Safe Use Of Anticoagulants Research Articles

An Evaluation of Oral Anticoagulant Safety Indicators by England's Community Pharmacies.

Anticoagulants are life-saving medicines that can prevent strokes for patients diagnosed with atrial fibrillation (AF) as well as treating patients with venous thromboembolism (VTE), but when used incorrectly, they are frequently associated with patient harm. To evaluate the impact of community pharmacy teams on optimising patient knowledge and awareness and improving medication safety from the use of anticoagulants. Two national audits, consisting of 17 questions assessing and improving patients' understanding of anticoagulant therapy, identifying high-risk patients, and contacting prescribers when clinically appropriate were incentivised for England's community pharmacies in 2021-2022 and 2023-2024 using the Pharmacy Quality Scheme (PQS) commissioned by NHS England. Approximately 11,000 community pharmacies audited just under a quarter of a million patients in total, whilst making almost 150,000 interventions for patients taking oral anticoagulants, i.e., identifying and addressing medication issues which could increase the risk of bleeding/harm. Out of the 111,195 patients audited in 2021-2022, only 24,545 (23%) patients were prescribed vitamin K antagonists. The remaining patients were prescribed direct oral anticoagulants (DOACs). By 2023-2024, this decreased to 17,043 (16%) patients. Most patients knew that they were prescribed an anticoagulant (95.6%, 106,255 in 2021-2022 and 96.5%, 101,006 in 2023-2024, p < 0.001). The audits resulted in a statistically significant increase in patients with a standard yellow anticoagulant alert card, as identified in audit 2 (73,901 66.5% in 2021-2022 to 76,735, 73.3% in 2023-2024, p < 0.001). Furthermore, fewer patients were prescribed concurrent antiplatelets with an anticoagulant (6021; 4.6% in 2021-2022 to 4975; 4% in 2023-2024, p < 0.001). Although there was an increase in the number of patients prescribed NSAIDs with anticoagulants, more of these patients were also prescribed gastroprotection concurrently (927 77.2% in 2021-2022 to 1457 84.1% in 2023-2024, p < 0.05). The majority of patients on warfarin had their blood checked within 12 weeks. Further there was an increase for these patients in the percentage of people prescribed VKAs who knew dietary changes can affect their anticoagulant medicine (16,764 67.4% in 2021-2022 to 12,594 73.9% in 2023-2024 p < 0.001). Community pharmacy teams are well placed in educating and counselling patients on the safe use of anticoagulants and ensuring that all patients are correctly monitored.

The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants

ObjectiveTo use the electronic prescribing system to identify how prescribers have responded to the duplicate ‘Anticoagulant Alert’ and the extent to which the system has prevented unintentional prescription of Low Molecular Weight Heparins (LMWHs) to patients prescribed Direct Acting Anticoagulants (DOACs). To determine the clinical appropriateness of the actions taken by the prescriber following the alert override and the impact this has on patient safety. Material and methodsA retrospective service evaluation was conducted to determine the impact of a duplicate ‘Anticoagulant Alert’ on the prevention of prescription of LMWHs to patients already prescribed DOACs at a 950-bed acute teaching hospital in the UK. The number of alert overrides, actions taken by the prescriber following the alert override, and the clinical appropriateness of prescribers’ actions over the 15-month period 26th June 2017 – 8th October 2018 were evaluated. ResultsOf the 894 alerts that triggered over the study period 111 were in response to attempts to prescribe a LMWH to a patient prescribed a DOAC. The alert was overridden in 65 (58.6%) cases but accepted, preventing co-prescription of duplicate anticoagulants, in 46 (41.4%) cases. Overrides were appropriate and justified in 44/65 cases. In 6 cases duplicate anticoagulants were prescribed and administered but without patient harm. ConclusionThe anticoagulant alert prevented duplicate anticoagulant prescribing for 46 patients reducing the risk of patient harm from duplicate-anticoagulation. The 58.6% of alerts that were overridden were appropriate and justified in the majority of cases. Where duplicate doses were administered, no harm was observed. The electronic alert has improved the safe use of anticoagulants within our organisation.

Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners' case reports.

BackgroundThe global burden of cardiovascular disease (CVD) is forecast to increase, and anticoagulants will remain important medicines for its management. Coroners' Prevention of Future Death reports (PFDs) provide valuable insights that may enable safer and more effective use of these agents.AimTo identify CVD-related PFDs involving anticoagulants.Design & settingCase series of coronial reports in England and Wales between 2013 and 2019.MethodA total of 3037 PFDs were screened for eligibility. PFDs were included where CVD and an anticoagulant caused or contributed to the death. Included cases were descriptively analysed and content analysis was used to assess concerns raised by coroners and who had responded to them.ResultsThe study identified 113 CVD-related PFDs involving anticoagulants. Warfarin (36%, n = 41), enoxaparin (11%, n = 12), and rivaroxaban (11%, n = 12) were the most common anticoagulants reported. Concerns most frequently raised by coroners included poor systems (31%), poor communication (25%), and failures to keep accurate medical records (25%). These concerns were most often directed to NHS trusts (29%), hospitals (10%), and general practices (8%). Nearly two-thirds (60%) of PFDs had not received responses from such organisations, which are mandatory under regulation 28 of the Coroners' (Investigations) Regulations 2013. A publicly available tool has been created by the authors (https://preventabledeathstracker.net), which displays coroners’ reports in England and Wales to streamline access, and identify important lessons to prevent future deaths.ConclusionNational organisations, healthcare professionals, and prescribers should take actions to address the concerns of coroners in PFDs to improve the safe use of anticoagulants in patients with CVD.

Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol

BackgroundUse of direct oral anticoagulants (DOAC) is rapidly growing for treatment of atrial fibrillation and venous thromboembolism. However, incorrect dosing of these medications is common and puts patients at risk of adverse drug events. One way to improve safe prescribing is the use of population health tools, including interactive dashboards built into the electronic health record (EHR). As such tools become more common, exploring ways to understand which aspects are effective in specific settings and how to effectively adapt and implement in existing anticoagulation clinics across different health systems is vital.MethodsThis three-phase project will evaluate a current nation-wide implementation effort of the DOAC Dashboard in the Veterans Health Administration (VHA) using both quantitative and qualitative methods. Informed by this evaluation, the DOAC Dashboard will be implemented in four new health systems using an implementation strategy derived from the VHA experience and interviews with providers in those new health systems. Quantitative evaluation of the VHA and non-VHA implementation will follow the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Qualitative interviews with stakeholders will be analyzed using the Consolidated Framework for Implementation Research and Technology Acceptance Models to identify key determinants of implementation success.DiscussionThis study will (1) evaluate the implementation of an EHR-based population health tool for medication management within a large, nation-wide, highly integrated health system; (2) guide the adoption in a set of four different health systems; and (3) evaluation that multi-center implementation effort. These findings will help to inform future EHR-based implementation efforts in a wide variety of health care settings.

Evaluation of patients\u2019 knowledge about oral anticoagulant medicines and use of alert cards by community pharmacists

Background Anticoagulants continue to pose high risk of harm to patients despite the discovery of novel direct-acting oral anticoagulant agents that require less monitoring than warfarin. Objective To evaluate patients’ knowledge about their oral anticoagulants and the potential role for community pharmacists in optimising safety. Setting Community pharmacies in England. Methods An online survey-based evaluation conducted over a 5-month period to ascertain patients’ knowledge, use of anticoagulant alert cards, compliance with national monitoring requirements for warfarin, and frequency and nature of community pharmacist involvement in optimisation. Differences between patients on direct-acting oral anticoagulant agents and warfarin were assessed using Chi squared tests. Main outcome measure Patients’ knowledge and use of anticoagulant alert cards. Results A total of 1515 pharmacies participated. Of 22,624 patients, 97% knew that they were taking anticoagulants; 20% had alert cards with them at time of dispensing; 17% had no card and 10% refuted their usefulness. Patients on warfarin were more aware of interactions with over-the-counter or herbal medicines than those on direct-acting oral anticoagulant agents. Of the patients on warfarin, 82% confirmed monitoring in the previous 12 weeks in accordance with national standards, with the international normalised ratio value known for 76%. Pharmacists intervened in a fifth of the patients to issue an alert card, contact the general practitioner for a change in the prescription or due to interacting medicines. Conclusion Patients had reasonable knowledge of their anticoagulation therapy, but areas for improvement were identified. Community pharmacists are well placed to optimise the safe use of anticoagulants.

Initiating and Managing Patients with Venous Thromboembolism on Anticoagulant Drugs: A Practical Overview.

Several new oral anticoagulants have recently been approved for the treatment of venous thromboembolism (VTE). In this review, we discuss the currently approved drugs and the factors that influence the choice of anticoagulant in a given patient. Once anticoagulation is initiated, periodic monitoring of adequacy of anticoagulation may be necessary depending on the choice of anticoagulant and patient-related factors, such as renal function. Situations that may warrant need for monitoring and the tests available for this purpose are discussed. We review reversal of anticoagulation in urgent/emergent situations as well as perioperative anticoagulation interruption in the elective setting. The data on use of direct oral anticoagulants in patients with compromised renal function, obesity and bariatric surgery, and in the treatment of cancer-associated thrombosis are discussed. The review aims to provide the clinician with the essential information to allow effective and safe use of anticoagulants for the treatment of VTE.

A CLINICAL CASE OF HEREDITARY THROMBOPHILIA IN A PATIENT WITH ULCERATIVE COLITIS

We present a clinical case of a 24-year old female patient who was hospitalized with high active ulcerative colitis associated with latent hereditary thrombophilia uncontrolled due to the exacerbation of ulcerative colitis and local steroid treatment. The patient was treated with combination of systemic steroids, adalimumab and anticoagulants. We emphasize the necessity of the multidisciplinary approach to her treatment. The clinical case demonstrates the possibility of safe use of anticoagulants to prevent thromboembolic complications in patients with ulcerative colitis and high risk of thrombus formation, under careful monitoring of coagulation parameters and thromboelastography. We discuss the need in clear guidelines to determine treatment strategy for patients with inflammatory bowel diseases, coagulopathies and thromboembolic complications.

Erratum to: Pharmacology of anticoagulants used in the treatment of venous thromboembolism.

Anticoagulant drugs are the foundation of therapy for patients with VTE. While effective therapeutic agents, anticoagulants can also result in hemorrhage and other side effects. Thus, anticoagulant therapy selection should be guided by the risks, benefits and pharmacologic characteristics of each agent for each patient. Safe use of anticoagulants requires not only an in-depth knowledge of their pharmacologic properties but also a comprehensive approach to patient management and education. This paper will summarize the key pharmacologic properties of the anticoagulant agents used in the treatment of patients with VTE.

Direct oral anticoagulants: New drugs with practical problems. How can nurses help prevent patient harm?

The safe use of anticoagulants requires a delicate balance between the risk of bleeding and the risk of thrombosis, particularly in drug-sensitive patients, such as older people. Recently-marketed "direct oral anticoagulants" are now being increasingly prescribed and administered in the hospital setting. Direct oral anticoagulants have pharmacological properties that are often unpredictable, and inter-patient variability in drug response is high. Therefore, people often require meticulous review and planning to ensure they receive optimal dosing and monitoring. The multidisciplinary medication management of those receiving these drugs needs to be effectively coordinated to reduce the risk of patient harm. All clinical staff, including nurses, doctors, and pharmacists, should be competent in the pharmacology of these drugs, and know which people require individualized care plans. In this study, we introduced important concepts via the use of case studies developed from commonly-seen scenarios at our quaternary hospital. In particular, the important role of nurses in ensuring patient safety in the periprocedural setting is highlighted.

Pharmacology of anticoagulants used in the treatment of venous thromboembolism.

Anticoagulant drugs are the foundation of therapy for patients with VTE. While effective therapeutic agents, anticoagulants can also result in hemorrhage and other side effects. Thus, anticoagulant therapy selection should be guided by the risks, benefits and pharmacologic characteristics of each agent for each patient. Safe use of anticoagulants requires not only an in-depth knowledge of their pharmacologic properties but also a comprehensive approach to patient management and education. This paper will summarize the key pharmacologic properties of the anticoagulant agents used in the treatment of patients with VTE.

Optimizing Anticoagulation Management Through the Use of a Hospital Engagement Network Metric for Inpatient Anticoagulant-Associated Hemorrhage.

The University HealthSystem Consortium (UHC), a national hospital engagement network (HEN), establishes health-system metrics to assess and improve quality of care. In 2012, a metric for inpatient anticoagulant hemorrhage was developed. The utility of this metric to improve anticoagulation care has not been assessed. To identify opportunities to improve anticoagulation safety through the use of a HEN metric for inpatient anticoagulant-associated hemorrhage. This was a single-center, retrospective, observational study of metric identified patients with presumed inpatient anticoagulant hemorrhage. Records were reviewed to confirm anticoagulant hemorrhage and identify bleed site and severity. A structured process was used to assess bleed preventability and subsequently identify opportunities for improving care. Each bleed was reviewed by 2 investigators. Anticoagulant hemorrhage was confirmed in 85.9% (61/71) with heparin infusion the most common anticoagulant. Patients were primarily medical, with a mean age of 72.7 ± 15 years. The most common bleed sites were gastrointestinal (24.6%) and retroperitoneal (21.3%). Major bleeding occurred in 60.7% (37/61). Anticoagulant hemorrhage was preventable in 18% (11/61) of cases with heparin protocol noncompliance the most common cause of a preventable bleed. Several opportunities for improving heparin infusion therapy were recognized and protocol changes were implemented. The UHC metric accurately captures inpatient anticoagulant-associated hemorrhage the majority of time. The UHC metric on anticoagulant-associated hemorrhage can be a useful part of a health system's overall plan for the safe use of anticoagulants in the hospital setting.

The Development of Evidence-Based Care Recommendations to Improve the Safe Use of Anticoagulants in Children

Evidence-based care recommendations and standardized protocols improve outcomes. In addition, anticoagulant management has been recognized by The Joint Commission (TJC) as an opportunity for improving patient safety. A National Patient Safety Goal requiring a standardized process for patients receiving anticoagulants was established by TJC. This requirement provided an opportunity to apply evidence-based care recommendations to the issue of safe anticoagulant use. To meet TJC requirement, the following searchable clinical question was drafted: "In children receiving anticoagulation therapy, what are the appropriate dosing, laboratory monitoring, timing, and dosing adjustments for warfarin, unfractionated heparin, and low-molecular-weight heparin to prevent coagulation-related complications?" The team used the Appraisal of Guidelines Research and Evaluation Collaboration (AGREE) instrument to evaluate the quality and relevance of identified guidelines in answering the clinical question. Best Evidence Statements (BESts) were developed for each of the medications (warfarin, low-molecular-weight heparin, and unfractionated heparin). BESts provide the format for the presentation of recommendations, discussion, and methods for point-of-care providers seeking synthesized evidence to guide care decisions. The primary goal of developing and implementing these statements was to standardize the use of anticoagulants and to prevent unsafe practices. A secondary goal was to ensure accessibility of the BESts throughout our organization, including the electronic medical record, various internal division home pages, and our organization's external website. The anticoagulant BESts developed at our organization show how an interprofessional approach to patient care results in the development of evidence-based care recommendations. The BESts were developed to standardize care associated with the use of anticoagulants and to provide dosing and monitoring parameters to ensure safe care to all patients receiving these medications. The development of evidence-based care recommendations can be accomplished with a focused interprofessional team dedicated to providing the safest possible care to patients.

A review of the safety of anticoagulants in older people using the medicines management pathway: weighing the benefits against the risks.

Anticoagulant drugs maintain a high potential for adverse events due to their inherent risk of haemorrhage and/or complex pharmacology. In addition, compromising the safety of these agents is the context in which they are principally used; that is, in the long-term prevention of thromboembolic diseases in an older patient population. These challenges are especially pronounced in the prevention of stroke in older persons with atrial fibrillation (AF), where the need for thromboprophylaxis is paramount and in whom the arrhythmia is most prevalent, but where the target population is simultaneously at high risk of adverse drug events. Essentially, this translates to the use of high-risk therapies on an indefinite basis, in persons who have multiple comorbidities, use polypharmacy, and who may have age-related functional and cognitive decline, culminating in a higher potential for medication misadventure. For this reason, anticoagulants mandate extra pharmacovigilance, and therefore the aim of this review is to address some of the key safety considerations in the use of anticoagulant drugs (warfarin, dabigatran, rivaroxaban), spanning the initiation of therapy to its ongoing management. Using the Medication Management Pathway (MMP) as a framework, in this review we canvas and highlight specific developments in practical strategies to facilitate the safe use of anticoagulants (particularly warfarin) in 'at-risk' elderly patients including: comprehensive risk/benefit assessment using novel risk stratification tools; focused medicines review services; therapeutic drug monitoring services delivered in the primary care setting; and practical education strategies and resources targeting the older patient population. Until newer alternative anticoagulants become viable options for widespread use, clinicians will necessarily need to rely on specific resources and interventions to facilitate the safe use of currently available anticoagulants (i.e. warfarin) in 'at-risk' older people.

Key Articles and Guidelines in the Treatment of Venous Thromboembolism

Venous thromboembolism (VTE) is a significant medical diagnosis that affects millions of patients each year. Appropriate management of VTE can help treat the initial event as well as reduce the frequency of complications such as postthrombotic syndrome, pulmonary hypertension, and death. Due to increasing regulatory requirements, hospitals nationwide are developing necessary documentation of appropriate and safe use of anticoagulants for the management of VTE. It is essential that a wide range of clinicians have an understanding of what constitutes appropriate VTE treatment in various patient populations. With the existence of numerous pharmacologic agents, abundance of major clinical trials, and nationally recognized clinical guidelines, compiling the needed reference material to make evidence-based decisions on appropriate VTE treatment can be difficult for clinicians. Therefore we have provided bibliographies of key articles and guidelines related to the treatment of VTE with a number of different strategies in a variety of special patient populations. It is our hope that this compilation will serve as a resource for pharmacists, physicians, nurses, residents, and students responsible for the care of patients with VTE.

Perioperative Low-Molecular-Weight Heparin and Neuraxial Anesthesia: A Review of Current Practice Guidelines

Over the past nine years, the wide acceptance of low-molecular-weight heparins (LMWHs) in the United States has been the result of this class of drugs excellent safety and efficacy profile across multiple applications to prevent and treat arterial and venous thromboembolic disease. There has been concern, however, about the safety of using anticoagulant-based deep vein thrombosis (DVT) prophylaxis with regional anesthesia. This concern arose from a number of case reports in which the development of spinal hematoma was linked to the administration of LMWHs in patients receiving concomitant neuraxial anesthesia. In December 1997, the FDA issued an advisory about these adverse events indicating that there might be a relationship between epidural hematoma and neuraxial anesthesia in patients receiving LMWH's. Manufacturers of LMWHs subsequently added a boxed warning to their prescribing information alerting clinicians to these potential effects. Subsequently, the American Society of Regional Anesthesia (ASRA) produced guidelines with respect to the safe use of anticoagulants in patients receiving neuraxial anesthesia/analgesia based upon the available case reports and evidence. Upon review of the data, the inherent efficacy and widespread acceptance of LMWHs for prophylaxis of DVT, it may be concluded that conscientious use of LMWHs and neuraxial anesthesia may be provided safely in nearly every situation if attentive towards proper administration relative to the use of anesthesia. The fact that regional anesthesia reduces the risk of venous thromboembolism when other pharmacologic prophylaxis is not used after joint replacement surgery is well documented (Table 1).1,2,3,4 Further, it is recognized that in joint replacement, clot formation begins intraoperatively. Thus the use of neuraxial anesthesia and post-operative analgesia combined with early pharmacologic prophylaxis would appear to be the most efficacious approach toward preventing thromboembolic complications. The purpose of this review is to summarize the proper guidelines for the management of patients undergoing joint replacement surgery in the context of pharmacologic DVT prophylaxis and neuraxial anesthesia and analgesia.