A scoping review of direct oral anticoagulant ambulatory management practices

Models of care for managing direct oral anticoagulant (DOAC) therapy are evolving. Little is known of what services are provided by anticoagulation managements services (AMS) for DOACs, or what necessitates comprehensive DOAC management and what differentiates it from usual care. The purpose of this scoping review was to describe services, management, or monitoring of DOACs distinct from prescriber-managed or usual care of DOACs. This scoping review reported followed the 2018 Preferred Reporting Items for Systematic Review and Meta-Analyses extension for scoping reviews (PRISMA-ScR). We searched PubMed, CINAHL, and EMBASE from inception to November 2020 to identify articles of interest. No language restriction was applied. Articles were included if they provided a description of DOAC management services, and described longitudinal anticoagulation follow-up that occurred in ambulatory care, community, or outpatient-related settings. Data was extracted from a total of 23 articles. The specific types of DOAC management interventions provided varied across the included studies. Nearly all studies described some form of DOAC therapy appropriateness assessment. Other common interventions included assessments of DOAC therapy compliance, adverse event triage and management, assessment of DOAC dosing appropriateness, periprocedural management of DOAC therapy, educational interventions, and renal function monitoring. A variety of DOAC management interventions were identified, but additional studies are needed to help health systems decide whether specific interventions performed by dedicated services are preferred over the usual care provided by clinicians prescribing DOAC therapy.

Review on mechanisms and interactions in concomitant use of herbs and warfarin therapy

The effectiveness of warfarin, an oral anticoagulant originally derived from a plant, is strongly affected by patient's characteristics such as the age, presence of comorbidities, and concomitant use of another drug. Warfarin has the potential to interact with many drugs, medicinal plants, and food, which increases the risk of adverse events. A critical analysis of scientific literature was conducted to assess the interferences of medicinal plants with blood haemostasis and then with warfarin anticoagulation. We found 58 different plants that may alter the blood haemostasis and anticoagulation with warfarin. The herbs that showed the greatest potential to interact with warfarin include garlic, ginger, ginkgo, St. John's wort, and ginseng, i.e. plants normally consumed as food and also used for therapeutic purposes. The interactions between drugs and herbs are varied because of the complex chemical matrix of plants. Mainly coumarins, quinones, xanthones, terpenes, lignans, and vitamin K showed significant influence on warfarin treatment. In general, these plants can potentiate the effect of warfarin by stimulating anticoagulation in multiple ways, and the clinical outcome associated with this interaction is the increase of bleeding risk. Moreover, potential interactions between herbal products and drugs are a safety concern, especially for drugs with a narrow therapeutic index or for patients receiving drug treatment for chronic diseases, and both of these apply to warfarin pharmacotherapy. Therefore, this review article summarises the data on the influence of medicinal plants on warfarin treatment and analyses this information in view of the interaction targets. The relevant plants were categorised according to their target, and their effects are discussed in order to organise the isolated information and to highlight the need of further discussion and new studies on the safety of herbal medicines and warfarin.