DOAC Educational Webinar 12 th November 2020 1-2pm and repeated 17 - PowerPoint PPT Presentation

DOAC Educational Webinar  12 th November 2020 1-2pm and repeated 17 th November 2020 7-8pm  Thank you to everyone involved in caring for patients taking anticoagulation in South East London  The aim of this session is to ensure that: • You are aware of the changes to the transfer of care for patients prescribed DOACs (in place from 1 st October 2020) • You have the support and guidance to monitor patients taking DOACs to ensure their safety and effectiveness • You know when to seek advice and guidance from hospital teams or medicines optimisation teams • You are able to prescribe DOACs in elderly and frail patients and according to their risk:benefit

DOAC Educational Webinar: Housekeeping  This webinar is being recorded, we ask you all mute yourselves. The recording will be uploaded and you will receive a link to this webinar.  There will be opportunities for you all to ask questions, you can do this by using the chat function on Microsoft Teams.  Please use the raise your hand function on Microsoft Teams to indicate your answer to any questions asked.

Agenda  Welcome, introductions and overview : Helen Williams (SEL CCG)  DOAC pathways and support for primary care : Rachel Howatson (SLCVMWG)  Case study 1: A low risk patient: Rosalind Byrne (12 th ) or Georgina Harrison (17 th ) (LGT)  Case study 2: A high risk patient : Rosalind Byrne (12 th ) or Alison Brown (17 th ) (KCH)  Monitoring of DOACs in primary care : Helen Williams (12 th ) or Vicki Collings (17 th ) (GSTT)  DOACs in the elderly +/- frail : Dr Raj Patel (haematologist- KCH)  Q & A  Useful references

SEL DOAC patient pathways: Why do we need to change? Identified Issue Learning Points Communication issues TOC and initiation forms not received by primary care or incorrectly coded on EMIS Differences in practice Among specialities in acute Trusts and borough community clinics Waiting times for AC clinic Need to prioritise and risk:stratify patients referred Medicines compliance aids Safety issues with over/under coagulation- duplication of therapy and missed doses Unfamiliar prescribing DOAC choices and dosing regimes Annual reviews Are not being achieved New Medicines Service Promote community pharmacy support for DOAC adherence and counselling

SEL DOAC patient pathway for NVAF

SEL Actions Taken Action Taken Outcomes Edoxaban for NVAF Preferred DOAC agents Rivaroxaban for VTE Replace information in discharge and clinic letters Removal of TOC and initiation forms Baseline blood tests, monitoring recommendations Primary care to prescribe, review and monitor DOACs for NVAF TOC for NVAF at 1 month following initiation- consistent with other medications supplied at discharge from hospital Supported by guidance and AC teams contactable by email “High risk” patients followed up by AC clinics Define high risk patients in NVAF Consistency of referral among specialities and across interfaces pathway Medicines compliance aid and Encourage communication: Current variations in practise across SEL- primary care housebound patients prescribing often required earlier

Primary care support tools (see link SEL APC CV guidelines)  FAQs for DOACs in primary care  Initiation of AC for NVAF (edoxaban)  AC choice for VTE (rivaroxaban)  Initiation and monitoring of DOACs template- includes dosing tables and counselling checklist  Calculating renal function for DOACs updated  DOAC patient pathway for NVAF  DOAC patient pathway for VTE  Table summary of changes from 1 st October (SEL comms letter)  Stepwise approach to DOAC prescribing in primary care (summary page)  Educational webinars  Task and Finish group focusing on standards of AC community service

Case Study 1: Low risk DOAC patient  Mr NL , 55 years  On warfarin for NVAF for the last 10 years (started in Vietnam, recently moved to the UK)  PMH: HTN, IHD (angina – no previous ischaemic event)  Medications: warfarin, amlodipine, ISMN, GTN spray  Social History: owner of a restaurant, drinks alcohol 1 pint of 4% lager every night (16 units a week)  CHADsVASC: 2 (HTN, IHD- angiographically significant CAD)- risk factors for ischaemic stroke in AF patients  HASBLED: 1 (ETOH) (maximum recommended 8 units a week)

First appointment in anticoagulation clinic: Secondary care  Struggling to make warfarin clinic appointments  Time in Therapeutic Range = 38% (Target 65%)  At AC clinic: discussed DOAC options (risks and benefits)  Counselled: have 2 alcohol free days (aim <8 units a week)  Adherence to medication supported  Mr NL decided to switch to a DOAC  See warfarin to DOAC guidance during COVID-19:  https://www.anticoagulationuk.org/downloads/NHS%20clinical%20guide %20for%20management%20of%20anticoagulation.pdf

DOAC commenced  Baseline Bloods Checked and in range on initiation: FBC, Renal Profile, LFTs, INR 2.0 • See SEL initiation and monitoring template for DOACs  Renal function (CrCl) : Weight: 88.7kg, Cr 81, CrCl 114 ml/min based on actual body weight • See SEL renal monitoring guidance for DOACs  Edoxaban not the best choice as CrCl >90mL/min hence cautioned • See SEL Initiation of AC for NVAF guidance  Rivaroxaban 20mg Once a day commenced the following day as INR <3

DOAC initiation for NVAF- Special Circumstances Special Recommendation Special Recommendation Special circumstances Recommendation circumstances circumstances Pregnancy/ LMWH preferred/ Mechanical heart Warfarin/specialist Severe renal Warfarin/specialist specialist advice valves (includes advice- impairment (CrCl < advice Breast feeding TAVI/TAMI, tMVR or haematology/cardi 15ml/min) MV repair within 3 ology months) Active Specialist advice Moderate to severe Warfarin High CrCl >95ml/min Rivaroxaban/specialist malignancy/ mitral stenosis advice chemotherapy HIV Specialist advice Post coronary Cardiology advice: Antiphospholipid Warfarin/specialist antiretrovirals event/intervention antiplatelet review Syndrome (APLS) advice and hepatitis antivirals Menorrhagia Specialist advice Extremes of body Specialist advice On anti-epileptic Specialist advice weight <50kg and medication >120kg See SEL AC initiation for NVAF guidance

Example clinic letter for this patient  DOAC choice, indication and dose: • Rivaroxaban 20mg Once a day started for NVAF and warfarin stopped  Baseline Bloods: • from 01/11/2020:- Hb: 156, ALT: 14, Weight: 88.7kg, Cr 81, CrCl 114 ml/min based on actual body weight  DOAC supply given to patient: • 4 weeks supply given on initiation  Monitoring advice: • GP please continuing prescribing and monitoring rivaroxaban • Based on the initial bloods, recheck in one year (FBC, LFTs, renal profile)

Follow up in Primary care  This patient does not require secondary care follow up – See high risk criteria for AC clinic referral in DOAC patient pathway for NVAF  At next routine GP appointment: • Check for side effects/bleeding issues • Check adherence/understanding concerning therapy with patient • Ensure supply of rivaroxaban is continued • Next routine bloods required in one year based on initial bloods • Review annually as may require more frequent monitoring in the future ( More on monitoring later ) • See SEL renal monitoring for DOAC guidance • See SEL initiation and monitoring of DOACs template

Follow-up review – low risk patients Weight Record weight (at least annually) Renal function Record CrCl (see SEL guidance for frequency- 3 to 6 to 12 monthly) Drug interactions including OTC Ensure repeat prescription is current Confirm other changes: if antiplatelet or NSAIDs deprescribed? PPIs started? Medicines adherence Check for non-adherence and address as appropriate Bleeding or other adverse effects Review bleeding symptoms and adverse effects Confirm understands red flags for bleeding If not tolerated, refer back to anticoag clinic/clinician who initiated Thromboembolism Confirm patient is clear on indication and duration Re-educate as appropriate Modifiable factors for bleeding e.g. concurrent medications, uncontrolled BP and EtOH intake Monitoring plan Document appropriate plan ( see later slide ) High risk patient will be followed up by anticoagulation clinics The 2018 European Heart Rhythm Association Practical Guide on the Use of Non-vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation; European Heart Journal (2018); 39 (16): 1330-1393. Accessible via: https://doi.org/10.1093/eurheartj/ehy136. SEL Integrated Medicines Optimisation Committee: Direct Oral Anticoagulant (DOAC) Initiation and Monitoring Guidance Template. September 2020. Available via: https://www.lambethccg.nhs.uk/news-and-publications/meeting- papers/south-east-london-area-prescribing-committee/Documents/Cardiovascular%20Disease%20Guidelines/DOAC%20initiation%20and%20monitoring%20template%20SEL%20SEPT%202020%20FINAL.pdf

Case Study 2: High risk patient  Mrs TP , 76 years old, new diagnosis of NVAF  PMHx : HTN, DM, CABG 2015, Hyperlipidaemia  DHx : ramipril, metformin, frusemide, simvastatin, bisoprolol, aspirin  Social : No alcohol, lives with partner  CHA 2 DS 2 -VASc score 6 , HAS-BLED score 1- modifiable risk factor is current antiplatelet therapy  Weight 135kg , Height 163cm  Referred from cardiology to start anticoagulation for stroke prevention