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Warfarin Your Days are Numbered PowerPoint Presentation

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Description : Check out this medical presentation on Anticoagulant, which is titled "Warfarin, Your Days are Numbered!", to know about the available oral anticoagulants, patient characteristics that would suggest using one product over another, a plan for switching from one oral anticoagulant to another, and know how to manage oral anticoagulants in the peri-procedural period.

Tags : Anticoagulant, Warfarin, oral anticoagulants

Published on : May 25, 2021 | Views : 1602 | Downloads : 0

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Slide 1-

Warfarin, Your Days are Numbered! Linda R. Kelly PharmD PhC CACP Pharmacy Anticoagulation Specialist Presbyterian Healthcare System
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Objectives Identify and classify the available oral anticoagulants Evaluate patient characteristics that would suggest using one product over another Design a plan for switching from one oral anticoagulant to another Manage oral anticoagulants in the peri-procedural period
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Terminology VKA-Vitamin K Antagonist (warfarin) DOAC-Direct Oral Anticoagulant TSOAC-Target Specific Oral Anticoagulant NOAC-Novel (or New or Non-vitamin K) Oral Anticoagulant
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Resources
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Available Direct Acting Oral Anticoagulants (DOACs) Dabigatran Rivaroxaban Apixaban Edoxaban
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DOAC Mechanism of Action
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DOAC Indications and Dosing Focus on Venous Thromboembolism and Non-valvular Atrial Fibrillation
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Marge is a 72 year old female with non-valvular atrial fibrillation (NVAF). She has been taking warfarin for stroke prevention. Her history also includes hypertension. What is her CHA2DS2-VASc score? Meet Marge
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CHA2DS2-VASc Score
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Marge comes to see you about starting a new product, bringing you a souvenir from her latest excursion. What factors should be considered when planning to start or switch a patient to a DOAC? Marge
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DOAC Indications and Dosing NVAF DVT PE
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DOAC Indications and Dosing NVAF DVT PE
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DOAC Renal Dosing **No dose reduction in DVT/PE patients. However, patients with SCr > 2.5 or CrCl < 25 mL/min not studied
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DOAC Renal Dosing
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DOAC Hepatic Dosing Child- Pugh Score calculator can be found at PresNet Anticoagulation Oral Anticoagulants Rivaroxaban (Xarelto) Child-Pugh Classification Score
Slide 17-

DOAC Hepatic Dosing Child- Pugh Score calculator can be found at PresNet Anticoagulation Oral Anticoagulants Rivaroxaban (Xarelto) Child-Pugh Classification Score
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Drug Interactions Dabigatran: Substrate for p-glycoprotein Rivaroxaban: Substrate for p-glycoprotein 51% CYP 3A4 metabolism Apixaban: Substrate for p-glycoprotein 25% CYP 3A4 metabolism Edoxaban Substrate for p-glycoprotein Minimal CYP 3A4 metabolism
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Drug Interactions Common Interacting Classes Anticonvulsants including barbiturates Antiretrovirals Antifungals Antiplatelet drugs and NSAIDS Your favorite drug interaction program is your best friend
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Oral Anticoagulant Product Selection Focus on Venous Thromboembolism and Non-valvular Atrial Fibrillation
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Is a DOAC a Good Choice For Marge? What should we consider before prescribing a DOAC?
Slide 22-

DOAC Selection
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Anticoagulant Selection Valvular atrial fibrillation Valve replacement Myocardial infarction requiring dual antiplatelet therapy Breast feeding
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Anticoagulant Selection Yes Yes No No Non-valvular atrial fibrillation Secondary VTE prevention VTE prophylaxis following knee/hip replacement surgery
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Anticoagulant Selection Yes Patient Characteristics Favoring DOAC Highly like to be adherent with DOAC therapy and follow up plan Reliable to notify health care provider about changes to health and pertinent medical issues Confirmed ability to obtain DOAC on a longitudinal basis from a financial, insurance coverage and retail availability standpoint Unstable diet or malnutrition Frequent illness or health status changes Frequent medicine changes or need for medications that interact with warfarin but not with DOAC Frequent medical procedures with bleeding risk No
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Anticoagulant Selection Drug 2 Newer, less familiar No diet interaction and fewer interactions with other medications Cannot easily monitor level of anticoagulation and reversal agent may not be readily available Frequent monitoring and dose changes not required Bridging NOT required around procedures Lower risk of intracranial hemorrhage Drug 1 Older, more established Strong interaction with diet and other medications Reversible and easily monitored Frequent monitoring and dose changes often required Bridging may be required around procedures Higher risk of intracranial hemorrhage
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Drug affordability Warfarin $ Rivaroxaban, Apixaban, Dabigatran, Edoxaban $$$$ Commercial plans (not Medicare/ Medicaid) Patient copay Medicare Consider coverage gap TrOOP vs. Drug spend Use sample card and/or coupon Sample clinic Patient pay
Slide 28-

Drug affordability- Medicare Medicare coverage gap or “Donut Hole” Must pay deductible (PHS plan deductible= $0) Copay ~$45 per month Gap starts at $3700 total cost or “drug spend” This is copay + balance insurance pays In 2017, when in the gap patient pays ~51% cost for generic, ~40% for brand. Out of gap at $4,950 paid in out of pocket expenses True out of pocket cost= “TrOOP” Cost the patient sees, copay, coinsurance, spending during the coverage gap
Slide 29-

Drug Affordability- Medicare Example- Rivaroxaban alone Rivaroxaban total cost= $431.4 Rivaroxaban copay = $45 Will meet gap in 8.6 months ($3700) After gap, drugs cost = $172.56 per month TrOOP ($4950 to get out of gap) $360 (on copays) before gap with no deductible $690.24 (4 months in gap) Drug spend for catastrophic = $4950 After gap $21.57 (5%) (if patient is on other medications)
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Drug Affordability- Medicare Example – Warfarin alone Warfarin total cost $6 (5 mg per day x 30 days. ) Warfarin copay= $4 Will not meet gap with warfarin In the gap, warfarin cost approx $3 After gap will pay $1.60 per month
Slide 31-

Patient Assistance Utilize patient savings cards Sample Cards 1st month free! Regardless of insurance plan. Copy Card $0 copay for commercial insurance Samples may be available
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Patient selections takeaway LMWH preferred in patients with active cancer DOAC preferred in patients with DVT/ PE NVAF -2016 European and Canadian guidelines recommend DOAC over warfarin, 2014 AHA/ACC/HRS guidelines do not recommend one over the other Must consider patient co-morbidities and ability to afford therapy
Slide 33-

Is a DOAC a Good Choice For Marge?
Slide 34-

Questions?
Slide 35-

Oral Anticoagulant Switching
Slide 36-

Enoxaparin TO/FROM DOAC Stop old medication and start new medication when the next dose is due Abo-Salem J Thromb Thrombolysis (2014)
Slide 37-

DOAC TO DOAC Stop DOAC 1 and start DOAC 2 when the next dose is due Abo-Salem J Thromb Thrombolysis (2014)
Slide 38-

DOAC to Warfarin/Warfarin to DOAC Abo-Salem J Thromb Thrombolysis (2014)
Slide 39-

Warfarin to DOAC Discontinue warfarin Begin rivaroxaban when INR below 3.0 Begin dabigatran or apixaban when INR below 2.0
Slide 40-

DOAC to warfarin Need overlap therapy until INR equal or above 2.0 DOAC May interfere with INR reading Must use DOAC trough for INR draw Make clear to the patient that they MUST go in for an INR draw right before next DOAC dose is due. OR LMWH Transition like normal LMWH bridge per PMG policy. Start LMWH when next DOAC dose due.
Slide 41-

Anticoagulant Transitions Warfarin to DOAC, DOAC to Warfarin ** INR < 3.0 for Rivaroxaban
Slide 42-

How Does Marge Switch from Warfarin to Rivaroxaban?
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Peri-Procedural Anticoagulation
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Peri-procedural bridging Avoid overlapping LMWH and DOACS Can the procedure be delayed until patient is not on anticoagulation therapy? Is the bleeding risk of procedure high enough to warrant DOAC interruption? Consult bleed risk tables. Can we delay procedure to increase time for elimination? DOAC elimination based on renal function. Resume DOAC after hemostasis is achieved Low bleed risk: 24 hours High bleed risk: 48-72 hours.
Slide 45-

MAPPP Online and App www.mappp.ipro.org
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Bleeding Risk
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Peri-Operative Management
Slide 48-

Peri-Operative Management
Slide 49-

Peri-Operative Management
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Peri-Operative Management
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DOAC temporary interruption Allow for 95% drug elimination prior to procedure (~5 drug half lives) Resume DOAC 24-72 hours post procedure based on bleeding risk
Slide 52-

Case Study: MR. JF Creatinine Clearance is about 60ml/min
Slide 53-

Case Study: Mr. JF
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Bleeding Risk
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Peri-Operative Management
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Overview DOACS used for DVT/PE and NVAF Double check dosing for drug/ indication DOACS may not be the best option for everyone Consider your patient and their preferences DOACS come with added cost, but help is available We can transition between drug classes with monitoring DOAC temporary interruption AKA “peri-procedural bridging” is possible. Be aware of procedure bleeding risk and patient risk factors. Do not overlap LMWH with DOACS
Slide 57-

Questions?
Slide 58-

References www.xarelto.com Antithrombotic Therapy For Vte Disease: Chest Guideline And Expert Panel ReportKearon C, Akl EA, Ornelas J, et al.Chest. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026 Abo-salem E, Becker R. Transitioning to and from the novel oral anticoagulants: a management strategy for clinicians. J Thromb Thrombolysis. 2014;37(3):372-9. Connolly SJ, Milling TJ, Eikelboom JW, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2016;375(12):1131-41. Burnett AE, Mahan CE, Vazquez SR, Oertel LB, Garcia DA, Ansell J. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis. 2016;41(1):206-32. Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. J Am Coll Cardiol. 2015;66(12):1392-403. www.drugsafety.ipro.org Management of Anticoagulation in the Peri-Procedural Period Thrombosis Canada. New/ Novel oral anticoagulants (NOACS): Peri-Operative Management