Warfarin • Direct Oral Anticoagulants

  4. What’s the Problem? • Direct Oral Anticoagulant (DOAC) therapy is relatively new to anticoagulation therapy • Patients started on DOAC therapy are not being monitored at all • No lab monitoring • Bleeding risk • Education is needed for both the patient and provider regarding the use of DOACs Dabigatran Oct 2010 Edoxaban Jan 2015 Apixaban Dec 2012 Rivaroxaban July 2011 2014 2015 2012 2011 2013 2010

  5. Goal: • Develop a comprehensive evidence-based monitoring service that can be implemented in the clinic to increase the safety and efficacy of these high risk medications.

  6. Methods • Develop a patient education handout • Important information about each medication • Adverse effects • Where to find more information • Develop a flow chart for providers to monitor DOAC use • Important labs • Appropriate follow-up and questions • Collect Data • Follow-up phone calls • Patient education provided • Remarkable Findings

  7. Patient Handout

  8. Direct Oral Anticoagulants (DOAC)

  9. Your DOAC

  10. Patient Friendly Language

  11. Provider Flow Chart

  12. Start of Therapy • Collect Labs: BMP and calculate CrCl, CBC​ • Educate about signs and symptoms of DVT and stroke​ • DVT/PE: unilateral pain, numbness, shortness of breath, chest pain​ • Stroke: Facial droop, Arm weakness, Slurred speech, Time to call 911​ • Financial Analysis​ • Is the medication covered by patient’s insurance?​ • Is there a manufacturer’s coupon available? • Collect patient past medical history​ • Provide patient with patient education handout​ • Determine indication for usage (DVT, PE, stroke, Afib), and duration of therapy​ • Switching from warfarin? (See Figure 1)​ • First provoked clot 3-6 months​ • Unprovoked clot 3 months-to extended​ • 2nd clot or A Fib extended therapy

  13. 2 Week Follow-Up • Ask patient if they have any questions or concerns​ • Assess adherence have they missed any doses in the last week​ • Are there any bleeding concerns? Ex: excessive bruising, bloody nose, black tarry stools​ • Any signs or symptoms of stroke, or DVT/PE?​ • Have they started any new medications? If yes, see Figure 2 for possible interactions

  14. 4-6 Week Follow-Up • Repeat same questions as in week 2 • Ask about refills. Have they refilled their medication? Do they need refills on their medication?

  15. 3 Month Follow-Up • Repeat same questions from weeks 4-6 Follow-up 1 year (low risk) Follow-up 6 months (High Risk) • Appointment in person annually for all others: ​ • Same questions • Repeat labs • Appointment in person every 6 months if: ​ • CrCl <60 ml/min​ • Age ≥75 y/o​ • Same questions, and repeat labs ​

  16. Results

  17. Patient Demographics • Average age: 68.5 years • Race: 79% Caucasian • Sex: 61% male

  18. Interventions

  19. Monitoring • 22 patients were called: • 2 reported bruising • 1 reported bleeding (non-significant) • 1 reported financial concerns

  20. Conclusion

  21. Moving Forward • Follow-up and monitoring are important in patients taking DOACs • Pharmacy students can be utilized to provide safe and effective monitoring to patients on DOACs • Continue to implement monitoring into the workflow • Continue to collect data • Assess adherence • Report remarkable outcomes

  22. References • Bartoli-Abdou JK, Patel JP, Crawshaw J, et al. Exploration of adherence and patient experiences with DOACs one year after switching from vitamin-K antagonists- insights from the switching study. Thromb Res. 2018;162:62-68.​ • Conway SE, Hwang AY, Ponte CD, Gums JG. Laboratory and Clinical Monitoring of Direct Acting Oral Anticoagulants: What Clinicians Need to Know. Pharmacotherapy 2017;37:236-48.​ • Douxfils J, Ageno W, Samama CM, Lessire S, et all. Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians. J ThrombHaemost. 2018;16(2):209-219.​ • Kim JJ, Hill HL, Groce JB, Granfortuna JM, Makhlouf TK. Pharmacy Student Monitoring of Direct Oral Anticoagulants. J Pharm Pract 2018.​ • Savaysa (R) [package insert]. Tokyo, Japan: Daiichi Sankyo Inc; 2015.​ • Pradaxa (R) [package insert]. Ingelheim am Rhein, Germany: Boehringer Ingelheim; 2010.​ • Xarelto( R) [package insert].  Beerse, Belgium: Janssen Pharmaceuticals Inc; 2011.​ • Eliquis (R) [package insert] New York, NY: Pfizer Inc; 2016

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