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Mangrum JS, Saunders JA, Chaiyakunapruk N, Witt DM, King JB. A scoping review of direct oral anticoagulant ambulatory management practices. J Thromb Thrombolysis 2023; 55:700-709. [PMID: 36977918 DOI: 10.1007/s11239-023-02794-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
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.
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Affiliation(s)
- Jasmine S Mangrum
- University of Washington School of Pharmacy, Seattle, WA, USA.
- Clinical Practice, University of Washington School of Pharmacy, South Campus Center | 1601 NE Columbia Rd, Suite 246A, Seattle, WA, 98195-7631, USA.
| | - John A Saunders
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Jordan B King
- Department of Population Health Sciences, University of Utah School of Medicine, 295 Chipeta Way, Williams Building, Salt Lake City, UT, 84108, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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Elewa H, Qurishi I, Abouelhassan R, Abou Safrah S, Alhamoud E, Bader L. Effect of SAMe-TT 2R 2 score and genetic polymorphism on the quality of anticoagulation control in Qatari patients treated with warfarin. J Thromb Thrombolysis 2021; 49:659-666. [PMID: 32274641 PMCID: PMC7182538 DOI: 10.1007/s11239-020-02102-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There is no strong evidence on pharmacogenetics role on the quality of INR control after the initiation phase and on the maintenance of stable INR on the long term as measured by the time in therapeutic range (TTR). The benefit of a score such as SAMe-TT2R2 is that it can preemptively guide clinicians on whether to start the patient on warfarin or direct oral anticoagulant. To determine the association between genetic variants in CYP2C9, VKORC1, and CYP4F2 and TTR. To validate SAMe-TT2R2 score predictive ability on the quality of anticoagulation in Qatari patients. This is an observational nested case–control study that was conducted on a cohort of Qatari patients treated with warfarin with previously identified genotype for the CYP2C9, VKORC1, and CYP2F4. The sample size of this cohort was 148 patients. Mean TTR was 62.7 ± 21%. TTR was not significantly different among carriers of the CYP2C9*2 &*3, VKORC1(–1639G>A) or CYP4F2*3 compared to their non-carriers alleles. None of the factors in the SAMe-TT2R2 score had a significant effect on the TTR except for the female gender where TTR was significantly lower in females (n = 89) compared to males (n = 59) (59.6 ± 21% vs. 67.2 ± 20%, p = 0.03). Furthermore, patients with SAMe-TT2R2 score of zero had significantly better TTR compared to those with higher scores (76.5 ± 17% vs. 61.8 ± 21%, p = 0.04). Logistic regression analysis showed that high SAMe-TT2R2 score was the only statistically significant predicting factor of poor INR control (odds ratio (OR) 5.7, 95% confidence interval (CI) 1.1–28.3, p = 0.034). Genetic variants have no contribution to the quality of INR control. SAMe-TT2R2 score was predictive for the poor quality of anticoagulation in a cohort of Qatari patients.
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Affiliation(s)
- Hazem Elewa
- Clinical Pharmacy and Practice Section, College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
| | - Iqrah Qurishi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | | | | | | | - Loulia Bader
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Fahmi AM, Mohamed A, Elewa H, Saad MO. Preemptive Dose Adjustment Effect on the Quality of Anticoagulation Management in Warfarin Patients With Drug Interactions: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2019; 25:1076029619872554. [PMID: 31482725 PMCID: PMC6829638 DOI: 10.1177/1076029619872554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
One strategy to manage patients on warfarin starting an interacting drug is to increase
the frequency of monitoring. Another strategy is to adjust warfarin dose around the time
patient is started on an interacting medication, which is known as “preemptive warfarin
dose adjustment.” The main objective of this study is to compare preemptive to
nonpreemptive strategy and their impact on the quality of anticoagulation management. This
is a retrospective cohort study performed at the pharmacist-managed anticoagulation clinic
in a tertiary hospital in the State of Qatar. Over a 4-year period, 340 patients were
evaluated, and 58 warfarin–drug interaction encounters were identified. Mean age of the
patients was (57.7 ± 13.7), and 50% of them were females. Preemptive dose adjustment was
used in 17 (29.3%) cases. Incidence of out-of-target international normalized ratio (INR)
was statistically lower in the preemptive arm compared to the control group (41.2% [7/17]
vs 69.2% [27/39], P = .048). Incidence of extreme out-of-target INR was
numerically lower in the preemptive arm compared to the control but did not reach
statistical significance (11.8% [2/17] vs 29.3% [12/41], P = .139).
Change in frequency of INR monitoring was not different between the 2 groups. However,
overall frequency of INR monitoring after onset/discontinuation of interacting medication
increased compared to baseline (7 [9] vs 21 [16] days, P < .001).
Preemptive strategy was shown in our study to decrease incidence of the out-of-target INR
visits, although patients remained in need for close monitoring.
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Affiliation(s)
| | - Adham Mohamed
- 1 Al Wakra Hospital, Hamad Medical Corporation, Al Wakra, Qatar
| | - Hazem Elewa
- 2 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
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Maly J, Dvorackova S, Zimcikova E, Kubena AA, Kolar J, Vlcek J, Penka M, Mala-Ladova K. Patterns in anticoagulant utilization in the Czech Republic during 2007–2017. J Thromb Thrombolysis 2019; 47:305-311. [DOI: 10.1007/s11239-019-01806-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Paravattil B, Elewa H. Approaches to Direct Oral Anticoagulant Selection in Practice. J Cardiovasc Pharmacol Ther 2018; 24:1074248418793137. [PMID: 30092658 DOI: 10.1177/1074248418793137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Direct oral anticoagulants (DOACs) carry many advantages over warfarin and are now considered first line or an alternative for mnay thromboembolic disorders. With the emergence of 5 DOAC agents to the market as well as the accumulating evidence gathered from head-to-head comparisons between the agents, we attempt to provide direction for clinicians when selecting the most appropriate DOAC agent. Important aspects such as efficacy, safety, cost effectiveness, approved indications, and other drug-related factors will be addressed to highlight the major similarities and diversities among the DOACs. When considering the safety profile of DOACs, evidence points toward apixaban as the safest followed by dabigatran and then rivaroxaban. On the other hand, dabigatran currently has the only approved antidote, idarucizumab. According to the approved DOAC indications, rivaroxaban may be favorable in European countries given its additional indication for secondary prevention of myocardial infarction. Following rivaroxaban, dabigatran and apixaban have the largest number of approved indications and lastly comes edoxaban and then betrixaban. For patients with renal impairment, betrixaban is the safest option, followed by apixaban and edoxaban, then rivaroxaban and lastly dabigatran. When considering DOAC dosing, rivaroxaban, edoxaban, and betrixaban are mainly dosed once daily compared to dabigatran and apixaban, which are dosed twice daily. However, rivaroxaban and betrixaban must be administered with food, which adds another level of complexity to the DOAC dosing. Lastly, taking into consideration drug interactions, dabigatran, edoxaban, and betrixaban have the least amount of interactions compared to apixaban and rivaroxaban. Each DOAC has its own set of features that makes it better suited than others based on the exact clinical situation. Therefore, no conclusion can be drawn to the most superior DOAC based on the aspects discussed in this review.
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Affiliation(s)
- Bridget Paravattil
- 1 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Hazem Elewa
- 1 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
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Elewa H, El-Makaty H, Ali Z. Appropriateness of Dabigatran and Rivaroxaban Prescribing in Qatar: A 5-Year Experience. J Cardiovasc Pharmacol Ther 2017; 23:155-161. [DOI: 10.1177/1074248417731536] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hazem Elewa
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Honain El-Makaty
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Zainab Ali
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
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Chang C, Hoyos M, Owusu Y, Elewa H. Direct Oral Anticoagulant Use in Atypical Thrombosis-Related Conditions. Ann Pharmacother 2017; 52:185-197. [PMID: 28918657 DOI: 10.1177/1060028017731850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Elewa H, Jalali F, Khudair N, Hassaballah N, Abdelsamad O, Mohammed S. Evaluation of pharmacist-based compared to doctor-based anticoagulation management in Qatar. J Eval Clin Pract 2016; 22:433-8. [PMID: 26766552 DOI: 10.1111/jep.12504] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES For over 60 years, warfarin has been the mainstay anticoagulant used in the outpatient setting for the prevention and treatment of a wide variety of thromboembolic clinical conditions. Guidelines recommend that health care providers managing oral anticoagulation therapy should do so in a systematic and coordinated fashion. Studies have shown that, when compared to traditional doctor-based anticoagulation management, pharmacist-managed anticoagulation services can improve patient outcomes. The first pharmacist-based anticoagulation clinic in Qatar was launched in 2013 at Alwakra Hospital. The primary objective of this research was to evaluate the impact of pharmacist versus doctor-based anticoagulation management on the percentage time under therapeutic INR (International Normalized Ratio; TTR), INR within therapeutic range and the extreme out of range INRs. METHOD A retrospective cohort study was designed to compare the anticoagulation control of pharmacist-based warfarin clinic to the usual doctor-care. RESULTS Data from 278 patients taking warfarin (78 managed at pharmacist and 200 at doctor-based clinic) were evaluated. Subjects followed at the pharmacist-based clinic had a superior TTR compared to those managed at the doctor-based clinic (81.8% vs. 69.8%, P < 0.001). Additionally, the percentage of visits within therapeutic range were significantly higher in the pharmacist's group compared to doctor's group (76.5% vs. 71.2%, P = 0.011). At the same time, percentage of visits with extreme subtherapeutic INR was reduced in the pharmacist-managed clinic (5.17% vs. 7.05%, P = 0.007) CONCLUSIONS: Our study indicates that pharmacist-based anticoagulation has better INR control when compared to the traditional anticoagulation management. Pharmacist-managed anticoagulation clinics should be considered and supported for warfarin management.
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Affiliation(s)
- Hazem Elewa
- College of Pharmacy, Qatar University, Doha, Qatar
| | | | - Nada Khudair
- College of Pharmacy, Qatar University, Doha, Qatar
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Impact of target-specific oral anticoagulants on transitions of care and outpatient care models. J Thromb Thrombolysis 2013; 35:304-11. [DOI: 10.1007/s11239-013-0879-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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