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FIBRILLATIONINSALFORDPATIENTS
Version2
December2012
1.Background
Threeneworalanticoagulants(NOAC)drugsdabigatran,rivaroxabanandapixabanhavebeenlicensedintheUKforthe
managementofpatientswithAtrialFibrillation(AF).
NICEhavereviewedtwoofthecurrentlylicenseddrugs:
Dabigatran(Pradaxa)NICETA249;Dabigatranetexilateforthepreventionofstrokeandsystemic
embolisminatrialfibrillation
Rivaroxaban(Xarelto)NICETA256;Rivaroxabanforthepreventionofstrokeandstrokeandsystemic
embolisminatrialfibrillation
NICEguidanceonApixaban(Eliquis)isdueApril2013.
Thesedrugsarenewtomarketandthepotentiallongtermsideeffectsarenotyetfullyknown.Concernsalsoincludethat
theoptimalmethodofemergencyreversaloftheanticoagulanteffectsoftheseagentsiscurrentlyunclearinthosepatients
whopresentwithmajorbleeding.Therearealsoconcerns,highlightedbytheMHRAregardingdabigatranuseinrenal
insufficiencyasexposureissubstantiallyincreasedinthesepatients.Thebenefitsofdabigatranandrivaroxabanover
warfarindeclineasINRcontrolonwarfarinincreases.Inpatientswherewarfariniswellcontrolled(timeintherapeuticrange
[TTR]>65%),theuseofdabigatranorrivaroxabanmaybelessfavourable.Onthisbasis,theuseofthesedrugsshouldbe
implementedcarefullyandtargetedtothosepatientsthatarelikelytogainthemostbenefitfromthemi.e.patientspoorly
controlledonwarfarinorthoseeligiblefor,butchoosenottobeanticoagulatedwithwarfarin.
2.ImplementationinSalford
TheGreaterManchesterandCheshireCardiacandStrokeNetwork(GMCCSN)haveproducedguidancetoensurethereisa
plannedintroductionforthesedrugs.Guidancedocumentshavebeendevelopedandfulldocumentsareavailableonthe
GMCCSNwebsite.ThisguidancehaswarfarinasfirstlinetreatmentunlesscommencementofaNOACisclinically
appropriateoritisthepatientschoicetocommenceNOAC(withinlicensedindications).ThisisinlinewithNICETA249and
NICETA256.AllpatientscommencinganticoagulanttreatmentmusthaveaCHA2DS2VASC>1.
FurtherclarificationonCHA2DS2VASCof1
ItisadvisedbytheEuropeanSocietyGroupwhodevelopedthe2010ESCguidanceonAFthatscoring1pointforfemalesex
shouldbeappliedonlytofemalesaged65orover.
3.ManagedentryofNewOralAnticoagulants(NOAC)initiatingandswitchinganticoagulanttherapysafely
Toensurethatprescribingofthesenewdrugsiscontrolledandappropriate,allnewinitiationsofNOACwillbemonitoredby
theNHSSalfordCCGlocalitymedicinesmanagementteam.Therewillbenoformalgatekeeperrole,butthesedrugshave
notbeenapprovedforanyofflabeluseinprimarycareexceptinlinewiththecardiacnetworkalgorithm(seefigure1).
3.1Acutesetting(SRFT)
PatientswhoarediagnosedwithAFwhilstaninpatientatSRFT,maybecommencedonwarfarinasperexistingprotocols.If,
afteranindepthdiscussionwiththeconsultant,theyrequestaNOACthenSRFTwillberesponsibleforensuringallelements
oftheprescribingchecklist(appendix4)arecompletedandthatthisiscommunicatedtotheGP.Patientswhoare
commencedonanticoagulationforAFshouldhaveaCHA2DS2VASCscore>1
3.2PatientswithadiagnosisofAFalreadyprescribedwarfarin(underthecareoftheanticoagulantclinic)
Theanticoagulantclinicwillreviewpatientscurrentlyprescribedwarfarin/sinthrometoidentifythosepatientswhoare
currentlyinadequatelycontrolledandmeetthecriteriaasspecifiedbythecardiacnetworkguidance:
TheINR%oftimeinthetherapeuticrangeof23lessthat65%(unexplained)(asdeterminedbytheRosendaal
method)and/or
INR>5morethan2time(in12months)(unexplained)and/or
Otherclinicalconsideratione.g.intolerancethatmustbespecifiedinthereferraltotheGP
Followingreview,thesepatientswillbehighlightedandacommunicationletter(seeappendix3)willbesentfromthe
anticoagulantclinictotheGP.ThiswillbetoadvisetheGPto:
1.UndertakeaCHA2DS2VASCscore
2.Followtheappropriatealgorithm(seefigure1below)dependentuponthepatientsscore.
3.IfthepatientsCHA2DS2VASCscoreis>1andwarfarin/sinthrometreatmenthasnotledtoadequatecontrol
(asperGMcriteria),aneworalanticoagulantagent(NOAC)shouldbecommenced.
4.Patientsmedicalhistory(e.g.renalimpairment),concomitantdrugs/interactionse.g.verapamilshouldbe
reviewedpriortocommencingNOAC.
5.Inthemajorityofcases,patientswillalreadybeprescribedwarfarinandwillneedtohavetherapyswitchedover.
Thiswillrequireliaisonwiththeanticoagulantclinicaswarfarin/sinthromeiswithdrawn.
6.ToaidswitchingofanticoagulationtoNOACorcommencementofNOAC,patientinformationleafletsare
availablefordabigatranandrivaroxaban,bothcontainingapatientalertcardthatthepatientisadvisedtokeep
ontheirpersonandshowtohealthcareprofessionalspriortotreatment.Anticoagulantclinicshavestocksof
theseortheycanbeobtaineddirectlyfromthemanufacturer.Inaddition,toensuresafechangeoverof
medicationfromwarfarin/sinthrometoNOAC,asummarychecklistcanbefoundinappendix2.
7.Asummaryoftheoralanticoagulantscurrentlyavailableforthisindicationcanbefoundinappendix5tosupport
treatmentchoice.
3.3PatientswithanewdiagnosisofAF,identifiedbytheGP
PatientswhohaveanewdiagnosisofAF(withaCHA2DS2VASCscore>1)shouldbecommencedonwarfarinifnot
contraindicated,unlessafteranindepthdiscussionwiththeGP,theyrequestaNOAC.IfaNOACistobecommenced,follow
theflowchartinappendix1.
Ifwarfarinistobecommenced,referimmediatelytotheanticoagulantclinicforcommencementofwarfarin.
Ifafter3monthsthepatienthas:
TheINR%oftimeinthetherapeuticrangeof23lessthan65%unexplained(asdeterminedbytheRosendaal
method)and/or
INR>5morethan2timesunexplained(in12months)
Thentheyshouldbereviewedasaboveinsection3.2
3.4PatientswithanewdiagnosisofAF,identifiedbysecondarycareoutpatients
PatientswhohaveanewdiagnosisofAF(withaCHA2DS2VASCscore>1)shouldbecommencedonwarfarinunless
contraindicatedorafteranindepthdiscussionwiththeconsultanttheyrequestaNOAC.Patientsshouldbeinformedthat
theirGPwillneedtoreviewthemforappropriatenessofaNOAC.SecondarycareshouldthenrequestthattheGPreviews
thepatientsand,ifappropriateafterafurtherinformeddiscussioncommencesaNOAC.IfaNOACistobecommenced,
ensuretheprescribingchecklistiscompleted(appendix4).Secondarycaredonotneedtoinformthelocalitymedicines
managementteamattheCCGasthereisnolongeragatekeeperrole.
Ifthepatientistobecommencedonwarfarin,theGPshouldreferthepatientthroughtothenewstartanticoagulationclinic
ASAPandinformthepatientssecondarycareconsultantthatthepatienthasbeenanticoagulated.TheGPwillthen
prescribewarfarinaspercurrentarrangements.Theanticoagulationofthesepatients(witheitherwarfarinoraNOAC)
remainstheresponsibilityoftheGPtoarrangeinatimelymannerwithoutdelay.
3.5PatientswithadiagnosisofAFwhoarenotanticoagulated
GPsshouldreviewallpatientsontheirAFregistersandidentifythosepatientswhoarenotonanytreatmentorwhohave
chosentotakeaspirin.ThesepatientsshouldbereviewedandiftheirCHA2DS2VASC>1andtheydecidethattheydonot
wishtotakewarfarinthentheoptiontotakeaNOACshouldbediscussedwiththepatient,bearinginmindseveralofthe
contraindicationstowarfarinalsoapplytotheNOACdrugs(seeappendix5).
4.Miscellaneousinformation
4.1NOACgeneralsafetyinformation
TheMHRAissuedadrugsafetyupdateforDabigatraninDecember2011afteranumberofserousandfatalhaemorrhages
werereportedinelderlypatientswithrenalimpairment.TheyalsoreleasedafurtherdrugsafetyupdateinJuly2012which
clarifiesthetypeofclinicalconditionsandmedicinesthatarecontraindicatedforusewithdabigatran,tohelpminimisethe
knownriskofhaemorrhage.
Dabigatranisalsonowcontraindicatedwithdronedarone,andwiththeuseofotheranticoagulantagents,exceptwhen
switchingtherapytoorfromdabigatran,orwiththeuseofunfractionatedheparinformaintenanceofvenousorarterial
catheterpatency.Italsoremindsprescribersabouttheimportanceofmonitoringrenalfunctioninpatientswhoreceive
dabigatran.
CardiologyhaveadvisedthatduetoalackofdataitisadvisabletoavoidtheuseofNOACsincombinationwithaspirin
>100mganddualantiplatelettherapy.Inaddition,coumarinsratherthenNOACsshouldbeusedinallpatientswith
rheumaticheartdiseasecausinganydegreeofmitralstenosisandthosewithsevereaorticstenosisofanycause.
4.2NOACuseinpatientswithreducedrenalorhepaticfunction
Theyrecommendedthatrenalfunctionshouldbeassessedinallpatientsbeforecommencingdabigatrantreatmentandat
leastonceayearinpatientsolderthan75orthosewithsuspecteddeclineinrenalfunction.Dabigatraniscontraindicatedin
patientswithsevererenalimpairment(CRCl<30ml/min).Patientswithelevatedliverenzymes>2ULNwereexcludedfrom
thestudyinvestigatingthepreventionofstrokeandSEEassociatedwithatrialfibrillation.Notreatmentexperienceis
availableforthissubpopulationofpatients,andthereforetheuseofdabigatranisnotrecommendedinthispopulation.
Forrivaroxaban,cautionisrequiredinpatientswithsevererenalimpairment(creatinineclearance<30mL/min)ormoderate
hepaticimpairment.Itisnotrecommendedinpatientswithacreatinineclearanceoflessthan15mL/min.Limitedclinical
dataforpatientswithsevererenalimpairment(creatinineclearance1529ml/min)indicatethatrivaroxabanplasma
concentrationsaresignificantlyincreasedtherefore,rivaroxabantobeusedwithcautioninthesepatients.Rivaroxabanis
alsocontraindicatedinpatientswithhepaticdiseaseassociatedwithcoagulopathyandclinicallyrelevantbleedingrisk,andis
notrecommendedinthosealsotakingstronginhibitorsofcytochromeP3A4enzymeorPglycoprotein,suchastheazole
antimycotics(eg,ketoconazole)orHIVproteaseinhibitors(eg,ritonavir).
4.3NOACsinmonitoreddosingsystems(MDS)
Dabigatranmustremaininitsoriginalpackingupuntilitistakentoprotectitfrommoisture.IfitwastogointoanMDS,then
thewholeblisterwouldneedtogoinandthepatientwouldhavetopeelthebackingoffpriortotaking(notpushitthrough
asthismaydamagethecoating).InpracticethisisnotworkableandthesizewouldlimititgoingintomostoftheMDS
systemsthatcommunitypharmacistsuse.
RivaroxabandoesnothaveanyspecificstoragerequirementsandsomaybeanoptionifthepatientrequiresanMDS.
4.3OpeningofDabigatrancapsules
Theoralbioavailabilitymaybeincreasedby75%comparedtothereferencecapsuleformulationwhenthepelletsaretaken
withouttheHydroxypropylmethylcellulose(HPMC)capsuleshell.Hence,theintegrityoftheHPMCcapsulesshouldalwaysbe
preservedinclinicalusetoavoidunintentionallyincreasedbioavailabilityofdabigatranetexilate.Therefore,patientsshould
beadvisednottoopenthecapsulesandtotakethepelletsalone(e.g.notsprinkledoverfoodorintobeverages).
4.5NOACdiscontinuation
IntheRELYstudymoredabigatransubjectsdiscontinuedstudymedicationduetoadverseeffectscomparedwithwarfarin
subjects.Gastrointestinaladverseevents(e.g.,dyspepsia,gastrointestinalhaemorrhage,nausea)occurredmorefrequently
withdabigatranvs.warfarin(35%vs.24%)andwerethemostfrequentlyreportedadverseeventsresultingintreatment
discontinuation.Theriskofdyspepsiawithdabigatranwashighestwithinthefirstfewweeksoftreatment.Dyspepsiacanbe
reducedbytakingdabigatranwithfood,butitisnotimprovedbyaddingaPPI.
Forrivaroxaban,inROCKETAFthetotalnumberofsubjectswhopermanentlydiscontinuedstudydrugwassimilarbetween
thetwotreatmentgroups:rivaroxabansubjects35.44%andwarfarinsubjects34.64%.TheKaplanMeierestimated
cumulativediscontinuationratesat1and2yearswere21.83%and34.72%forrivaroxabanand21.12%and33.52%for
warfarin,respectively.
Thenumberofsubjectsreceivingrivaroxabanwhopermanentlydiscontinuedstudydrugforbleedingadverseevents:304
(4.28%)subjectsintherivaroxabangroupcomparedwith219(3.07%)subjectsinthewarfaringroup.
Patientsondabigatranorrivaroxabanshouldtherefore,beadvisedtotakethesemedicationswithfood,toincrease
absorptionandreduceheartburn.
4.6Misseddoses
Dabigatranistakentwiceadayandtheadviceonmisseddosesis;aforgottendosecanstillbetakenupto6hourspriorto
thenextduedose.Amisseddoseshouldbeomittediftheremainingtimeisbelow6hourspriortothenextduedose.Donot
takeadoubledosetomakeupformissedindividualdoses.
Rivaroxabanistakenoncedailyandpatientsareadvisediftheyhavemissedadose,takeitassoonastheyremember.Do
nottakemorethanonetabletinasingledaytomakeupforaforgottendose.Takethenexttabletonthefollowingdayand
thencarryontakingonetabletonceaday.
4.7PreoperativemanagementofpatientstakingNOACs
Dabigatran
ThetimetostoppingtreatmentpriortosurgerydependsonthepatientsrenalfunctionandisdetailedintheSPCandis
summarisedbelow.
Rivaroxaban
Ifaninvasiveprocedureorsurgicalinterventionisrequired,rivaroxabanshouldbestoppedatleast24hoursbeforethe
interventionifpossibleandbasedontheclinicaljudgementofthephysician.Iftheprocedurecannotbedelayed,the
increasedriskofbleedingshouldbeassessedagainsttheurgencyoftheintervention.Rivaroxabanshouldberestartedafter
theinvasiveprocedureorsurgicalinterventionassoonaspossible,providedtheclinicalsituationallowsandadequate
haemostasishasbeenestablished.
Bridgingtherapy
OccasionallysomepatientsmayrequirebridgingtherapywithLMWH.Secondarycarewilladviseregardingthisonacaseby
casebasis.
4.8SwitchingpatientsfromNOACsbacktowarfarin
SomepatientsmaynotbeabletotolerateaNOACandsomayhavetoconvertbacktowarfarin
Dabigatrantowarfarin
Whenconvertingfromdabigatrantowarfarin,adjustthestartingtimeofwarfarinbasedoncreatinineclearanceasfollows:
CrCL 50ml/min,startwarfarin3daysbeforediscontinuingdabigatran.
CrCL 30<50ml/min,startwarfarin2daysbeforediscontinuingdabigatran.
BecausedabigatrancancontributetoanelevatedINR,theINRwillbetterreflectwarfarinseffectafterdabigatranhasbeen
stoppedforatleast2days.
Rivaroxabantowarfarin
Whenconvertingfromrivaroxabantowarfarin,warfarinshouldbegivenconcurrentlyuntiltheINRis 2.0.Forthefirsttwo
daysoftheconversionperiod,standardinitialdosingofwarfarinshouldbeusedfollowedbywarfarindosingguidedbyINR
testing.Whilepatientsareonbothrivaroxabanandwarfarin,theINRshouldnotbetestedearlierthan24hoursafterthe
previousdosebutpriortothenextdoseofrivaroxaban.
OncerivaroxabanisdiscontinuedINRtestingmaybedonereliablyatleast24hoursafterthelastdose.
PatientswhohavediscontinuedwarfarinandmovedontoNOACtreatmentwhothenneedtorevertbacktowarfarin
treatmentwillneedtogobackintotheanticoagulantserviceasanewstartastheywillhavebeendischargedfromthis
service.
Figure1:GM&CCardiacNetworkalgorithmfollowingCHA2DS2VASC
Appendix1:PatientflowchartforswitchingfromwarfarintoaNOAC
Patientreviewedinprimarycare.Patient Patientreviewedinanticoagulantclinic
unabletoachieveINRcontrolandisunder (ACC).Patientinadequatelycontrolledon
coagulatedINR<2onwarfarin/sinthromeat warfarin/Sinthromeatpresent.
present.
PatientmeetsGreaterManchestercriteriafor
neworalanticoagulants
(NOAC)(seeGMCCNguidance)
Yes Patientsuitable No
forNOACs
ACC:ReferbacktoGPto
GPActions discussoptionswith
Checksrenalfunction patient
ChecksCHADs2scoreandthatpatientfitslicence
criteriaorGMCCNguidanceforNOAC
Seespatientanddiscussespros&conson
treatment,sideeffects,importanceofcompliance
Dabigatran:IfINR>2IssueACUTEprescriptionfor
1/12NOACDabigatrantobetakenwhenINR<2
managedbyACC
Rivaroxaban:IfINR>3IssueACUTEprescriptionfor
1/12NOACRivaroxabantobetakenwhenINR<3
managedbyACC
IfINR<2NOACcanbecommencedbyGPandpatient
dischargedfromACC
Checksnointeractingdrugs
BookF/Uappointmentfor1/12
Anticoagulationclinic
MonitorINRuntil<2or3andpatientcancommence
NOAC
ReinforcecounsellingaroundNOAC
DischargefromA/Cclinic
PatientcommencesNOAC
GP
Seenagainat1/12
Compliance,sideeffectsreviewed
NOACissuedmonthlyonrepeat
GPannualreviewtomonitorrenal PatientunabletotolerateNOAC
functionandconcordance ConsideranalternativeNOAC
Ifgoesbackonwarfarinmanageas
intextrerefertoanticoagulation
clinicasnewstart
Appendix2:GuidelineforswitchingfromvitaminKantagonists(VKA)e.g.warfarintoaneworal
anticoagulanttherapy(NOAC)
(Inadditionseepatientflowchart)
GPistodiscusspossiblechangewithpatientandexplainreasonrisks/benefits
Consultwithanticoagulantclinicsiforalanticoagulantswitchingisrequired
Ifpatientconsentstochange:
Checkrenalfunction/LFTrequired
Considerdosetobeprescribedbasedonpatientage/renalfunctionseeSPC/appendix4
Reviewmedicationsforpotentialdruginteractions
Contactanticoagulantclinicandinformthemofimpendingconversationandbeadvisedtostopwarfarinwhen
patientattendsandwhentheclinicwillcheckINR
Givepatientanacuteprescriptionsothatpharmacistcanarrangesupply
VitaminKantagonisttobediscontinuedfor2days
PatientsINRmonitoredatclinic
INRtobetakenafter2daysomission
FordabigatranifINR<2NOACcancommence
ForrivaroxabanifINR<3NOACcancommence
GivethepatientanalertcardandpatientinformationleafletfortheNOAC
Ensurepatient/carersareawaretosendredundantwarfarinsupplybacktothepharmacyforsafe
destruction
EnsurerecallforannualU&Eisontheclinicalsystem.
Adverseeventsshouldbereported.Reportingformsandinformationcanbefoundatwww.yellowcard.gov.uk.Adverse
eventsshouldalsobereportedtoBoehringerIngelheimDrugsafetyon08003281627(freephone)fordabigatranorBayer
plcon01635563500forrivaroxaban.
Appendix3TemplatelettersentfromanticoagulationclinictoGP
Communityanticoagulationservice
DrBThinner
ThePractice
Salford
M56FW
Date
DearDrBThinner
Re:MrIRBeat24ACleveleysAvenue,Swinton,SalfordM27OLL
HospNo: 1000000
NHSNo: 6000000000
DateofBirth: 2/7/1945
Thispatientiscurrentlyunderourcareformonitoringofwarfarintherapy.Forthereasonshighlightedbelow,weare
requestingaGPreviewofthispatientsanticoagulationtherapyneedsinordertodecidedwhichdrugisbestforoptimal
strokepreventioninthisindividual.
TheINR%oftimeinthetherapeuticrangeof23lessthan65% Y/N
(TTRshouldbemeasuredforindividualpatientsusingtheRosendaalMethod)
UnexplainedINR>5morethan2times(in12months) Y/N
Otherclinicalconsiderations Y/N
Intolerancetowarfarin
Newlydiagnosedpatientforadvice
Newreferralpoststroke/TIA
Otherpleasestate
ReviewofanticoagulationtherapyshouldbeundertakeninlinewithGreaterManchestertreatmentalgorithms,includinga
reviewoftheindividualsCHADS2/VASCscorewhichwilldetermineifaneworalanticoagulantdruge.g.dabigatran/
rivaroxabanisindicatedasareplacementforwarfarin.
AdetailedguideonhowtomangethetransitionofthesepatientsisavailableonthePCTintranetat
http://nww.salfordpct.nhs.uk/MedicinesManagement/documents/NOAC.pdf
Wewouldbegratefulifyouwouldinformusassoonaspossibleofyourdecision.Pleasefeelfreetocontactmeon(insert
contactnumber)ifyouwishtodiscussthismatter.FurtherinformationcanalsobeobtainedfromtheCCGmedicines
managementteam.
Yourssincerely
AnticoagulantClinic
Appendix4:Prescribingchecklistfordabigatranandrivaroxaban
Patientname:DOB:
NHSNumber:Address:
(A)NICECriteria(2)forDABIGATRANuse(allmustbemettickallapplicable) Yes No
1. NonValvularAtrialFibrillation(AF)
Routineechocardiographyisnotrequiredpriortoinitiationofdabigatran.Itisnotrecommended
inpatientswithknownhaemodynamicallysignificantvalvularheartdiseaseorinpatientswith
prostheticheartvalves
2. eGRF>30mL/min
(N.B.IfeGFRisnotavailablee.g.inpatienttheCreatinineClearanceshouldbecalculated
instead(usingCockcroftformula).
3.DoesthepatienthaveaCHAD2SVAS2Cscoreof1?
4. Nocontraindicatedconcomitantmedications:
Ketoconazole,cyclosporineA,itraconazoleandtacrolimus,dronedarone
CautionshouldbeexercisedwithotherPgpinhibitors/inducers
(e.g.amiodarone,quinidineorverapamil,clarithromycin,rifampicin,
carbamazepine,phenytoin).ThislistisnotexhaustiverefertoBNF/manufacturersdatasheet
forfurtherdetails.
(B)GeneralAssessment Yes No
5. Abilitytocomplywithmedicationdosing
N.B.Duetotheshorthalflifeofdabigatrancomparedtowarfarinerraticcompliancecouldresult
inworseanticoagulation.Dosingistwicedaily.
6. Noothercontradictionstoanticoagulation(notlistedabove)
Majorbleedingpotentialortendencye.g.severehaemophilia
Activepepticulcer,oesophagealvarices,aneurysm,proliferativeretinopathy
Recentorganbiopsy
Recenttraumaorsurgerytothehead,orbitorspine
Recentstroke(usually<2weeks)
Confirmedintracranialorintraspinalbleed(usuallywithinlast4weeksalthoughrequires
individualassessment)
Uncontrolledhypertension
InfectiveEndocarditis
7. Baselinebloodssatisfactory:
Notrecommendedif
FBC:Platelet<70x109/L
eGFR:seeabove
LFT:Liverenzymeselevated>2xnormal
CoagulationScreen:APTT>1.5xnormal;INR>1.4
8. Explainpurposeofanticoagulation/dabigatran
Avoidanceofembolicstroke/peripheralemolisationsecondarytoatrialfibrillation
9. ExplainSeriousSideEffects:Bleeding
Seekurgentmedicalattentionifdevelopsnew:
Bloodinurine,faeces,vomitorsputum,vaginalbleeding(otherthanregularperiod)
Severeunusualheadache(particularlyiffollowingheadtrauma)
10. Explain
Needtoinformanyoneprescribingmedicationsthattheyareondabigatranandto
confirmthatitdoesnotinteract
Explainneedforannualreview/bloodtesttoassessrenalfunctionorifchange
DyspepsiaandGIbleedingweretheonlyadverseeventsnotedtobestatisticallymore
commonwithdabigatranthanwarfarin.Dyspepsiamaybeamelioratedbytaking
medicationwithfood.Cautionshouldbeexercisedifsymptomspersit/recenthistoryof
pepticulcerdisease
Thereisnoknownantidotetodabigatran(unlikewarfarin).Intheeventoflife
threateningbleedingorneedforemergencysurgerystopdabigatrananticoagulant
effectwillwearoffafterapproximately2436hourspostlastdose
Althoughtherearenoanticipatedlongtermadverseeffectsfromthelargemultinational
studythereisnolongdatacurrentlyavailable.Dabigatranhasblacktrianglestatus
prescribersarerequiredtocompleteayellowcardforanysuspectedadversedrug
reactions
Renalfunctionshouldbeassessedatleastonceayearinpatientstreatedwith
dabigatranormorefrequentlyasneededincertainclinicalsituationswhenitis
suspectedthattherenalfunctioncoulddeclineordeteriorate(suchashypovolemia,
dehydration,andwithcertaincomedications,etc)
Dabigatranisnotsuitableformonitoreddosesystems(e.g.dosetteboxes)andmustbe
storedinoriginalpackaging.Onceabottleisopenedthetabletsmustbefinishedwithin
4months(SPC)
Standardcoagulationtestse.g.INRandAPTTmaybeprolongedbydabigatranbutare
notpredictableandshouldnotberoutinelymonitored
DosingRecommendation:
(1) 150mgbdPOStandarddose
(2) 110mgbdPOSuitablepatients:
Allpatientsaged>80y
Selectedpatientsaged>75yifbleedingrisk
Otherhighriskbleedingpatients,especiallyifborderlinerenalfunction
Concomitantverapamil
IfpatientsareswitchingfromwarfarincommencedabigatranwhenINR<2.
Misseddoses:Aforgottendosemaystillbetakenupto6hourspriortothenextscheduleddose.From
6hourspriortothenextscheduleddoseon,themisseddoseshouldbeomitted.Nodoubledoseshould
betakentomakeupformissedindividualdoses.
Authorisation:
Signatureofmedicalpractitionerundertakingassessment:
PrintName:
OptionalCHAD2SVAS2cScoreScore(circle)
Congestiveheartfailure/LVdysfunction 1
Hypertension 1
Age75y 2
Diabetesmellitus 1
Stroke/TIA/TE 2
VascularDisease(MI/PVD/AorticPlaque) 1
Age6575 1
SexCategoryi.e.female 1
TOTAL..
Reference:
1 MHRADrugsafetyupdateVol5Issue5,Dec2011:A2
2 NICETA249(15thMarch2012)dabigatranetexilateforthepreventionofstrokeandsystemicembolismin
atrialfibrillation
Patientname:DOB:
NHSNumber:Address:
(A)NICECriteria(2)forRIVAROXABANuse(allmustbemettickallapplicable) Yes No
1. NonValvularAtrialFibrillation(AF)
Routineechocardiographyisnotrequiredpriortoinitiationofrivaroxaban.Itisnot
recommendedinpatientswithknownhaemodynamicallysignificantvalvularheartdiseaseorin
patientswithprostheticheartvalves
2. eGFR>15mL/min
IfeGFR<50and15doseshouldbereducedto15mgOD.
Rivaroxaban istobeusedwithcautioninpatientswithcreatinineclearance1529ml/min.
Useisnotrecommendedinpatientswithcreatinineclearance<15ml/min
3.DoesthepatienthaveaCHAD2SVAS2Cscoreof1?
4.Nocontraindicatedconcomitantmedications:
TheuseofRivaroxabanisnotrecommendedinpatientsreceivingconcomitantsystemic
treatmentwithazoleantimycotics(suchasketoconazole,itraconazole,voriconazoleand
posaconazole)orHIVproteaseinhibitors(e.g.ritonavir).ThislistisnotexhaustiverefertoBNF
/manufacturersdatasheetforfurtherdetails.
(B)GeneralAssessment Yes No
5.Abilitytocomplywithmedicationdosing
N.B.DuetotheshorthalflifeofRivaroxabancomparedtowarfarinerraticcompliancecould
resultinworseanticoagulation.Dosingisoncedaily.
6.Othercontradictionstoanticoagulation(notlistedabove)
congenitaloracquiredbleedingdisorders
uncontrolledseverearterialhypertension
activeulcerativegastrointestinaldisease
recentgastrointestinalulcerations
vascularretinopathy
recentintracranialorintracerebralhaemorrhage
intraspinalorintracerebralvascularabnormalities
recentbrain,spinalorophthalmologicalsurgery
bronchiectasisorhistoryofpulmonarybleeding.
7. Baselinebloodssatisfactory:
Notrecommendedif
Creatinineclearance<15ml/min(eGFR<15ml/min/1.73m2)
8. Explainpurposeofanticoagulation/rivaroxaban
Avoidanceofembolicstroke/peripheralembolisationsecondarytoatrialfibrillation
9. ExplainSeriousSideEffects:Bleeding
Seekurgentmedicalattentionifdevelopsnew:
Bloodinurine,faeces,vomitorsputum,vaginalbleeding(otherthanregularperiod)
Severeunusualheadache(particularlyiffollowingheadtrauma)
10. Explain
Needtoinformanyoneprescribingmedicationsthattheyareonrivaroxabanandto
confirmthatitdoesnotinteract
Explainneedforannualreview/bloodtesttoassessrenalfunctionorifchange
Thereisnoknownantidotetorivaroxaban(unlikewarfarin).Intheeventoflife
threateningbleedingorneedforemergencysurgerystoprivaroxabananticoagulant
effectwillwearoffafterapproximately2436hourspostlastdose
Althoughtherearenoanticipatedlongtermadverseeffectsfromthelargemultinational
studythereisnolongdatacurrentlyavailable.Rivaroxabanhasblacktrianglestatus
prescribersarerequiredtocompleteayellowcardforanysuspectedadversedrug
reactions
Renalfunctionshouldbeassessedatleastonceayearinpatientstreatedwith
rivaroxabanormorefrequentlyasneededincertainclinicalsituationswhenitis
suspectedthattherenalfunctioncoulddeclineordeteriorate(suchashypovolemia,
dehydration,andwithcertaincomedications,etc)
Standardcoagulationtestse.g.INRandAPTTmaybeprolongedbyrivaroxabanbutare
notpredictableandshouldnotberoutinelymonitored
DosingRecommendation:
(3) 20mgoncedailyPOStandarddose
(4) 15mgoncedailyPOSuitablepatients:
Patientswithmoderate(creatinineclearance3049ml/min)orsevere(creatinineclearance15
29ml/min)renalimpairment
IfpatientsareswitchingfromwarfarincommencerivaroxabanwhenINR<3.
Misseddoses:Rivaroxabanistakenoncedailyandpatientsareadvisediftheyhavemissedadose,take
itassoonastheyremember.Donottakemorethanonetabletinasingledaytomakeupforaforgotten
dose.Takethenexttabletonthefollowingdayandthencarryontakingonetabletonceaday.
Authorisation:
Signatureofmedicalpractitionerundertakingassessment:
PrintName:
OptionalCHAD2SVAS2CScoreScore(circle)
Congestiveheartfailure/LVdysfunction 1
Hypertension 1
Age75y 2
Diabetesmellitus 1
Stroke/TIA/TE 2
VascularDisease(MI/PVD/AorticPlaque) 1
Age6575 1
SexCategoryi.e.female 1
TOTAL..
Reference:
(1) NICETA256(May2012)Rivaroxabanforthepreventionofstrokeandsystemicembolism
inpeoplewithatrialfibrillation
Appendix5Choiceoforalanticoagulante.g.warfarin,dabigatran,rivaroxaban
Thissummaryprovidedanoverviewofthevariousoralanticoagulantsnowavailable.TheindividualSummaryofProduct
characteristicsshouldbeaccessedforfullprescribinginformationwhenaspecificdrugisselectedforprescribing.
Indication
Dose,monitoringandformulation
Contraindications
Cautions
DrugInteraction
RelevantResources
Appendix6:SRFTGuideline:Emergencyreversalofanticoagulationinpatientstakingnoveloral
anticoagulants(eg.Dabigatran,Rivaroxabanetc)