Educational Event
23rd & 24th January 2013
West Suffolk Hospital Education Centre
New Oral Anticoagulants (NOACs)
Dabigatran and Rivaroxaban
for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation
WSCCG NOACs in AF Prescribing Guidelines
Linda Lord
Head of Medicines Management (GP Prescribing)
West Suffolk Clinical Commissioning Group
WSCCG NOAC Guidelines
• Detailed advice on use of NOACs for
prevention of stroke and systemic embolism
in nonvalvular AF
• Based on NICE TA 249 and 256
• Includes expert advice of local clinicians
• Core guidance: 15 pages
• Appendices
• Manufacturers’ Summaries of Product
Characteristics
GP Responsibilities
1
Initiating a NOAC
2
Converting from warfarin
to a NOAC
3
Prescribing a NOAC as
on-going treatment
4
Referring to hospital for
possible NOAC initiation
Please refer to
WSCCG guidelines
Page number
Initiating a NOAC
1. Ensure NICE criteria met
Dabigatran
One or more of following risk factors:
• Previous stroke or TIA
• Left ventricular ejection fraction <40%
• Symptomatic heart failure NYHA ≥ class 2
• Age ≥ 75 years
• Age ≥ 65 years with one of following:
diabetes mellitus, coronary artery disease,
hypertension
1. Ensure NICE criteria met
Rivaroxaban
One or more risk factors such as:
• Congestive heart failure
• Hypertension
• Age ≥ 75 years
• Diabetes mellitus
• Prior stroke or TIA
2. Consider further points
(strong recommendations)
• CHADS2 or CHA2DS2-VASc ≥ 2
• eGFR
> 40 for dabigatran
p.3-4
> 25 for rivaroxaban
• No history of significant peptic ulcer disease
2. Consider further points
(strong recommendations)
At least one of these:
• Warfarin contraindicated
• Venous access for INR not possible
• Insurmountable difficulties with safe
compliance of INR monitoring and dose
adjustments, e.g. cognitive decline
• HAS-BLED ≥ 3
• Warfarin has been stopped due to
intolerance, poor response or significant
bleed while taking warfarin
2. Consider further points
(strong recommendations)
• No significant ischaemic heart
disease
• No other contraindications
• Special warnings, precautions and
drug interactions have been
considered (appendices 6,7,8)
p.4-5
2. Consider further points
(strong recommendations)
• Informed discussion with patient has
taken place: disadvantages/ advantages
p.9-10
3. Record details in patients’
notes
• Which NICE criteria satisfied
• Why a NOAC (name and dose) has been
selected rather than warfarin*
* Use of checklist 4a recommended
p.21
4. Perform baseline
blood tests
• FBC (platelet count must be >100 x
109/L & stable)
• U&Es
• Clotting screen
• LFTs
• eGFR
5. Counsel patient
•
•
•
•
Indication
Treatment schedules and duration
Side effects
Common interactions, including OTC
medicines
• Avoid pregnancy and breast feeding
• Importance of compliance
p.18
• More…
6. Issue alert card
Available free
from stores
7. Provide on-going
treatment and monitoring
Discussed later
Converting from
warfarin to a NOAC
Converting from warfarin
to a NOAC
1. Ensure NICE criteria met – as before
2. Consider further points (strong
recommendations) – as before
3. Record details in patients’ notes:
 Which NICE criteria met
 Why warfarin converted to a NOAC
(name and dose)*
*Use of checklist 4b recommended
p.23
Converting from warfarin
to a NOAC
4. Counsel patient – as before
5. Issue alert card – as before
Converting from warfarin
to a NOAC
6. Implement conversion safely:
Step 1 – Stop warfarin
Step 2 – Wait for 3 days
Step 3 – Check INR. Dabigatran can be
given as soon as INR <2. Rivaroxaban
should be initiated when INR ≤ 3
Converting from warfarin
to a NOAC
7. Inform anticoagulant services that warfarin
has been stopped
8. Provide on-going treatment and
monitoring (discussed later)
Prescribing a NOAC as
on-going treatment
On-going treatment and
monitoring
• At least annual clinical review
p.15
• At least annual eGFR if renal
function normal, more frequent if
impaired
• Twice yearly FBC, LFT and U&E if
renal function normal, more frequent
if impaired
• Close clinical surveillance (looking
for signs of bleeding or anaemia)
On-going treatment and
monitoring
p.15
• Being alert to:
 Risks if acute decline in renal
function, e.g. due to dehydration,
shock, initiation of nephrotoxic
medicines such as NSAIDs,
ACEIs, aminoglycosides
 Possibility of discharge on
extended prophylaxis to reduce
risk of VTE
Referring to hospital for
possible initiation of a
NOAC
Referral is appropriate if:
• Patient has complex co-morbidities
• GP does not know what to do/ cannot
weigh up pros and cons of anticoagulation
in whatever form
• Criteria and strong recommendations for
NOAC satisfied but GP does not feel
competent to prescribe a NOAC
Referral – further information
• Referral not normally expected
• No specific NOAC clinic at WSH
• Referral to general medical or cardiology
clinics in exceptional cases
• Use of checklist 4a (initiation of NOAC) or
4b (conversion from warfarin)
recommended
p.21-22
Summary
Warfarin is suitable for most patients
and is the preferred option if:
• eGFR <40
(eGFR 40-50: beware of risk of
progressive/acute renal dysfunction)
• History of significant peptic ulcer disease
• Significant ischaemic heart disease
Please keep a vigilant eye on medication
safety literature regarding NOACs.
Potentially life-threatening side effects
Educational Event
23rd & 24th January 2013
West Suffolk Hospital Education Centre
New Oral Anticoagulants (NOACs)
Dabigatran and Rivaroxaban
for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation
WSCCG NOACs in AF Prescribing Guidelines
Linda Lord
Head of Medicines Management (GP Prescribing)
West Suffolk Clinical Commissioning Group