RIVAROXABAN FOR ATRIAL FIBRILLATION Amber Initiation Guideline

Size: px
Start display at page:

Download "RIVAROXABAN FOR ATRIAL FIBRILLATION Amber Initiation Guideline"

Transcription

1 RIVAROXABAN FOR ATRIAL FIBRILLATION Amber Initiation Guideline The purpose of this guideline is to provide prescribing and monitoring advice on rivaroxaban in the treatment of AF for the prevention of stroke and systemic embolism in people with nonvalvular atrial fibrillation with a CHA 2 DS 2 VAS c score of one or more. This is a new indication for rivaroxaban for which there are clear risks and benefits. As a general rule rivaroxaban is only considered for prescribing where neither warfarin nor dabigatran are suitable. Use of rivaroxaban for treatment of DVT is hospital only for use in Buckinghamshire. This guideline should be read in conjunction with the Summary of Product Characteristics (SPC) available on and the BNF. 1. BACKGROUND FOR USE The decision about whether to start treatment with rivaroxaban should be made after an informed discussion between the clinician and the person about the risks and benefits of rivaroxaban compared with warfarin and dabigatran. For people who are taking warfarin, the potential risks and benefits of switching to a new oral anticoagulant (NOAC) should be considered in light of their level of INR control 1.1. Risks/disadvantages of NOACs compared to warfarin Long term safety of warfarin is well established. Warfarin has been in clinical use for more than 60 years, in contrast the safety profile of dabigatran & rivaroxaban are still not fully understood and there is no long term safety data. Rivaroxaban is under intensive surveillance by the MHRA There is limited knowledge of use of NOACs in certain patient groups, e.g. extremes of body weight, renal or hepatic impairment, women of child bearing potential, breast feeding mothers, age over Rates of GI symptoms/bleeds are greater with NOACs than warfarin. Major GI bleeding rates for dabigatran compared to warfarin are 2 : 1.56% vs 1.07% per year; GI side effects 11.3% vs 5.8% per year; NNH 18. Figures are based upon 150 mg twice daily dose. Simliarly rivaroxaban causes more GI bleeds than warfarin 5 3.2% compared to 2.2% Overall there is a dose-related associated bleeding risk with NOACs. The relative risk of major bleeding with NOACs is believed to increase with age There is currently no licensed product available to rapidly reverse major bleeding with dabigatran or rivaroxaban. Warfarin is easier to reverse. The degree of anticoagulation with warfarin is measured using INR results. Dabigatran and rivaroxaban cannot be monitored using INR. However, death from bleeding does not appear to be increased in patients taking NOAC drugs compared to warfarin Patients with poor compliance need individual assessment. Warfarin and rivaroxaban are one daily treatments, rivaroxaban can be put into monitored dosage systems. The twice daily administration of dabigatran could be a disadvantage for patients who find compliance a challenge Because NOACs are not monitored, assessment and reinforcement of compliance does not take place. INR monitoring enables assessment of compliance with warfarin Dabigatran requires dose adjustment in renal impairment and is contraindicated in severe impairment GFR<30, rivaroxaban is contraindicated if GFR<15ml/min.. Renal function should be checked prior to initiation and monitored annually or more often if any decline is suspected. Warfarin is not contraindicated in renal impairment, although smaller doses are usually given to renally impaired patients. Guideline of 15 Uncontrolled if printed

2 1.2. Benefits/advantages of NOACs compared to warfarin There is no need for INR anticoagulation monitoring In the RE-LY trial, dabigatran: 150 mg twice daily reduced the absolute risk of stroke or systemic embolism by 0.6% per year compared to warfarin (1.71% vs. 1.11%; NNT 167). 150 mg twice daily showed a rate of major bleeding similar to warfarin. 110 mg twice daily showed a rate of stroke or systemic embolism similar to warfarin. 110 mg twice daily reduced the absolute risk of major bleeding by 0.7% per year (2.87% vs. 3.57%; NNT 143). Both doses reduced the absolute risk of intracranial bleeding compared to warfarin. ARR 0.44% per year for 150 mg twice daily dose (0.32% vs. 0.76%; NNT 227) In the Rocket AF multicentre study comparing rivaroxaban to warfarin, rivaroxaban was non-inferior to warfarin for effectiveness Warfarin and rivaroxaban has similar rates of major and non-major bleeding The absolute risk of intracranial bleeding was lower with rivaroxaban compared to warfarin. Risk: 0.5% per year with rivaroxaban and 0.7% per year for warfarin Major GI bleeds were more common with rivaroxaban than with warfarin (3.2% versus 2.2%) Myocardial infarctions (MI) occurred in 101 patients on rivaroxaban but 126 on warfarin. This difference was not statistically significant The NOAC effect is not significantly affected by changes in alcohol consumption and diet A more stable level of anticoagulation is achieved assuming 100% compliance Rapid onset of action (2 to 4 hours after the first dose). Rapid offset of action, therapeutic effect lost within 24 to 48 hours post dose In general, drug interactions are less of a clinical problem with NOACs compared to warfarin 1.3. Benefits/advantages of rivaroxaban compared to dabigatran Rivaroxaban is given only once a day & can be put into monitored dosage systems to assist with compliance Rivaroxaban can be crushed, making it suitable for patients unable to swallow solid food or being fed by PEG tubing In MI dabigatran poses an increased risk of a future MI compared with warfarin or rivaroxaban 2. If there is a known history of MI, 1 st consider warfarin. If warfarin is unsuitable rivaroxaban is the preferred NOAC Rivaroxaban can be given at an adjusted dose in renal dysfunction where the GFR=15-30ml/minute. Where warfarin is not suitable for this group, rivaroxaban is a possible option (dabigatran is not recommended). 2. CRITERIA FOR USE 2.1. NEW patients generally NOT suitable to start NOACs History of poor compliance with medication which cannot be improved in the foreseeable future. Serious consideration should be given to whether these patients are suitable for any oral anticoagulation Active gastritis is a relative contraindication to dabigatran, GI bleeds were higher with rivaroxaban than warfarin in the Rocket AF trial. Warfarin remains the usual 1 st line choice Contraindications to NOACs 2

3 Severe renal impairment (CrCl <30 ml/min for dabigatran; CrCl< 15ml/min for rivaroxaban; adjust dose if GFR=15 30ml/min). Hepatic impairment (elevated liver enzymes >2 x ULN) or liver disease expected to have any impact on survival. Interacting drugs with dabigatran: Dronedarone, systemic ketoconazole, itraconazole, ciclosporin, and tacrolimus.* * Caution is needed with interacting drugs which require dabigatran dose reduction, e.g. verapamil. Interacting drugs with rivaroxaban Dronedarone, ketoconazole, ritonavir, itraconazole, voriconazole, posaconazole, HIV protease inhibitors, rifampicin, caution with erythromycin and other macrolides. Rivaroxaban affects CYP3A4 and so in theory other interactions are possible but remain unstudied NEW patients generally suitable to start dabigatran High risk of interactions with warfarin leading to unacceptable INR fluctuations which cannot be addressed Co-morbidities which make INR control challenging (clinically unstable or medically complex), e.g. unstable severe COPD, uncontrolled LVF, recurrent cellulitis Regular INR monitoring is difficult or impractical after exploring all possible alternatives, e.g. immobile patients requiring home visits from phlebotomy Adherence to variable dosage regimens is likely to be poor, e.g. learning disabilities Patients being considered for cardiac ablation Secondary prevention of AF patients with recent stroke or TIA to be initiated by a consultant in the secondary care stroke service. Initiated at least 2 weeks after the stroke or TIA when there has been associated brain infarction 2.3. NEW patients generally suitable to start rivaroxaban Where an individual fits criteria for dabigatran in 2.2 but dabigatran is contraindicated or not suitable Where a monitored dosage system or once daily dosing is likely to make the difference with compliance for an individual. Careful individual patient assessment is required EXISTING WARFARIN PATIENTS generally NOT suitable to start NOACs Good INR control (TTR >70%) - patients should be advised that there is no clear data to support switching to a NOAC in patients with good INR control. There are clear disadvantages/risks associated with NOACs as described above Patients taking warfarin for indications other than anticoagulation in AF, due to a lack of clinical trial data in these groups (and unlicensed). In DVT treatment rivaroxaban is licensed for use but due to limited local experience this indication for use is managed by the hospital with all supplies coming from secondary care Patients with mitral valve disease or any heart valve replacements (unlicensed in this group even if the patient has co-existing AF) EXISTING WARFARIN patients who may be suitable to consider NOAC or warfarin Moderate INR control (TTR 60 to 69%) despite evidence of compliance - patients should be advised that the benefit of switching to a NOAC is unclear. Efforts should be made to find and resolve underlying causes of reduced control. If this proves impossible then a switch to a NOAC e.g. dabigatran may be considered. Dabigatran disadvantages/risks as described above should be discussed. If dabigatran and warfarin both unsuitable then rivaroxaban should be considered EXISTING WARFARIN patients generally suitable to start NOAC Poor INR control (TTR <60%) despite evidence of compliance Allergy to or intolerable side effects from warfarin which would require warfarin withdrawal. 3

4 2.6.2 Consider rivaroxaban where use of a monitored dosage system compliance aid will help to ensure compliance. Patients should be adequately assessed and other avenues to aid compliance should be actively discussed 3. CONTRAINDICATIONS AND PRECAUTIONS All clinical contraindications to warfarin anticoagulation are also contraindications to NOACs Absolute contraindications to both warfarin and NOACs Known large oesophageal varices Decompensated liver disease, a raised bilirubin (consult if >2 x ULN) or deranged baseline clotting screen (INR >1.5) refer to gastroenterology/hepatology Significant thrombocytopenia (platelet count < 50 x 10 9 /L) - refer to haematologist Pregnancy or within 48 hours postpartum - usually refer to secondary care for dalteparin under haematological advice Within 72 hours of major surgery with risk of severe bleeding - defer and reassess risk post-operatively Previously documented severe hypersensitivity reaction to either the drug or excipients consider cardiology opinion Acute clinically significant bleed - defer and re-assess stroke versus bleeding risk within 3 months Malignant neoplasms Recent brain or spinal injury Recent brain, spinal or ophthalmic surgery Arteriovenous malformation Vascular aneurysms Major intraspinal or intracerebral vascular anomalies Secondary prevention of AF patients with recent stroke or TIA - starting a NOAC will be deferred for 2 weeks after a stroke, sometimes longer after a large stroke. After a TIA the timing will depend on whether there has been associated brain infarction Relative contraindications to both warfarin and NOACs Previous history intracranial haemorrhage. Some AF patients, especially those considered at higher stroke risk (i.e. CHA 2 DS 2 VAS c score 3), may benefit from antithrombotic therapy, seek the opinion of a stroke specialist Major extracranial bleed within the last 6 months where the cause has not been identified or treated decision for oral anti-thrombotic therapy should be deferred Documented peptic ulcer within last 3 months decision for oral anti-thrombotic therapy should be deferred until treatment for peptic ulcer completed and for PPI cover Recent history of recurrent iatrogenic falls in patient at higher bleeding risk. A risk of falls is not a contraindication to initiating anti-thrombotic therapy Higher bleeding risk assessed by patient having 1 or more following risk factors: Age >80 years. Previous history bleed. Low platelet count <100 x 10 9 /L. On concomitant drugs associated with an increased bleeding risk, e.g. SSRIs, oral steroids, NSAIDs, methotrexate or other immunosuppressants Dementia or marked cognitive impairment with documented poor medicines compliance and no access to carer support. (Neither warfarin nor dabigatran are recommended to be put into a monitored dosage system, rivaroxaban can be placed in a monitored dosage system device.) Chronic alcohol abuse especially if associated with binge drinking. 4

5 4. RESPONSIBILITIES 4.1. Secondary care/specialist responsibilities Patients must meet local criteria for implementing NICE TA 256 and TA 249 or be approved for PCT funding under the exceptional cases process (ICRP) The anticoagulant specialist pharmacist will ensure that the patient initiated by the clinic fits local criteria for use Dabigatran or rivaroxaban should only be initiated by the new oral anticoagulant (NOAC) specialist pharmacist, or by consultant cardiologist, consultant stroke physician or consultant haematologist if treatment is required urgently (within one week) A prescription for continuation of a NOAC, once initiated by a specialist listed in 3 above, may be written by any prescriber NOACs should not be initiated in the Accident and Emergency department Patients initiated by consultant cardiologist, consultant stroke physicians or consultant haematologists will be reviewed in the NOAC clinic as soon as is practical after initiation to ensure they meet local criteria and may be switched to warfarin if they do not. Those initiated during an inpatient stay will be reviewed at a suitable interval post discharge - within a month of the discharge from hospital The NOAC specialist pharmacist/consultant cardiologist/consultant stroke physician/consultant haematologist must have an informed discussion with the patient about the risks and benefits of NOACs compared to other anticoagulants The NOAC specialist pharmacist or consultant cardiologist/consultant stroke physician/consultant haematologist will write the prescription for the first month of any NOAC An audit/nice compliance form completed by the NOAC clinic should clearly document the reasons why the NOAC is being tried, including the time in therapeutic range while on warfarin (if the patient has tried warfarin) and all information required by the PCT for audit purposes (as stated in separate contract document). This will provide ongoing audit information for all patients The specialist NOAC pharmacist will contact the patient at, or close to, 2 weeks after initiation (unless inpatient) to assess the tolerability of the drug, and to review if any problems have occurred which can be rectified If the NOAC is stopped or changed to an alternative, the GP will be informed in writing in time for them to take appropriate action. This letter will need to be faxed if the review is urgent The NOAC clinic will provide advice to GPs (e.g. if side effects occur) Report all side effects to the MHRA via the yellow card system Provide audit data (specified in the contract) to NHS Buckinghamshire until 31 st March From April 2013 onwards this data will be reported to the Aylesbury Vale and/or Chiltern Clinical Commissioning Groups GP responsibilities The GP should assess the patient using the locally agreed criteria (above) and refer patients into the specialist service if they feel a new oral anticoagulant agent may be suitable. The referral to the NOAC clinic should state which criteria are met. It is not recommended to refer in patients who are well controlled on warfarin The GP should provide recent U&Es and FBC (within the last 3 months). LFTs and INR should also be provided if the GP feels they could be abnormal due to the patient s history The GP should provide a patient summary when referring into the NOAC clinic, including time in range for INR if known/relevant, allergies, past medical history, current and past medication over the last 3 to 6 months, alcohol use (if known), recent BP, CHA 2 DS 2 VAS c score and HASBLED score. Forms are available for GP referral (see appendix C) and hospital internal referral (see appendix D). 5

6 After the 1 st month of treatment provided by the specialist, the GP should: Continue to prescribe dabigatran or rivaroxaban as indicated Undertake ongoing review of the patient to ensure they continue to meet the criteria for anticoagulation and NOACs in particular. This review should include monitoring of renal function, clinical review as indicated by the patient s condition and compliance assessment Monitoring as described in 2 above should take place at least annually but more frequently if the patient s clinical condition changes or a reduction in creatinine clearance is suspected If a switch to warfarin is appropriate, they will need to be referred into the usual anticoagulant pathway (see section 5.3 on switching from NOAC to warfarin) This medicine is monitored intensively by the MHRA and CHCM and all adverse reactions should be reported via the yellow card system. 5. DOSAGE (see SPC for more information) Indication Prevention of stroke in patients with nonvalvular AF and with a CHA 2 DS 2 VAS c score of 1 or more 5.1. Missed doses A forgotten rivaroxaban dose may be taken as soon as the patient remembers, on the same day. No double dose should be taken to make up for missed doses Switching from warfarin/dabigatran to rivaroxaban This is undertaken under secondary care supervision Time to response (with rivaroxaban) Full anticoagulation is expected within 2-4 hours of initiation. The half life is hours and so its effects will completely wear of in 2 3 days. 6. PRE TREATMENT ASSESSMENT BY GP U&Es and weight, (to allow Creatinine clearance to be calculated) FBC. If the history suggests any likelihood of abnormal LFTs or INR these should also be checked and provided in the referral letter. 7. ONGOING MONITORING SCHEDULE BY GP U&E including assessment of renal function FBC including Hb Dose Re-check stroke versus bleeding risk i.e. CHADSVASC exceeds HASBLED score. Rivaroxaban 20 mg daily is the usual dose If GFR 15-30ml/minute 15mg daily is the recommended dose. Annually, more frequently if patient unwell or declining renal function suspected, e.g. loop diuretic dose needs increasing. Only re-check FBC if anaemia is suspected clinically. Annually but more frequently if clinical status changes. 8. SIDE EFFECTS AND ACTIONS TO BE TAKEN (See SPC for full list) Rivaroxaban is a new drug and is marked in the BNF which signifies intensive monitoring by the MHRA. Please report all suspected side effects through the yellow card system. There is a lack of long term follow up data available. The following table covers the common 6

7 side effects listed in the SPC. For uncommon and rare effects - see SPC to determine if they could be due to the drug and seek advice if severe. Side Effects Bleeding events like any anticoagulant there is a significant risk of bleeds Anaemia Dizziness, headache, syncope Eye haemorrhage Tachycardia GI upset Rashes Pain in extremeties Fever, peripheral oedema, decreased energy/strength Action See section 10 for management of more severe bleeds. Minor bleeds such as epistaxis may be managed symptomatically. Identify site of blood loss and consider treating as Section 10 advises if severe. May improve with continued therapy Treat symptomatically, seek expert advice Unless clinically worrying does not require action. Exclude haemorrhage. May improve over time. Minor rashes do not warrant treatment discontinuation, but more severe reactions do. An alternative treatment may be required. May be a sign of haemorrhage or may be idiopathic. It is not known if these symptoms are caused by the drug or not but they have been described in association with rivaroxaban 9. NOTABLE DRUG INTERACTIONS (Refer to BNF and SPC) Rivaroxaban affects CYP3A4 & P-gp and is a fairly new medicine. In theory other interactions are possible but many remain unstudied. Dronedarone ketoconazole itraconazole, voriconazole, posaconazole Avoid concomitant use. This drug increases the levels of rivaroxaban and increases the risk of a significant bleed. Avoid concomitant use. These drugs increase the levels of rivaroxaban and increase the risk of a significant bleed. HIV protease inhibitors e.g. ritonavir Caution with erythromycin and other macrolides Phenytoin, phenobarbitone, carbamazepine or St John s wort Rifampicin NSAIDs and antiplatelet agents Avoid concomitant use. These drugs increase the levels of rivaroxaban and increase the risk of a significant bleed. These drugs increase the levels of rivaroxaban to approximately 1.3 fold, caution is recommended, but concomitant use is not contraindicated. Avoid concomitant use. These significantly reduce the levels of rivaroxaban and so reduces its effectiveness. Avoid concomitant use. Rifampicin significantly reduces the levels of rivaroxaban and so reduces its effectiveness. Concomitant use increases the risk of significant GI bleeds. In the Rocket AF trial many patients were given low dose aspirin concomitantly for co-existing conditions. 7

8 10. MANAGEMENT OF OVERDOSE AND BLEEDING Dabigatran (Pradaxa ) is a direct thrombin inhibitor with a half-life of hours. Rivaroxaban is a direct Factor Xa inhibitor with a half-life of hours. Dabigatran is primarily excreted renally and the half-life is prolonged in renal impairment. Rivaroxaban is partly metabolised to inactive forms in the liver and partly excreted renally. The half life of both drugs is prolonged in renal impairment, though to a lesser extent with rivaroxaban than with dabigatran. The major adverse effect of all anticoagulant medications is bleeding. All patients Check coagulation screen indicating time of last NOAC dose when requesting test. dabigatran aptt Moderately sensitive to dabigatran, but non-linear at high levels. Thrombin time (TT) Very sensitive to the presence of dabigatran. A normal result excludes the presence of significant levels of the drug. Prothrombin Time Not sensitive to dabigatran - a (PT/INR) high result suggests overdose of a different anticoagulant such as warfarin. rivaroxaban Moderately sensitive to rivaroxaban, but not the most useful marker Not sensitive to the presence of rivaroxaban. Sensitive to rivaroxaban. High result expected with either rivaroxaban or warfarin excess Fibrinogen May be low - very variable! Variable response Check full blood count, renal function and electrolytes (including calcium). No bleeding or minor bleeding 1. Omit NOAC until the bleeding stops, unless the risk of thrombosis is very high. 2. Local measures may be helpful. 3. Consider cause of bleeding. 4. For oral cavity bleeding also consider tranexamic acid 250 mg/5 ml mouthwash 5 to 10 ml 8 hourly. (Unlicensed) Major/life-threatening haemorrhage (e.g. CNS/major GI) 1. Urgent admission to hospital is required - Hospital clinicians see guideline 34 Guideline 34 Dabigatran: Guidance for Management of Overdose and Bleeding 8

9 11. BACK-UP INFORMATION/ADVICE New Oral Anticoagulant (NOAC) Service Cardiology Haematology Stroke Specialists Hospital Pharmacy - Medicines Information Wycombe and Amersham Hospitals Contact Details Stoke Mandeville Hospital Satinder Bhandal, Head of NOAC Service and VTE Lead Pharmacist Fax: Dr Piers Clifford Fax: (secretaries) In an emergency contact Consultant Haematologist on-call Dr Matthew Burn Dr Amulya Misra Switchboards Amersham: Wycombe: REFERENCES Dr Andrew Money-Kyrle Dr Punit Ramrakha Fax: (leave message for Consultant call back) In an emergency contact Consultant Haematologist on-call Dr Chris Durkin Dr Dennis Briley Dabigatran for the prevention of stroke or systemic embolism in AF (NICE TA 249) March Available at <accessed 30/8/12> 2. Connolly-SJ et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation (Re-LY study). N Engl J Med 2009; 361: SPC for Pradaxa 150mg and 100mg strengths last updated Aug 2012 <accessed 6/08/12> 4. Rivaroxaban for the prevention of stroke and systemic embolism in people with AF (NICE TA 256) May Available at <accessed 30/10/12> 5. Patel-M et al Rivaroxaban versus warfarin in Nonvalvular AF (Rocket AF) New Engl J Med Sept 20122: 365: SPC for Xarelto 20 mg & 15mg strengths. Available at last updated May 2012 <accessed 6/11/12> 7. Kanaka KA, Szlam F, J Thromb Haemost 2010; 8:

10 Appendices Appendix B: Care Pathways: i) New AF Patient from Primary Care ii) Patients Initiated on Dabigatran by Buckinghamshire Healthcare NHS Trust (BHNHST) iii) Existing Patients on Warfarin Appendix C: Referral Form 1 - GP to NOAC Clinic Appendix D: Referral Form 2 - Hospital AF referrals to NOAC Clinic Title of Guideline Rivaroxaban for Atrial Fibrillation - Amber Initiation Guideline Guideline Number Version 1.5 Effective Date Dec 2012 Review Date Dec 2014 Original Version Produced Dec 2012 Approvals: Formulary Management Group Dec 2012 Clinical Guidelines Subgroup Area Prescribing Committee Feb 2013 Author/s Sarah Crotty, Interface Pharmacist, NHS Buckinghamshire, Satinder Bhandal, Maire Stapleton (Senior Pharmacists BHNHST) Dr Jonathan Pattinson, Consultant Haematologist SDU(s)/Department(s) responsible Pharmacy (Primary and Secondary Care) for updating the guideline Haematology Uploaded to Intranet 10

11 Appendix A: Care Pathways i) New AF Patient from Primary Care GP diagnoses patient with AF and refers to NOAC service NOAC clinic decides on anticoagulation option for patient in line with Bucks criteria Start warfarin treatment, provide prescription, counsel patient, provide anticoagulation therapy pack Start dabigatran provide prescription, counsel patient, provide Anticoagulant Alert Card Letter to GP If warfarin and dabigatran unsuitable, consider rivaroxaban or referral Refer into usual warfarin anticoagulant clinic for patients from that GP practice Second patient contact by NOAC clinic usually by phone at 2 weeks: Address issues/concerns Highlight importance of compliance Discharge to care of GP for ongoing anticoagulation with dabigatran If NOAC not to be continued inform GP If patient needs to be switched to warfarin, refer into usual anticoagulation clinic for patients from that GP practice Guideline of 15 Uncontrolled if printed

12 ii) Patients initiated on a NOAC by BHT Consultant cardiologist/stroke physician or haematologist identifies patient potentially requiring NOAC as inpatient or outpatient Initiation not urgent: refer to NOAC service Initiation urgent (within 1 week): Consultant prescribes NOAC Patient referred to NOAC service NOAC clinic decides/reviews anticoagulation options for patient in line with Bucks criteria Start warfarin treatment, provide prescription, counsel patient, provide anticoagulation therapy pack Start/continue dabigatran, provide prescription if necessary, counsel patient, provide Anticoagulant Alert Card Letter to GP If warfarin and dabigatran unsuitable, consider rivaroxaban or referral Refer into usual warfarin anticoagulant clinic for patients from that GP practice Second patient contact by NOAC clinic usually by phone at 2 weeks: Address issues/concerns Highlight importance of compliance Discharge to care of GP for ongoing anticoagulation with NOAC If NOAC not to be continued inform GP If patient needs to be switched to warfarin refer into usual anticoagulation clinic for patients from that GP practice 12

13 iii) Anticoagulation Pathway for Existing Patients on Warfarin Warfarin anticoagulant clinic identifies patient with poor INR control. If patient is not being seen by clinical staff (postal system) then a standard letter will be sent to ask the GP to consider referring to NOAC clinic If being seen by an anticoagulant nurse or doctor they should refer the patient to the NOAC clinic directly and inform the GP. GP/anticoagulant clinician (as appropriate) refers to NOAC clinic if patient potentially meets Bucks criteria for NOAC NOAC clinic decides on anticoagulation option for patient in line with Bucks criteria Continue warfarin after counselling Start dabigatran, provide prescription, counsel patient, provide Anticoagulation Alert Card Letter to GP If warfarin and dabigatran unsuitable, consider rivaroxaban or referral Second patient contact by NOAC clinic usually by phone at 2 weeks: Address issues/concerns Highlight importance of compliance Discharge to care of GP for ongoing anticoagulation with NOAC If NOAC not to be continued inform GP If patient needs to be switched to warfarin refer into usual anticoagulation clinic for patients from the GP practice 13

14 Appendix B: Referral Form 1 GP to NOAC Clinic Patient name: DoB: Sex: NHS No: Address: GP Referral to New Oral Anticoagulant Service at BHNHST GP Name: Address: Postcode: Tel (day): Tel (mobile): Patient Patient requires transport: Patient needs interpreter: Language: Ethnicity: Date of referral: Postcode: Practice code: Tel: Fax: Reason for referral: On warfarin Time in range OR warfarin naive Renal function info must be supplied: Date creatinine and weight kg Known history of poor compliance? Give details In addition please provide a Patient Summary which details: Allergies, PMH, current medication and recent past medication, alcohol use if known, recent BP, FBC LFTs and INR (if any reason to suspect may be abnormal from history) Please ring the scores for your patient: Points Clinical Characteristic Points C LVF/LVD dysfunction 1 H Hypertension 1 H Hypertension 1 A Renal or LFTs abnormal 1 or 2 A 2 >75 years 2 S Stroke 1 D Diabetes mellitus 1 B Bleeding 1 S 2 Prior stroke or TIA 2 L Labile INRs 1 V Vascular disease 1 E >65 years 1 A Age D Drugs or alcohol >8 U/week 1 or 2 Sc Female 1 Total Total Signed... (GP) Preferred clinic: Amersham Wycombe Stoke Mandeville (please ring) FAX ALL REFERALS TO: TELEPHONE NUMBER:

15 Appendix C: Referral Form 2 Hospital AF Referrals to NOAC Clinic Hospital AF Referrals to New Oral Anticoagulant (NOAC) Clinic Addressograph or Name/Address/MRN/DOB/NHS No. Telephone Mobile Consultant Outpatient Clinic or Ward Name of referrer Bleep Signature Date Hospital Dear NOAC Pharmacist, Please prescribe and monitor anticoagulant therapy as appropriate in line with Bucks PCT/BHNHST criteria for: Uncomplicated AF / AF for cardioversion / AF for ablation / AF and TIA or stroke (circle) If warfarin has already been started give details Date INR Dose For warfarin target INR of 2 3. Delete if other range required state alternative and reason for change NOACs will be started in those patients fitting Bucks PCT/BHNHST criteria by the NOAC Clinic. If your patient needs to start a NOAC whilst an inpatient or within 7 days of discharge then refer to a Consultant Cardiologist/Consultant Haematologist or Consultant Stroke Physician for initiation. If a NOAC is started, state: Drug name and dose. Date. Name of Consultant issuing 1 st prescription. BLOODS WITHIN LAST 2 WEEKS NB: If unavailable, they must be requested. Referral cannot be accepted without them. Blood Test Creatinine Platelets Baseline INR LFTs normal Y/N Date checked Comments that would impact on anticoagulation Please circle the scores for your patient: Points Clinical Characteristic Points C LVF/LVD dysfunction 1 H Hypertension 1 H Hypertension 1 A Renal or LFTs abnormal 1 or 2 A 2 >75 years 2 S Stroke 1 D Diabetes mellitus 1 B Bleeding 1 S 2 Prior stroke or TIA 2 L Labile INRs 1 V Vascular disease 1 E >65 years 1 A Age D Drugs or alcohol >8 U/week 1 or 2 Sc Female 1 Total Total Preferred clinic: Amersham Wycombe Stoke Mandeville Fax all referrals to:

Rivaroxaban: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF

Rivaroxaban: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF Leeds Rivaroxaban: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF Amber Drug Level 3 (amber drug with monitoring requirements) We have started your

More information

Dabigatran: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF

Dabigatran: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF Leeds Dabigatran: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF Amber Drug Level 3 (amber drug with monitoring requirements) We have started your

More information

Dorset Cardiac Centre

Dorset Cardiac Centre P a g e 1 Dorset Cardiac Centre Patients with Atrial Fibrillation/Flutter undergoing DC Cardioversion or Ablation procedures- Guidelines for Novel Oral Anti-coagulants (NOACS) licensed for this use February

More information

Patient Group Direction Hospital: Bristol Royal Infirmary Department: UHBristol Thrombosis Service University Hospitals Bristol NHS Foundation Trust.

Patient Group Direction Hospital: Bristol Royal Infirmary Department: UHBristol Thrombosis Service University Hospitals Bristol NHS Foundation Trust. Patient Group Direction Hospital: Bristol Royal Infirmary Department: UHBristol Thrombosis Service University Hospitals Bristol NHS Foundation Trust. This Patient Group Direction (PGD) has been written

More information

295FM.1 RIVAROXABAN FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM Amber initiation guideline

295FM.1 RIVAROXABAN FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM Amber initiation guideline 295FM.1 RIVAROXABAN FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM Amber initiation guideline 1. BACKGROUND FOR USE... 1 1.1. Risks/disadvantages of rivaroxaban compared to warfarin... 1 1.2. Benefits/advantages

More information

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below Name: generic (trade) Rivaroxaban (Xarelto ) HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below What it is Indications

More information

Rivaroxaban shared care guidelines for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation.

Rivaroxaban shared care guidelines for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation. South West Essex Rivaroxaban Shared Care Guideline (SCG) Rivaroxaban shared care guidelines for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation. Introduction

More information

Objectives of Session

Objectives of Session Objectives of Session Project Background Why the need Decision Support Tool summary of key evidence Promotion Key Messages Project Background Grasp AF Audit Initial Grasp AF project undertaken in NHS Buckinghamshire

More information

New Oral Anticoagulants. How safe are they outside the trials?

New Oral Anticoagulants. How safe are they outside the trials? New Oral Anticoagulants How safe are they outside the trials? Objectives The need for anticoagulant therapy Indications for anticoagulation Traditional anticoagulant therapies Properties of new oral anticoagulants

More information

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF)

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) Key priorities Identification and diagnosis Treatment for persistent AF Treatment for permanent AF Antithrombotic

More information

Rivaroxaban: Prescribing Guidance for the treatment of provoked venous thromboembolism (VTE)

Rivaroxaban: Prescribing Guidance for the treatment of provoked venous thromboembolism (VTE) Rivaroxaban: Prescribing Guidance for the treatment of provoked venous thromboembolism (VTE) Amber Drug Level 2 Leeds We have started your patient on rivaroxaban for the treatment of provoked VTE (deep

More information

Appendix C Factors to consider when choosing between anticoagulant options and FAQs

Appendix C Factors to consider when choosing between anticoagulant options and FAQs Appendix C Factors to consider when choosing between anticoagulant options and FAQs Choice of anticoagulant for non-valvular* atrial fibrillation: Clinical decision aid Patients should already be screened

More information

VOLUME No: 21 04 written by Sara Wilds & Kathryn Buchanan. Date of issue: June 2012 (updated November 2012 following NICE TA 256)

VOLUME No: 21 04 written by Sara Wilds & Kathryn Buchanan. Date of issue: June 2012 (updated November 2012 following NICE TA 256) Prescribing Points A NEWSLETTER FOR ALL HEALTH CARE PROFESSIONALS IN OXFORDSHIRE, WRITTEN BY THE MEDICINES MANAGEMENT TEAM, OXFORDSHIRE PCT, JUBILEE HOUSE, OXFORD BUSINESS PARK SOUTH, OXFORD, OX4 2LH.

More information

Birmingham, Sandwell and Solihull Cardiac and Stroke Network. Rivaroxaban or warfarin for treatment of Atrial Fibrillation: Position statement

Birmingham, Sandwell and Solihull Cardiac and Stroke Network. Rivaroxaban or warfarin for treatment of Atrial Fibrillation: Position statement Birmingham, Sandwell and Solihull Cardiac and Stroke Network Rivaroxaban or warfarin for treatment of Atrial Fibrillation: Position statement Introduction This guidance informs prescribers and commissioners

More information

Dabigatran SCG for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation

Dabigatran SCG for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation South West Essex Dabigatran Shared Care Guideline (SCG) Dabigatran SCG for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation Introduction Indication and Licensing

More information

NORTH WEST LONDON GUIDANCE ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION

NORTH WEST LONDON GUIDANCE ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION North West London CardioVascular & Stroke Network NORTH WEST LONDON GUIDANCE ON ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION Key Messages 1. Efforts should be made to identify patients with Atrial

More information

Prescriber Guide. 20mg. 15mg. Simply Protecting More Patients. Simply Protecting More Patients

Prescriber Guide. 20mg. 15mg. Simply Protecting More Patients. Simply Protecting More Patients Prescriber Guide 20mg Simply Protecting More Patients 15mg Simply Protecting More Patients 1 Dear Doctor, This prescriber guide was produced by Bayer Israel in cooperation with the Ministry of Health as

More information

Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism

Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism Implementation of NICE TA 261 Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism Contents 1. Executive summary 2. Introduction

More information

Novel Oral Anticoagulants (NOACs) Prescriber Update 2013

Novel Oral Anticoagulants (NOACs) Prescriber Update 2013 Novel Oral Anticoagulants (NOACs) Prescriber Update 2013 Indications/Contraindications Indications Orthopedic VTE Prophylaxis VTE Treatment Stroke Prevention for non-valvular AF Contraindications 150 mg

More information

The Role of the Newer Anticoagulants

The Role of the Newer Anticoagulants The Role of the Newer Anticoagulants WARFARIN = Coumadin DAGIBATRAN = Pradaxa RIVAROXABAN = Xarelto APIXABAN = Eliquis INDICATION DABIGATRAN (Pradaxa) RIVAROXABAN (Xarelto) APIXABAN (Eliquis) Stroke prevention

More information

PENINSULA NETWORK GUIDANCE ON NOVEL ANTICOAGULANTS FOR STROKE AND TIA MANAGEMENT 1. Aim/Purpose of this Guideline

PENINSULA NETWORK GUIDANCE ON NOVEL ANTICOAGULANTS FOR STROKE AND TIA MANAGEMENT 1. Aim/Purpose of this Guideline PENINSULA NETWORK GUIDANCE ON NOVEL ANTICOAGULANTS FOR STROKE AND TIA MANAGEMENT 1. Aim/Purpose of this Guideline The aim of this document to guide clinicians on use of novel anticoagulants for stroke

More information

Rivaroxaban for the treatment of Deep Vein Thrombosis in patients unsuitable for vitamin K antagonists

Rivaroxaban for the treatment of Deep Vein Thrombosis in patients unsuitable for vitamin K antagonists Rivaroxaban for the treatment of Deep Vein Thrombosis in patients unsuitable for vitamin K antagonists Traffic light classification- Amber 2 specialist initiation Information sheet for Primary Care Prescribers

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION

STROKE PREVENTION IN ATRIAL FIBRILLATION STROKE PREVENTION IN ATRIAL FIBRILLATION OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention of ischemic stroke and arterial thromboembolism in patients

More information

All Wales Risk/Benefit Assessment Tool for Oral Anticoagulant Treatment in People with Atrial Fibrillation

All Wales Risk/Benefit Assessment Tool for Oral Anticoagulant Treatment in People with Atrial Fibrillation All Wales Risk/Benefit Assessment Tool for Oral Anticoagulant Treatment in People with Atrial Fibrillation October 2013 This report has been prepared by a multiprofessional collaborative group, with support

More information

TA 256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation

TA 256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation Service Notification in response to DHSSPS endorsed NICE Technology Appraisals TA 256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation 1 Name of Commissioning

More information

GRASP-AF Coming to a PCT near you.

GRASP-AF Coming to a PCT near you. GRASP-AF Coming to a PCT near you. ADAS Anticoagulation dosing advisory service Blackpool Teaching Hospitals Trust Sean O'Brien; Anticoagulation Specialist BMS Grasp-AF and the implications on our Anticoagulation

More information

NOAC Prescribing in Patients with Non-Valvular Atrial Fibrillation: Frequently Asked Questions

NOAC Prescribing in Patients with Non-Valvular Atrial Fibrillation: Frequently Asked Questions AC Prescribing in Patients with Non-Valvular Atrial Fibrillation: Frequently Asked Questions FAQ document jointly prepared by NHSGGC Haematology Service & Medicines Infmation On behalf of the Heart MCN

More information

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk Anticoagulation at the end of life Rhona Maclean Rhona.maclean@sth.nhs.uk Content Anticoagulant Therapies Indications for anticoagulation Venous thromboembolism (VTE) Atrial Fibrillation Mechnical Heart

More information

East Kent Prescribing Group

East Kent Prescribing Group East Kent Prescribing Group Rivaroxaban (Xarelto ) Safety Information Approved by the East Kent Prescribing Group. Approved by: East Kent Prescribing Group (Representing Ashford CCG, Canterbury and Coastal

More information

DVT/PE Management with Rivaroxaban (Xarelto)

DVT/PE Management with Rivaroxaban (Xarelto) DVT/PE Management with Rivaroxaban (Xarelto) Rivaroxaban is FDA approved for the acute treatment of DVT and PE and reduction in risk of recurrence of DVT and PE. FDA approved indications: Non valvular

More information

Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation

Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation Drew Baldwin, MD Virginia Mason Seattle, Washington NCVH May 29,

More information

Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008:

Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008: Key Points to consider when prescribing NOACs Introduction Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008: Dabigatran Etexilate (Pradaxa ) 75mg, 110mg, 150mg. Rivaroxaban

More information

FDA Approved Oral Anticoagulants

FDA Approved Oral Anticoagulants FDA Approved Oral Anticoagulants Generic (Trade Name) Warfarin (Coumadin, Jantoven ) 1 FDA approved indication Prophylaxis and treatment of venous thromboembolism (VTE) Prophylaxis and treatment of thromboembolic

More information

Anticoagulants for stroke prevention in atrial fibrillation Patient frequently asked questions

Anticoagulants for stroke prevention in atrial fibrillation Patient frequently asked questions Anticoagulants for stroke prevention in atrial fibrillation Patient frequently asked questions What is atrial fibrillation?...2 What are dabigatran, rivaroxaban and apixaban and what are they used for?...2

More information

Dorset Medicines Advisory Group

Dorset Medicines Advisory Group Shared Care Guideline for prescribing rivaroxaban in the prevention of adverse outcomes after acute management of acute coronary syndrome in adults INDICATION In accordance with NICE TA335 rivaroxaban

More information

The author has no disclosures

The author has no disclosures Mary Bradbury, PharmD, BCPS Clinical Pharmacy Specialist, Cardiac Surgery September 18, 2012 Mary.bradbury@inova.org This presentation will discuss unlabeled and investigational use of products The author

More information

Guidance for prescribing of Dabigatran (Pradaxa ) Rivaroxaban (Xarelto ) and Apixaban (Eliquis ) in Patients with Non-Valvular AF

Guidance for prescribing of Dabigatran (Pradaxa ) Rivaroxaban (Xarelto ) and Apixaban (Eliquis ) in Patients with Non-Valvular AF Guidance for prescribing of Dabigatran (Pradaxa ) Rivaroxaban (Xarelto ) and Apixaban (Eliquis ) in Patients with Non-Valvular AF Lesley Davey Staffordshire and Lancashire CSU November 2013 (Review November

More information

Atrial fibrillation: medicines to help reduce your risk of a stroke what are the options?

Atrial fibrillation: medicines to help reduce your risk of a stroke what are the options? Patient decision aid Atrial fibrillation: medicines to help reduce your risk of a stroke what are the options? http://guidance.nice.org.uk/cg180/patientdecisionaid/pdf/english Published: June 2014 About

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF PHARMACEUTICAL SERVICES I. Requirements for Prior Authorization of Anticoagulants A. Prescriptions That Require Prior Authorization Prescriptions for Anticoagulants

More information

Implementation of NICE TA 249, 256, and 275

Implementation of NICE TA 249, 256, and 275 Dabigatran, rivaroxaban and apixaban, the new oral anticoagulants (NOACS), for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation Implementation of NICE TA 249, 256, and

More information

Version 8, 25 April 2013

Version 8, 25 April 2013 Hertfordshire Implementation of NICE TAs 249, 256 and 275 Apixaban, dabigatran and rivaroxaban, novel oral anticoagulants (NOACs) for the prevention of stroke and systemic embolism in non-valvular atrial

More information

NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation

NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation Date of First Issue 06/06/2012 Approved 06/06/2012 Current Issue Date 29/10/2014 Review Date 29/10/2016 Version 1.4 EQIA Yes 01/06/2012

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND:

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND: STROKE PREVENTION IN ATRIAL FIBRILLATION TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention

More information

Enoxaparin for long term anticoagulation in patients unsuitable for oral anticoagulants

Enoxaparin for long term anticoagulation in patients unsuitable for oral anticoagulants Enoxaparin for long term anticoagulation in patients unsuitable for oral anticoagulants Traffic light classification- Amber 2 Information sheet for Primary Care Prescribers Relevant Licensed Indications

More information

Introduction. Background to this event. Raising awareness 09/11/2015

Introduction. Background to this event. Raising awareness 09/11/2015 Introduction Primary Care Medicines Governance HSCB Background to this event New class of medicines Availability of training Increasing volume of prescriptions Reports of medication incidents Raising awareness

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization MEDICAL ASSISTANCE HBOOK I. Requirements for Prior Authorization of Anticoagulants A. Prescriptions That Require Prior Authorization Prescriptions for Anticoagulants which meet any of the following conditions

More information

Title of Guideline. Thrombosis Pharmacist)

Title of Guideline. Thrombosis Pharmacist) Title of Guideline Contact Name and Job Title (author) Guideline for patients receiving Rivaroxaban (Xarelto ) requiring Emergency Surgery or treatment for Haemorrhage Julian Holmes (Haemostasis and Thrombosis

More information

COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals.

COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals. COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS AND PHYSICIANS TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVES: To provide a comparison of the new

More information

NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation

NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation Date of First Issue 06/06/2012 Approved 06/06/2012 Current Issue Date 06/06/2012 Review Date 06/06/2014 Version 1.1 EQIA Yes /

More information

22-Oct-14. Oral Anticoagulation Which Drug for Which Patient in the era of New Oral Anti-coagulants. Atrial Fibrillation. AF as an embolic risk factor

22-Oct-14. Oral Anticoagulation Which Drug for Which Patient in the era of New Oral Anti-coagulants. Atrial Fibrillation. AF as an embolic risk factor Oral Anticoagulation Which Drug for Which Patient in the era of New Oral Anti-coagulants Dr Scott McKenzie BSc MBBS FRACP FCSANZ Cardiologist, Vascular Physician, Telehealth Specialist, Advanced Heart

More information

Anticoagulants in Atrial Fibrillation

Anticoagulants in Atrial Fibrillation Anticoagulants in Atrial Fibrillation Starting and Stopping Them Safely Carmine D Amico, D.O. Overview Learning objectives Introduction Basic concepts Treatment strategy & options Summary 1 Learning objectives

More information

An Audit of the Documentation and Correct Referral of Patients on Initiation of New Oral Anticoagulants (Dabigatran, Rivaroxaban, Apixaban)

An Audit of the Documentation and Correct Referral of Patients on Initiation of New Oral Anticoagulants (Dabigatran, Rivaroxaban, Apixaban) Sabiha Fatima Hussaini Sabiha.hussaini@salisbury.nhs.uk An Audit of the Documentation and Correct Referral of Patients on Initiation of New Oral Anticoagulants (Dabigatran, Rivaroxaban, Apixaban) April

More information

TSOAC Initiation Checklist

TSOAC Initiation Checklist Task Establish appropriate dose based on anticoagulant selected, indication and patient factors such as renal function. Evaluate for medication interactions that may necessitate TSOAC dose adjustment.

More information

XARELTO (RIVAROXABAN) PRESCRIBER GUIDE

XARELTO (RIVAROXABAN) PRESCRIBER GUIDE XARELTO (RIVAROXABAN) PRESCRIBER GUIDE Prescribing information found on pages 16-17 This guide is to be used to support the appropriate use of Xarelto in the following indications: Prevention of stroke

More information

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 New Treatments for Stroke Prevention in Atrial Fibrillation John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 Classification Paroxysmal atrial fibrillation (AF) Last < 7

More information

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Antiplatelet and Antithrombotic Therapy Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Disclosure of Potential for Conflict of Interest Dr. F.C. Grant Atrial Fibrillation FINANCIAL DISCLOSURE:

More information

Traditional anticoagulants

Traditional anticoagulants TEGH Family Practice Clinic Day April 4, 03 Use of Anticoagulants in 03: What s New (and What Isn t) Bill Geerts, MD, FRCPC Director, Thromboembolism Program, Sunnybrook HSC Professor of Medicine, University

More information

Implementation of NICE TAs 261 and 287

Implementation of NICE TAs 261 and 287 Corby Clinical Commissioning Group Kettering General Hospital NHS Trust Nene Clinical Commissioning Group Northampton General Hospital NHS Trust Northamptonshire Healthcare Foundation Trust Implementation

More information

Novel Oral Anticoagulants and Warfarin Comparative evidence and Information for Prescribers

Novel Oral Anticoagulants and Warfarin Comparative evidence and Information for Prescribers Novel Oral Anticoagulants and Warfarin Comparative evidence and Information for Prescribers How does it work? Dose and Administration Monitoring Warfarin Dabigatran Rivaroxaban Apixaban Warfarin has an

More information

Primary prevention of venous thromboembolic events in adult patients who have undergone elective total hip or knee replacement surgery.

Primary prevention of venous thromboembolic events in adult patients who have undergone elective total hip or knee replacement surgery. PRADAXA (DABIGATRAN ETEXILATE) PRESCRIBER GUIDE FOR PRIMARY PREVENTION OF VENOUS THROMBOEMBOLIC EVENTS (VTE) FOLLOWING ELECTIVE TOTAL HIP OR KNEE REPLACEMENT SURGERY This guide provides recommendations

More information

Dabigatran (Pradaxa) Guidelines

Dabigatran (Pradaxa) Guidelines Dabigatran (Pradaxa) Guidelines Dabigatran is a new anticoagulant for reducing the risk of stroke in patients with atrial fibrillation. Dabigatran is a direct thrombin inhibitor, similar to warfarin, without

More information

NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST

NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST NGAIRE IS 70 YEARS OLD AND IN AF. SHE HAS NO MURMURS, NORMAL BLOOD PRESSURE, EGFR OF 65ML/MIN AND NO SIGNIFICANT PAST MEDICAL HISTORY. REGARDING

More information

NHS DORSET CLINICAL COMMISSIONING GROUP POSITION STATEMENT ON ORAL ANTICOAGULANTS IN ATRIAL FIBRILLATION

NHS DORSET CLINICAL COMMISSIONING GROUP POSITION STATEMENT ON ORAL ANTICOAGULANTS IN ATRIAL FIBRILLATION Version 3 August 2014 NHS DORSET CLINICAL COMMISSIONING GROUP POSITION STATEMENT ON ORAL ANTICOAGULANTS IN ATRIAL FIBRILLATION Dorset CCG commissions the use of newer oral anti-coagulants in accordance

More information

Translating clinical evidence into real-world outcomes

Translating clinical evidence into real-world outcomes Annual Swiss Stroke Society Meeting 31st of January 2013 Symposium: From RE-LY to practice: Changing the attitude on stroke prevention in AF Translating clinical evidence into real-world outcomes Unité

More information

New Oral Anticoagulants

New Oral Anticoagulants New Oral Anticoagulants Tracy Minichiello, MD Associate Professor of Medicine Chief, San FranciscoVA Anticoagulation and Thrombosis Service Ansell, J. Hematology Copyright 2010 American Society of Hematology.

More information

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) The prevention of stroke and systemic embolism in atrial fibrillation (AF) with warfarin and New Oral Anticoagulants Warfarin remains the first-line option

More information

Xarelto (rivaroxaban) Prescriber Guide November 2012

Xarelto (rivaroxaban) Prescriber Guide November 2012 Xarelto (rivaroxaban) Prescriber Guide November 2012 Simple Protection for More Patients 2 Xarelto Prescriber Guide Patient Alert Card 4 Dosing Recommendations 4 Dosing in patients with atrial fibrillation

More information

NWMIC Medicines FAQ. New oral anticoagulants (NOACs) and management of dental patients - Dabigatran, rivaroxaban and apixaban.

NWMIC Medicines FAQ. New oral anticoagulants (NOACs) and management of dental patients - Dabigatran, rivaroxaban and apixaban. NWMIC Medicines FAQ New oral anticoagulants (NOACs) and management of dental patients - Date prepared: May 2013, updated November 2013 Summary In primary care; Consider liaising with the local hospital

More information

AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation

AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation A Statement for Healthcare Professionals from the American Heart Association/American Stroke

More information

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012 New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation Joy Wahawisan, Pharm.D., BCPS April 25, 2012 Stroke in Atrial Fibrillation % Stroke 1991;22:983. Age Range (years) CHADS 2 Risk

More information

PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent Primary Care Center

PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent Primary Care Center Speaker Introduction Jessica Wilhoite, PharmD, BCACP Doctor of Pharmacy: Purdue University Postgraduate Residency Training: PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent

More information

Uncontrolled when printed. Version 1.1. Acute Sector. Lead Author/Co-ordinator: Mr Simon Barker Consultant Orthopaedic Surgeon Julie Fraser

Uncontrolled when printed. Version 1.1. Acute Sector. Lead Author/Co-ordinator: Mr Simon Barker Consultant Orthopaedic Surgeon Julie Fraser Acute Sector NHS Grampian Staff Local Treatment Protocol For Venous Thromoboembolic Prophylaxis Using Rivaroxaban 10mg Tablets In Adult Patients Undergoing Elective Hip Or Knee Replacement Surgery. Lead

More information

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Family physician with Rivergrove Medical Clinic Practice in the north end since 1985 Medical Director of the Wellness

More information

Clinical Guideline N/A. November 2013

Clinical Guideline N/A. November 2013 State if the document is a Trust Policy/Procedure or a Clinical Guideline Clinical Guideline Document Title: Document Number 352 Version Number 1 Name and date and version number of previous document (if

More information

New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011

New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011 New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011 Warfarin Decreases stroke risk by 60-70% Superior to ASA and ASA plus clopidogrel

More information

XARELTO (RIVAROXABAN) PRESCRIBER GUIDE

XARELTO (RIVAROXABAN) PRESCRIBER GUIDE XARELTO (RIVAROXABAN) PRESCRIBER GUIDE Prescribing information found on pages 22-23 This guide is to be used to support the appropriate use of Xarelto in the following indications: Prevention of stroke

More information

Patient frequently asked questions

Patient frequently asked questions Patient frequently asked questions What is atrial fibrillation?...2 What are dabigatran and rivaroxaban and what are they used for?...2 Which is better, dabigatran or rivaroxaban?...2 For patients with

More information

rivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (756/12) Bayer PLC

rivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (756/12) Bayer PLC rivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (756/12) Bayer PLC 13 January 2012 The Scottish Medicines Consortium (SMC) has completed its assessment of the above product and advises NHS

More information

NHS FORTH VALLEY RIVAROXABAN AS TREATMENT FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM IN ADULTS

NHS FORTH VALLEY RIVAROXABAN AS TREATMENT FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM IN ADULTS NHS FORTH VALLEY RIVAROXABAN AS TREATMENT FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM IN ADULTS Date of First Issue 01/12/ 2012 Approved 15/11/2012 Current Issue Date 29/10/2014 Review Date 29/10/2016

More information

Donepezil (Aricept ), Galantamine (Reminyl XL ), Rivastigmine (Exelon ) and Memantine (Ebixa )

Donepezil (Aricept ), Galantamine (Reminyl XL ), Rivastigmine (Exelon ) and Memantine (Ebixa ) Donepezil (Aricept ), Galantamine (Reminyl XL ), Rivastigmine (Exelon ) and Memantine (Ebixa ) ESCA: For the treatment of Alzheimer s disease. SECONDARY CARE SECTION TO BE COMPLETED BY INITIATING DOCTOR

More information

Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical

Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical Center A.Fib affects 2.2 million Americans. The lifetime

More information

XARELTO (RIVAROXABAN) EDUCATIONAL PACK FOR 15MG AND 20MG DOSING

XARELTO (RIVAROXABAN) EDUCATIONAL PACK FOR 15MG AND 20MG DOSING XARELTO (RIVAROXABAN) EDUCATIONAL PACK FOR 15MG AND 20MG DOSING NOW UPDATED A N D I N C L U D E S A NEW INDICATION Prevention of stroke and systemic embolism in eligible adult patients with non-valvular

More information

Pathway for the management of DVT in primary Care

Pathway for the management of DVT in primary Care Pathway for the management of DVT in primary Care Final Version: Approved by NHS DGS CCG: June 2015 This document aims to support practices in DGS CCG in the Management & Treatment of patients with suspected

More information

**Form 1: - Consultant Copy** Telephone Number: Fax Number: Email: Author: Dr Bernard Udeze Pharmacist: Claire Ault Date of issue July 2011

**Form 1: - Consultant Copy** Telephone Number: Fax Number: Email: Author: Dr Bernard Udeze Pharmacist: Claire Ault Date of issue July 2011 Effective Shared Care Agreement for the treatment of Dementia in Alzheimer s Disease Donepezil tablets / orodispersible tablets (Aricept / Aricept Evess ) These forms (1 and 2) are to be completed by both

More information

Low Molecular Weight Heparin. All Wales Medicines Strategy Group (AWMSG) Recommendations and advice

Low Molecular Weight Heparin. All Wales Medicines Strategy Group (AWMSG) Recommendations and advice Low Molecular Weight Heparin All Wales Medicines Strategy Group (AWMSG) Recommendations and advice Starting Point Low Molecular Weight Heparin (LMWH): Inhibits factor Xa and factor IIa (thrombin) Small

More information

MEDICAL ASSISTANCE BULLETIN

MEDICAL ASSISTANCE BULLETIN ISSUE DATE June 22, 2015 SUBJECT EFFECTIVE DATE MEDICAL ASSISTANCE BULLETIN NUMBER *See below BY Prior Authorization of Anticoagulants Pharmacy Service Leesa M. Allen, Deputy Secretary Office of Medical

More information

Common Questions and Answers on the Practical Use of Oral Anticoagulants in Non-Valvular Atrial Fibrillation

Common Questions and Answers on the Practical Use of Oral Anticoagulants in Non-Valvular Atrial Fibrillation Common Questions and Answers on the Practical Use of Oral Anticoagulants in Non-Valvular Atrial Fibrillation South West Medicines Information and Training and Regional Drug and Therapeutics Centre (Newcastle)

More information

Anticoagulant therapy

Anticoagulant therapy Anticoagulation: The risks Anticoagulant therapy 1990 2002: 600 incidents reported 120 resulted in death of patient 92 deaths related to warfarin usage 28 reports related to heparin usage Incidents in

More information

Volume 7; Number 19 November 2013

Volume 7; Number 19 November 2013 Greater East Midlands Commissioning Support Unit in association with Lincolnshire Clinical Commissioning Groups, Lincolnshire Community Health Services, United Lincolnshire Hospitals Trust and Lincolnshire

More information

CCPN SPAF Tool. www.ccpn.ca STROKE PREVENTION IN ATRIAL FIBRILLATION (SPAF): POCKET REFERENCE

CCPN SPAF Tool. www.ccpn.ca STROKE PREVENTION IN ATRIAL FIBRILLATION (SPAF): POCKET REFERENCE SEPTEMBER 2012 CCPN SPAF Tool STROKE PREVENTION IN ATRIAL FIBRILLATION (SPAF): POCKET REFERENCE Approximately 20% of all strokes are attributable to Atrial Fibrillation (AF). 1 Of these, 20% will result

More information

A Patient s Guide to Antithrombotic Therapy in Atrial Fibrillation

A Patient s Guide to Antithrombotic Therapy in Atrial Fibrillation Patient s Guide to Antithrombotic Therapy in Atrial Fibrillation A Patient s Guide to Antithrombotic Therapy in Atrial Fibrillation PATIENT EDUCATION GUIDE What is atrial fibrillation? Atrial fibrillation

More information

Time of Offset of Action The Trial

Time of Offset of Action The Trial New Antithrombotic Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant Amgen Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University What I am Talking About

More information

ACCIDENT AND EMERGENCY DEPARTMENT/CARDIOLOGY

ACCIDENT AND EMERGENCY DEPARTMENT/CARDIOLOGY Care Pathway Triage category ATRIAL FIBRILLATION PATHWAY ACCIDENT AND EMERGENCY DEPARTMENT/CARDIOLOGY AF/ FLUTTER IS PRIMARY REASON FOR PRESENTATION YES NO ONSET SYMPTOMS OF AF./../ TIME DURATION OF AF

More information

Management of non-valvular Atrial Fibrillation

Management of non-valvular Atrial Fibrillation DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) Management of non-valvular Atrial Fibrillation Guidelines for anticoagulation apply to paroxysmal, persistent and permanent AF and atrial flutter. Do

More information

Xarelto (rivaroxaban) Prescriber Guide

Xarelto (rivaroxaban) Prescriber Guide Xarelto (rivaroxaban) Prescriber Guide Simple Protection For More Patients 2 Xarelto Prescriber Guide Patient Alert Card 4 Dosing Recommendations 4 Dosing in patients with atrial fibrillation 4 Patients

More information

Drug name: RIVAROXABAN (Xarelto ) For the treatment of acute venous thromboembolism in adult patients.

Drug name: RIVAROXABAN (Xarelto ) For the treatment of acute venous thromboembolism in adult patients. Drug name: RIVAROXABAN (Xarelto ) For the treatment of acute venous thromboembolism in adult patients. DOCUMENT TO BE SCANNED INTO ELECTRONIC RECORDS AS AND FILED IN NOTES Patient Name : Date of Birth:

More information

Prescribing Framework for Donepezil in the Treatment and Management of Dementia

Prescribing Framework for Donepezil in the Treatment and Management of Dementia Hull & East Riding Prescribing Committee Prescribing Framework for Donepezil in the Treatment and Management of Dementia Patients Name:.. NHS Number: Patients Address:... (Use addressograph sticker) GP

More information