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Three things care providers should consider for anticoagulation monitoring

By Hart Biologicals | 2nd March 2021

As a company who specialise in haemostasis testing, Hart Biologicals have been long-standing advocates of the importance of anticoagulation monitoring. We’ve decided to put our knowledge and expertise in this area to good use by providing some insight into the key things we think care providers should bear in mind when it comes to anticoagulants. This is a vitally important part of patient safety and wellbeing. We believe that developing a clinically led, patient-centred approach is crucial to delivering the best possible service. 

First thing’s first – getting the anticoagulant right

There are five main types of anticoagulant on the market: Apixaban (Eliquis), Dabigatran (Pradaxa), Edoxaban (Lixiana), Rivaroxaban (Xarelto) generally referred to as Direct Oral Anticoagulants (DOACS) and warfarin which is a Vitamin K Antagonist (VKA).(1)

The big difference between DOACS and warfarin is the monitoring requirements. DOACS don’t have the same ongoing monitoring as warfarin, although an initial blood test is needed before the patient starts taking the medication.(1) The fixed dosage requirements, lack of ongoing monitoring and quicker onset and offset of the anticoagulation affect have led some clinicians to view DOACS as advantageous over Vitamin K antagonists for anticoagulation.(2) 

However, DOACS are not without their limitations, lack of DOAC-specific anticoagulation testing can complicate treatment decisions in medical emergencies. (4) The lack of monitoring makes it more difficult to check if the dosage is appropriate, or to identify any compliance issues, potentially compromising patient safety. (3)

Make patient education a priority

Giving patients the right support and information to take their medications effectively is essential to ensure compliance. When it comes to anticoagulation medication, it is imperative that patients understand the ongoing monitoring requirements if they are prescribed warfarin, and the balance between the pros and cons of using DOACS. (5)

The interactions with other medications, contraindications and food that can result in adverse side effects and complications for the patient. (5)

There is clear evidence to suggest that informing patients about their medications improves patient engagement, delivers better care outcomes, and can reduce potential additional costs through noncompliance.(6) Patient education should be viewed as a process, not an event, as the information may need to be refreshed and reinforced on an ongoing basis. Patients should receive written and verbal instructions about their medication from a prescribing clinician or pharmacist. (7) This can subsequently be followed up through the provision of written materials and online video content where possible to ensure continuous access to learning resources.

The importance of warfarin monitoring and adaptability

One of the key requirements for taking warfarin is regular monitoring in the form of blood tests, to check patients International Normalised Ratio (INR) level, which assess how long it takes blood clots to form.(1) This is vital to assessing whether patients are receiving the correct dosage and to identify whether adjustments are needed to improve effectiveness.

Whilst many patients stabilise on warfarin very quickly, others require a longer period of adjustment. As part of this, patients are normally issued with a yellow book. This contains their previous test results, recommended warfarin dose and the date for their next evaluation appointment. (8) This ensures a clear roadmap is in place for the purposes of ongoing monitoring.    

The location where monitoring takes place is also an important consideration here. There are several options in this regard, such as an institutional clinical setting in a hospital haematology department and more community-based options that involve testing INR levels using a single finger prick blood sample. The latter method can be undertaken in the local community such as a local GP practice, providing a more patient-centred approach and delivering rapid results, that are available almost immediately.

Warfarin monitoring should be based around the patient’s individual needs not institutional structures. Adopting a more community-orientated approach to anticoagulation monitoring has the potential to improve patient experience and reduce pressure of secondary care services during this time of national crisis.

 

References

  1. Anticoagulation UK. Anticoagulants and monitoring [Internet] [cited 5/10/2020] Available online: https://www.anticoagulationuk.org/provision/anticoagulants-and-monitoring
  2. Sikorska J, Uprichard, J. Direct Oral Anticoagulants: A Quick Guide. Eur Cardiol. 2017 Aug;12(1):40-45. doi: 10.15420/ecr.2017:11:2. PMID: 30416551; PMCID: PMC6206466. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206466/
  3. Ebner M et al. Emergency Coagulation Assessment During Treatment With Direct Oral Anticoagulants Limitations and Solutions. 2017 American Heart Association, Inc. Stroke DOI: 10.1161/STROKEAHA.117.017981 Available online: https://www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.117.017981
  4. Levy JH, Douketis J, Steiner T, Goldstein JN, Milling TJ. Prothrombin complex concentrates for perioperative vitamin K antagonist and non–vitamin K anticoagulant reversal. Anesthesiology. 2018;129:1171–84.
  5. Clark NP. Role of the anticoagulant monitoring service in 2018: beyond warfarin. Hematology. 2018 Nov 30;2018(1):348-52. Available online: https://ashpublications.org/hematology/article/2018/1/348/277589/Role-of-the-anticoagulant-monitoring-service-in
  6. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores’. Health Aff (Millwood). 2013;32(2):216-222
  7. Medical Protection. Anticoagulant monitoring and dosing [Internet] 2017 [cited 5/10/2020] Available online: https://www.medicalprotection.org/uk/articles/anticoagulant-monitoring-and-dosing
  8. CQC. Nigel's surgery 92: Anticoagulant monitoring in primary care [Internet] 2019 [cited 5/10/2020] Available online:  https://www.cqc.org.uk/guidance-providers/gps/nigels-surgery-92-anticoagulant-monitoring-primary-care