Objectives. Patient Background. Transitioning a Patient To & From a New Oral Anticoagulant

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1 Objectives Transitioning a Patient To & From a New Oral Anticoagulant How to switch from warfarin to rivaroxaban Discuss the Medicare donut hole How to switch from rivaroxaban to warfarin Home INR monitoring 2 Patient Background 67 year old white male with chronic atrial fibrillation Currently taking warfarin Significant difficulty making it into the office for INR checks & wanted an alternative Decided to switch patient to rivaroxaban from warfarin Rivaroxaban is only once a day dosing Requires no monitoring of INRs 3 4 1

2 Other Options Dabigatran- twice daily dosing Apixaban- had not yet hit market in 2013 (also twice a day dosing) Edoxaban- had also not yet hit the market How to Switch to Rivaroxaban? Stop warfarin and start rivaroxaban when INR less than 2 Manufacturer recommends stopping warfarin and starting rivaroxaban when INR less than 3 Red Book Online [database online]. Greenwood Village, CO: Truven Health Analytics, Inc. Updated periodically. Accessed April 6, Moll, S. Management of Rivaroxaban in Adults, UNC Health Care Guideline, May 2012Updated periodically. Accessed March 6, Starting Rivaroxaban Patient s last INRs over last 4 months 2.4, 3.1, 1.7, 3.1 Patient was started on rivaroxaban 20 mg PO daily No significant risk of bleeds in this patient felt safe with an INR under 3 Pt did very well on rivaroxaban Until 7 8 2

3 The Medicare Doughnut Hole The Serious Eats Doughnut Style Guide. (n.d.). Retrieved April 6, 2015, from 9 Doughnut Holes? The Medicare Coverage Gap, Explained. (2012, July 26). Retrieved April 6, 2015, from 10 Cost of Rivaroxaban With Medicare patient cost was around $40/month Out of pocket cost while in donut hole was around $300/month It was then decided to switch patient back from rivaroxaban to warfarin because of COST

4 Bridging to Warfarin Switching Back from Rivaroxaban to Warfarin Bridge between switching, due to reports of stroke from stopping rivaroxaban with no continuous anticoagulation The bridge could be done with rivaroxaban or with LMWH Hunter, M., Miller, S., Miller, A., & Reed, B. (2012, May 1). Retrieved March 6, 2015, from Xarelto-2012.pdf 14 Reason rivaroxaban was chosen Easy adherence for the patient Cheap cost for patient The reason for using LMWH is that rivaroxaban can increase INR independently for 48 hours after stopping Therefore the INR during the bridge therapy may not be accurate 15 Hunter, M., Miller, S., Miller, A., & Reed, B. (2012, May 1). Retrieved March 6, 2015, from Xarelto-2012.pdf 16 4

5 Switching Patient From Rivaroxaban to Warfarin Patient fairly stable on 5 mg of warfarin in the past There are no studies looking at converting rivaroxaban to warfarin specifically, but several sources for clinical recommendations Plan Overlap with rivaroxaban x 5 days or when INR is 2-3 Start on warfarin once patient has five tabs of rivaroxaban remaining Hunter, M., Miller, S., Miller, A., & Reed, B. (2012, May 1). Retrieved March 6, 2015, from Xarelto-2012.pdf Note that rivaroxaban may increase INR. If kidney function poor (GFR<50), recommend shorter overlap Hunter, M., Miller, S., Miller, A., & Reed, B. (2012, May 1). Retrieved March 6, 2015, from pdf 19 Bridging Rivaroxaban to Warfarin: Patient Results Day INR Rivaroxaban Warfarin Cont rivaroxaban 20mg Start 5mg warfarin Cont rivaroxaban Stop rivaroxaban 7.5mg warfarin for 1day, then Cont warfarin 5mg Hold warfarin for 2 days and restart Cont 5mg warfarin Cont 5mg warfarin, cont rechecks weekly until normalized. 20 5

6 Home Monitoring Patient is now checking INR at home For services furnished on or after March 19, 2008, Medicare will cover for the use of home PT/INR monitoring for chronic, oral anticoagulation management for patients with Approved Indications for Home Monitoring Mechanical Heart Valve (MHV) Atrial Fibrillation Venous Thromboembolism, Deep Vein Thrombosis (DVT), or Pulmonary Embolism (PE) Hypercoagulable state (n.d.). Retrieved March 1, 2015, from 21 (n.d.). Retrieved March 1, 2015, from 22 Home Monitoring Anticoagulated for at least 3 months Face-to-face educational program (Company did training for me) The patient continues to correctly use the device No more than once a week testing (n.d.). Retrieved March 1, 2015, from 23 Alere INRatio 2 PT/INR Monitoring Systems. (n.d.). Retrieved March 1, 2015, from 24 6

7 Alere INRatio 2 PT/INR Monitoring Systems. (n.d.). Retrieved March 1, 2015, from 25 7

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