July 15, 2022

by Dr. Brenda Pahl

Anticoagulation: Not Just Warfarin Anymore

When the direct oral acting anticoagulants (DOACs) first came to market, the need for anticoagulation clinics was in question. While several patients may qualify for using a directed thrombin inhibitor or factor Xa inhibitor, many patients must remain on warfarin. Patients with mechanical valves, left ventricular assist devices, and hypercoagulable states must continue with warfarin therapy. As the number of patients on warfarin continues to decline, anticoagulation clinics must adapt their services to meet the changing needs of their patients.

Despite these changes, the need for effective anticoagulation monitoring continues. As a pharmacist who manages warfarin patients, I have certainly seen a decrease in the number of patients started on warfarin. Even though one of the benefits of DOACs is the decreased need for frequent monitoring, these patients should still be monitored for changing renal function, adherence, drug interactions, signs of bleeding or bruising, and peri-procedure management. Additionally, I continue to see patients initiated on one of the non-vitamin K antagonists but eventually switch to warfarin due to the inability to afford the more costly alternative medications. The need for anticoagulation monitoring may be changing, but these services are still critical to ensure patient safety and optimal care.

Reimagining Anticoagulation Services

Anticoagulation pharmacists are well-trained to assist physicians and other providers in the dosing and monitoring of patients on DOACs. With the ever-increasing indications for DOACs, dosing can be confusing. Several studies have shown that alternative doses of DOACs are used, especially when considering dosing adjustments for renal function. While pharmacists can assist in these areas, other providers are not always aware of the services we can provide.

The safe and effective use of anticoagulants is essential in providing quality, cost-effective care for patients.
Anticoagulation clinics should update their policies, consult agreements, and referral orders to include the dosing and monitoring of DOACs. Physicians should be notified of the expanded services. While studies have shown that inpatient pharmacist dosing services have decreased dosing errors in patients receiving DOACs, there is little research on the impact of outpatient pharmacist monitoring. Metrics should be developed to monitor patient outcomes and cost avoidance to evaluate the expansion of services to include DOACs in anticoagulation clinics.

The safe and effective use of anticoagulants is essential in providing quality, cost-effective care for patients. Pharmacy-led anticoagulation clinics are well poised to provide exceptional care to patients on DOACs as well as other anticoagulation medications.

Dr. Brenda Pahl is Assistant Professor of Pharmacy Practice and Assistant Dean of Student Affairs at the Cedarville University School of Pharmacy. Her interests include hospital pharmacy practice, anticoagulation in ambulatory care, medication/patient safety, and substance use disorder.

The Cedarville University School of Pharmacy is equipping its Doctor of Pharmacy students to be on the leading edge of healthcare innovation. Cedarville’s Pharm.D. students are fully prepared to begin a rewarding career as a pharmacist and to use their calling to make a difference for Christ as they serve with excellence and compassion.

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