17-23 CPD Module PM 0116 rtQ8.qxp:00-00 PM 0116 … module pull out and keep this cpd module plus pre-test and post-test is online at pharmacymagazine.co.uk pharmacy magazine january

CPD MODULE

continuingprofessionaldevelopment

the

programme

This module is suitable for use by community pharmacists as part of their continuing professional development. After reading this module in the magazine or online, complete the scenarios and post-test atwww.pharmacymagazine.co.uk and include in your personal learning log.CPD is one aspect of professional development and can be consideredalongside other activities for inclusion in your RPS Faculty portfolio.

Working in association with

module 243pharmacymagazine.co.uk

GOALTo help pharmacists feel confident aboutoffering the NMS and MURs for warfarin and the newer oral anticoagulants.

OBJECTIVESAfter studying this module you should be able to:• Appreciate how NHS medicines advice/supportservices can be used to make oral anticoagulants safer

• Explain the patient pathway regarding anticoagulation• Develop a structured approach to identifying andhelping patients prescribed anticoagulants.

Welcome to the two hundred and forty third modulein the Pharmacy Magazine Continuing ProfessionalDevelopment Programme, which looks at medicinesoptimisation in anticoagulation.

Journal-based educational programmes are animportant means of keeping up to date with yourclinical and professional knowledge. Completion of this module will contribute to the nine pieces of CPDthat must currently be recorded a year.

Before reading this module, test your existingunderstanding of the subject by completing the pre-testat www.pharmacymagazine.co.uk. Then, after studyingthe module in the magazine or online, work through the learning scenarios and post-test on the website tocheck your answers. Record your learning using yourpersonal Pharmacy Magazine online log.

The RPS Faculty and advancing yourprofessional developmentPharmacy Magazine’s CPD programme can form part of yourprofessional development, providing you with essentialknowledge and skills. It can also be considered alongsideother activities for inclusion in your RPS Faculty portfolio.

The RPS Faculty is a professional recognition programmefor all pharmacists in all sectors at all stages of their careerand involves assessment of a practice-based portfolio thatrecognises their professional development.

This allows you to demonstrate to others your level ofattainment and stage of advanced practice. It also helps youto identify what you need to know at different stages of yourcareer. Start your Faculty journey by accessing the portfolioand tools at www.rpharms.com/Faculty.

This module is also online at pharmacymagazine.co.uk 8

pharmacy magazine

First in professional development

forthismodule

Medicines optimisationin anticoagulationContributing author: Karen Rosenbloom,visiting senior lecturer at King’s College LondonIntroductionAnticoagulants are one of the classes ofmedicines most frequently identified ascausing preventable harm and admissionto hospital. There are two main groups oforal anticoagulants:• Vitamin K antagonists (VKA) including

warfarin • Non-vitamin K antagonists (apixaban,

dabigatran, edoxaban and rivaroxaban),known as new oral anticoagulants(NOACs) or direct oralanticoagulants (DOACs). There are several

indications for oralanticoagulants so it is important toknow why theyhave beenprescribed. This may presenta challenge,however, ascommunitypharmacists may not be aware of thepatient’s diagnosis.

The commonest uses of oralanticoagulants are for the treatment of deep vein thrombosis or pulmonaryembolism, collectively known as venousthromboembolism (VTE), and thesecondary treatment of stroke in non-valvular atrial fibrillation.

Vitamin K antagonistsWarfarin is the only licensed vitamin Kantagonist (acenocoumarol and

phenindione are other members of the group). Warfarin has

a half-life of 40 hours, an onset of action of

between two to fivedays and a mode ofaction that reducesthe availability ofvitamin K, therebyreducing theproduction of active

clotting factors II, VII,IX and X. Warfarin is

metabolised in the liver by cytochrome P450 and

metabolites are excreted in the

PULL OUT AND KEEP THIS CPD MODULE PLUS PRE-TEST AND POST-TEST IS ONLINE AT PHARMACYMAGAZINE.CO.UK PHARMACY MAGAZINE JANUARY 2016CPD i

17-23_CPD Module_PM_0116_rtQ8.qxp:00-00_PM_0116 08/01/2016 11:57 Page 17

pharmacymagazine.co.uk

ii CPD JANUARY 2016 PHARMACY MAGAZINE THIS CPD MODULE PLUS PRE-TEST AND POST-TEST IS ONLINE AT PHARMACYMAGAZINE.CO.UK PULL OUT AND KEEP

urine. Table 1 (below) summarises the INRtargets for different indications.In most localities warfarin remains the first-

line anticoagulant for patients with ischaemicstroke and non-valvular atrial fibrillation.

Direct oral anticoagulantsDirect oral anticoagulants (DOACs) have a direct action on factors in the clotting cascade.Apixaban, edoxaban and rivaroxaban are directinhibitors of Factor Xa, preventing thrombinproduction and thrombus formation. Dabigatranis a direct thrombin inhibitor. The half-life of this drug group ranges from

between seven and 14 hours, with the onset of action between one and four hours. DOACs are metabolised in the liver to form activemetabolites, which are excreted by the kidneys.Table 2 summarises key features of the DOACs.

Indications for use of anticoagulantsAetiology of thrombosisA thrombus is formed when soluble fibrinogenis converted to insoluble fibrin by thrombinfactor IIa, the end point of the clotting cascade.Vitamin K antagonists (warfarin) and direct oral

anticoagulants (apixaban, dabigatran, edoxabanand rivaroxaban) inhibit different sections of thecascade to prolong the amount of time it takesfor a clot to form.

Venous thromboembolic eventsDeep vein thrombosis (DVT) is the term used to describe the formation of a thrombus in adeep vein. DVT occurs in approximately one in1,000 people and is a major cause of morbidityand mortality. Venous thromboembolism can be described as provoked or unprovoked. Provoking factors include significant

immobility, surgery, trauma, pregnancy orpuerperium, the combined contraceptive pill and hormone replacement therapy. These riskfactors can be modified, reducing the risk ofrecurrence, in which case anticoagulation would normally be limited to three months(pharmacists should check their localanticoagulation guidelines). If the event was deemed to be unprovoked in

the absence of any transient risk factors, thenlong-term anticoagulation may need to beconsidered if the cause is not easily correctableor unknown.

Secondary prevention of stroke in non-valvular atrial fibrillationNon-valvular atrial fibrillation (AF) is thecommonest clinically significant cardiac

arrhythmia, with an estimated lifetime risk of 22-26 per cent conferring a five-fold risk of stroke. The estimated prevalence for thepopulation of England is 1.6 per cent. Throughits effects on rate and rhythm, atrial fibrillationstasis can result in pooling in the atria whereemboli may form. A stroke secondary to atrial fibrillation is

often severe and results in long-term disability.Twenty per cent of strokes are thought to berelated to atrial fibrillation but strokes couldalso be caused by carotid artery stenosis andhaemorrhage. The risk of death from a stroke is doubled if associated with atrial fibrillation.The criteria for anticoagulation for secondary

stroke prevention in non-valvular atrialfibrillation were established in 2006 but an auditin 2013 found that it was being used in only 55 per cent of those patients who fulfilled thecriteria. The treatment threshold was loweredfurther in June 2014. DOACs are not licensed totreat patients with non-valvular atrial fibrillationif they have a prosthetic mechanical valvereplacement.

Assessment of stroke risk Patients need to understand and be able todiscuss the options for anticoagulation andmake an informed choice based on their clinicalfeatures and preferences. Pharmacists also needto have an understanding of stroke risk toolsand scores. There are several stroke riskassessment tools: • The CHA2DS2-VASc stroke risk assessment toolidentifies patients who would benefit fromanticoagulation

• The HASBLED assessment tool identifies thoseat risk from a bleed when anticoagulated.

There are a number of web-based calculatorsbut NICE recommends a site developed by the

Pharmacy Magazine CPD modulesprovide you with knowledge to help you to develop and advance your practice and can be recorded in your Faculty portfolio.

Start your journey now by accessing the Faculty portfolio, tools and resources atwww.rpharms.com/Faculty.

Working in association with

When they first became available, the non-vitamin Kantagonists were referred to as novel or new oralanticoagulants (NOACs). Now that these medicines have been in use for several years, the term NOAC is considered to mean ‘non-vitamin K oralanticoagulants’. It has been recognised that the abbreviation ‘NOAC’ has the potential to bemisinterpreted as NO-anticoagulation, and some people argue that DOAC (direct anticoagulants) may be a safer abbreviation for this drug group.

�

Confusing terminologyUsing your PMR, find out the number of patients onanticoagulants where you have recorded the indication?

�

Reflection exercise 1

�

Table 1: Target INRs for maintenance regimens (NICE 2015)Indication

Atrial fibrillation/flutter

Atrial fibrillation/flutter

First distal DVT

First provoked proximal DVT/PE

First unprovoked DVT/PE

Recurrent VTE (when not anticoagulated)

Recurrent VTE (when fully anticoagulatedand anticoagulant control is within target)

Target INR

2.5

2.5

2.5

2.5

2.5

2.5

3.5

Duration

Long-term

Pending cardioversion (check if localguidelines suggest an increase to avoidcancellations due to low INR)

3 months (check local guidance as some mayindicate 6 weeks)

3 months

6 months and review

Consider indefinite – seek haematologyadvice

Seek clarification. In some localities thismay require haematologist review


CPD MODULE

PULL OUT AND KEEP THIS CPD MODULE PLUS PRE-TEST AND POST-TEST IS ONLINE AT PHARMACYMAGAZINE.CO.UK PHARMACY MAGAZINE JANUARY 2016CPD iii

American Society of Cardiology (acc.org/tools-and-practice-support/clinical-toolkits/atrial-fibrillation-afib).The NICE guidelines recommend that

anticoagulation should be considered for menwho have a CHA2DS2-VASc score of 1 and beoffered to male and female patients who have a CHA2DS2-VASc of 2. It is anticipated that thenumber of patients prescribed anticoagulants is set to increase, particularly with an ageingpopulation. The HAS-BLED assessment tool is used to

guide a decision where the risk of bleedingoutweighs the benefit of anticoagulation. If the HAS-BLED score is above 3, the risk mayoutweigh the benefit. In such cases patientsshould be informed of the risk factors andreferred back to their haematologist.

Medicines optimisation Medicines optimisation is a person-centredapproach to safe and effective medicines use, to ensure people obtain the best possibleoutcomes from their medicines. The success of oral anticoagulant treatment can bedetermined by the prevention of stroke ortransient ischaemic attack and the amount oftime the patient spends safely anticoagulated. The move away from routine monitoring of

anticoagulant activity presents a paradigm shift.Until DOACs became available, all patients

prescribed warfarin underwent therapeutic drugmonitoring with INR testing as frequently asweekly or monthly. When patients are seen by healthcare

professionals during routine monitoring, there are opportunities to educate patients,provide positive reinforcement to support thedevelopment of informed adherence, simplifyregimens or engage a patient’s support networkto achieve maximal thromboprophylaxis.So community pharmacists can play an

important role in ensuring the safe use ofDOACs. For example, DOACs are contraindicatedin specific patient groups including those withcancer or prosthetic mechanical heart valves,while missed and skipped DOAC doses have a greater patient risk compared to warfarin dueto the short half-life of the drug group.

You can complete this module online atpharmacymagazine.co.uk and record yourlearning outcomes and the impact on yourpractice in your personal learning log

Do you have access to your local anticoagulationguidelines? Where would you refer an anticoagulatedpatient who you felt was in need of a review?

�


�

Table 2: Summary of the direct oral anticoagulants (DOACs)

Target

Bioavailability

Renal clearance

Hepatic clearance

Compliance aid compatibility

Compliance

Missed dose

Rivaroxaban

Factor Xa

80-100%

36%

• Review SPC, avoid concomitanttreatment with strong inhibitorsof both CYP3A4 and P-gp(e.g. ketoconazole, itraconazole,voriconazole or HIV proteaseinhibitors)

• Caution with strong CYP3A4inducers (e.g. rifampicin,phenytoin, carbamazepine,phenobarbital or St John’s wort)as they may lead to reducedrivaroxaban concentrations

• Caution with dronedarone

Yes – shelf-life of 3 years and nospecial storage requirements

Once daily – except during 21-daycourse of 15mg twice daily,needed for acute VTE

Missed dose should be takenimmediately and then continuedon the following day with once a day dosing

Do not double dose within thesame day to make up for misseddose

Edoxaban

Factor Xa

55%

50%

• Review SPC, dose reduction is required with concomitanttreatment with strong inhibitorsof both CYP3A4 and P-gp (e.g. ketoconazole, itraconazole,voriconazole or HIV proteaseinhibitors)

• Caution with strong CYP3A4inducers (e.g. rifampicin,phenytoin, carbamazepine,phenobarbital or St John’s wort)as they may lead to reducededoxaban concentrations

Yes –shelf-life of 3 years and nospecial storage requirements

Once daily

Missed dose should be takenimmediately and then continuedon the following day with once a day dosing


Dabigatran

Thrombin

3-7%

80%

• Review SPC, potential for P-gpinteractions (e.g. amiodarone,verapamil, quinidine,ketoconazole, clarithromycin,rifampicin, phenytoin andcarbamazepine)

• Concomitant treatment withsystemic ketoconazole,ciclosporin, itraconazole,tacrolimus and dronedarone is contraindicated

No

Twice daily dosing

Missed dose may still be taken upto 6 hours prior to next scheduleddose

If within 6 hours of next dose, themissed dose should be omitted

Apixaban

Factor Xa

50%

27%

• Review SPC, avoid concomitantuse with strong inhibitors of both CYP3A4 and P-gp (e.g. ketoconazole, itraconazole,voriconazole or HIV proteaseinhibitors)

• Caution with strong CYP3A4inducers (e.g. rifampicin,phenytoin, carbamazepine,phenobarbital or St John’s wort)as they may lead to reducedapixaban concentrations

Yes – shelf-life of 3 years and nospecial storage requirements

Twice daily dosing

Missed dose should be takenimmediately and then continuedtwice a day as before




iv CPD JANUARY 2016 PHARMACY MAGAZINE THIS CPD MODULE PLUS PRE-TEST AND POST-TEST IS ONLINE AT PHARMACYMAGAZINE.CO.UK PULL OUT AND KEEP

Reinforcing safety messages in a range ofsettings, including community pharmacies, may make oral anticoagulants safer. Without the security associated with regular

INR testing, there is no system in place toidentify patients who are not taking theiranticoagulants. Patients who are prescribedDOACs need support and access to informationto develop sustained, informed adherence. Patients may have their DOAC treatment

initiated by specialist anticoagulant services but, following the initiation phase, the drugmay then be prescribed by the patient’s GP. A community pharmacist could be the onlyhealthcare professional to have regular contactwith the patient, so it is important not toassume that the hospital pharmacist or anothermember of the hospital team has been able tohave a full discussion with the patient abouthis/her medicine. Patients who are prescribed DOACs should

be identified as soon as possible and offeredsupport via the NMS or given a MUR. Wherepossible, the NMS and MURs should be builtinto integrated care pathways.

Evidence-based treatment In recent NICE clinical guidance (2014), oralanticoagulants (warfarin or DOACs) wererecommended as first-line treatment forpatients with AF and at an increased risk ofstroke. Evidence now indicates that patientswith AF should not be offered aspirin as amonotherapy for stroke prevention as it is abarrier to appropriate stroke prevention withoral anticoagulation. Audit data collected in 2013 found that only

36 per cent of patients with AF admitted tohospital with stroke were prescribed an oralanticoagulant. Patients with AF should also not be prescribed

antiplatelet drugs because this drug group isconsidered ineffective in stroke reduction. It isessential therefore that community pharmacyteams identify patients with AF, especially those

who buy low-dose aspirin OTC, and ensure thatthey have their treatment reviewed.There are also instances when patients should

have their anticoagulation therapy reassessed.NICE recommends a review of warfarin anti-coagulation in the following circumstances: • A time-in-therapeutic-range (TTR) of less than 65 per cent

• Two INRs less than 1.5 • Two INRs greater than 5 • One INR reading greater than 8 in the past six months.

Patients should be considered for a DOAC if appropriate but have their anticoagulationtherapy reassessed if they are non-adherent. In July 2015 NICE published quality standard

93: ‘Atrial fibrillation: treatment and management’.Community pharmacists can support localanticoagulation services by ensuring:• Adults with non-valvular atrial fibrillation and a CHA2CDA2-VASc stroke risk score of 2 or above are offered anticoagulation

• Adults with atrial fibrillation are notprescribed aspirin as monotherapy for stroke prevention

• Adults with atrial fibrillation who areprescribed anticoagulation discuss the optionswith their healthcare professional at leastonce a year

• Adults with atrial fibrillation taking a vitaminK antagonist who have poor anticoagulationcontrol have their anticoagulation reassessed

• Adults with atrial fibrillation whose treatmentfails to control their symptoms are referred forspecialised management within four weeks

• Adults with atrial fibrillation on long-termvitamin K antagonist therapy are supported to self-manage with a coagulometer.

Ensuring safe anticoagulant use The International Normalized Ratio (INR) can beused to advise what dose of warfarin is required.Current practice recommends that prescribersand pharmacists should check patients’ INRvalues at the point of prescribing and dispensingwarfarin. Some community pharmacy-basedservices include point-of-care INR monitoringusing a coagulometer.Vitamin K antagonists have a narrow

therapeutic range so need close monitoring to

Warfarin remains the first-line treatment for ischaemic stroke and AF in most areas

How do you deal with requests for low-dose aspirin?Discuss with your team what questions they could askto identify patients who may need to be prescribed ananticoagulant.

�Reflection exercise 3


CPD MODULE

PULL OUT AND KEEP THIS CPD MODULE PLUS PRE-TEST AND POST-TEST IS ONLINE AT PHARMACYMAGAZINE.CO.UK PHARMACY MAGAZINE JANUARY 2016 CPD v

ensure that a patient is not under- or over-anticoagulated. Moreover patients who areinitiated on DOACs or are being switched fromwarfarin to a DOAC may be concerned aboutachieving the right level of anticoagulation.

Such patients need to be reassured that, due to the pharmacokinetics of DOACs, theircoagulation does not need to be monitored –but they will need to have their renal and liverfunction monitored annually. Liver and kidneyfunction tests may be needed more frequentlywith older people.

Patients may also be concerned that there areno reversing agents for DOACs. Communitypharmacists are well placed to discuss theseissues during a NMS consultation or MUR. The safety profile of DOACs relies on patientsunderstanding the differences between warfarinand DOACs and the importance of adhering to their treatment to reduce the frequency ofmissed and skipped doses.

Community pharmacists have a role to play in ensuring patients have their liver and renalfunction monitored. They are also well placed to help patients understand that DOACs aremetabolised by the liver into an activemetabolite, and if their renal functiondeteriorates this will lead to an accumulation of active drug and an increased risk ofhaemorrhage. This may help patients tounderstand the importance of recognisingindications of over-anticoagulation and thatdose adjustment may be necessary in cases of renal or hepatic impairment.

Table 3 summarises adverse event and side-effect management.

Understanding the patientexperienceOnly 16 per cent of patients are fully adherentafter starting a new medicine, even when theyhave all of the information that they need. One-third are non-compliant 10 days afterstarting a new medication. Of these, 55 per cent are unaware that they are even taking their medication incorrectly and 45 per cent are intentionally non-adherent.

A typical model for patients prescribedwarfarin who do not attend for INR tests wouldbe to offer them three further chances to attendtheir appointment. If at that point they have still

�

Table 3: Anticoagulant adverse event and side-effect management Bleeding-related adverse effects(All anticoagulants)

Involved in major trauma Suffer a significant blow to the headUnable to stop bleeding

Prolonged nosebleeds (more than 10 minutes) Blood in vomitBlood in sputumPassing blood in urine or faeces Passing black faeces Severe or spontaneous bruisingUnusual headaches Heavy or increased bleeding during a woman’s period or any other vaginal bleeding

Non-bleeding-related adverse effects(All anticoagulants)

Diarrhoea AlopeciaRash

Non-bleeding-related adverse effects:Rivaroxaban

Dizziness, light-headednessIncidence: 1 in 10-100 (common)

Non-bleeding-related adverse effects:Dabigatran

Gastrointestinal discomfortIndigestion/GORDFrequent loose or liquid bowel movementsNauseaIncidence: 1 in 10 (common)

Non-bleeding-related adverse effects:Apixaban

NauseaIncidence: 1 in 100 (common)

OedemaSkin rashIncidence: more than 1 in 1,000 (uncommon)

Non-bleeding-related adverse effects:Edoxaban

NauseaIncidence: 1 in 100 (common)OedemaSkin rashIncidence: more than 1 in 1,000 (uncommon)

Action required

Seek immediate medical attention – A&E + informanticoagulation clinic

Seek medical attention – A&E or GP + informanticoagulation clinic

Action required

Check timing to see whether warfarin initiation coincideswith symptoms. Advise patient to see his/her GP or tocontact anticoagulation clinic for review

Action required

Typically wears off after initiation and often occurs whenrivaroxaban is at its peak concentration. Advise patientsto take it in the evening to try to improve tolerability.If unsuccessful may need to switch anticoagulant

Action required

Often patients describe intolerable gastrointestinaldiscomfort thought to be linked to the acidic coating ondabigatran. Consider switching anticoagulant agent

Action required

Review anticoagulant

Action required

Review anticoagulant



not been tested, the GP should be notified thatthe patient has stopped attending and thereforethey would not be able to prescribe warfarinsafely for this patient.

While available data suggests that DOACs are as effective as warfarin, the lack of INRmonitoring may mean patients’ medicines-taking behaviour is different. The short half-life of DOACs means patients who omit dosesintentionally or unintentionally are at risk ofthrombosis through inadequate anticoagulation.

Given that the anticoagulant effects of DOACsfade rapidly on cessation, it is imperative thatpoor adherence is identified at any patientcontact opportunities. Pharmacists should befamiliar with missed dose guidance.

Evidence suggests that patients initiated ondabigatran are more likely to persist with oralanticoagulation in comparison to those initiatedon warfarin. However, studies documenting ‘real world’ experience suggest that adherenceto DOACs is similar to that for other chronicconditions that require long-term medicationmanagement.

One study found that 28 per cent of patientswith non-valvular atrial fibrillation were non-

adherent within one month following initiationof dabigatran. (Non-adherence was defined as having a proportion of days covered by medication as less than 80 per cent.)Throughout a median follow-up period of eightmonths, approximately two in 10 patients had a gap longer than 30 days without medication.

Another study established that 30 per cent of patients prescribed dabigatran discontinuedtreatment in consultation with their doctor atsome time between three and 12 months ofinitiation. When interviewed, patients gave the following reasons for discontinuation, in descending order: • GI symptoms (which led to discontinuation

within days of the first dose) • Concerns that there was no antidote available • Worsening renal function • Myocardial infarction • Itching • Major haemorrhage.Not all patients who experienced GI symptomsdiscontinued treatment. Some patients wereinitiated on a proton pump inhibitor and thealleviation of GI symptoms allowed them topersist with dabigatran. These issues could be

discussed with patients during NMS and MURconsultations.

When discussing oral anticoagulant treatmentoptions with patients, the following issuesshould also be considered: • Burden of INR monitoring• Ability to develop sustained, persistent

adherence • Use of compliance devices• Polypharmacy medicines burden:

• Daily vs twice daily dosing• Beliefs about stroke prevention:

• Accept that those with a low CHA2DS2-VASc score may be less willing to considertreatment

• HAS-BLED risk • Patients who have taken aspirin for years

may be unwilling to switch to an oralanticoagulant.

Drug interactions A broad range of medicines interact withwarfarin. Patients prescribed warfarin shouldhave their INR re-checked three to five daysafter starting any new medication and beencouraged to notify their anticoagulation clinicto review the date of their next INR test.

As each DOAC has a slightly different profile,community pharmacists should review the SPCfor the DOAC required for specific guidanceregarding drug interactions.

Local anticoagulation services Although practice varies, patients prescribedDOACs are monitored routinely by specialistanticoagulation services for the first two tothree months of therapy, after which they maybe transferred to primary care where they willnot be monitored routinely. Some providers donot provide specialist monitoring in the initialphase, and in some localities GPs may alsoprescribe from initiation on the basis that theyfeel competent to do so.

Patients managed by specialist anti-coagulation services may have their DOACsdispensed on-site, but delays in appointmentsystems may result in patients running out ofmedication before their next appointment.

Patient safety can also be compromised ifdocumentation of an anticoagulant switch from warfarin to a DOAC is not received by GPs

vi CPD JANUARY 2016 PHARMACY MAGAZINE THIS CPD MODULE PLUS PRE-TEST AND POST-TEST IS ONLINE AT PHARMACYMAGAZINE.CO.UK PULL OUT AND KEEP

Coagulation does not need to be monitored with DOACs


before they prescribe a repeat supply of warfarin, resulting in duplicatedanticoagulation.

Ideally, patients who are started on a DOAC in secondary care should be referred to theirlocal community pharmacy for the NMS inaccordance with the service specification but, in reality, this is not common practice.

To improve patient safety, there is a need forcommunity pharmacy teams to adopt a proactiveapproach to case-finding patients who have beeninstigated on a DOAC. When dispensing regularrepeat medicines, pharmacy teams shouldconsider how they can capture and record all prescribed medicines, including DOACs,irrespective of where they are dispensed.

Members of the pharmacy team couldconsider asking patients questions, such as: • Have you been seen by any members of the

anticoagulation team?• Have you changed your blood thinning

medicines?• Do you take any medicines that are dispensed

in other places, including hospital services?• Do you take any medicines that are delivered

to you at home?• Do you take any medicines other than the

ones that are dispensed by this pharmacy?Some localities have developed protocols andpatient group directions to enable communitypharmacists to identify patients who requirewarfarin dose titration. Recent guidance

highlighted safety concerns associated withPGDs for drugs that required regular monitoringand dose adjustment. The guidance suggeststhat developing non-medical independentprescribing services for high-risk groups could be safer. This may provide communitypharmacists with an opportunity to develop anon-medical prescribing anticoagulation servicelinked with other service providers (see panelbelow).

New medicine service The NMS is a valuable tool to determine if a patient is tolerating an anticoagulant and to reinforce understanding with regards to theindication, duration and what to do in the eventof a minor or major bleed (see Figure1).

If, during a NMS consultation, it transpiresthat the patient is suffering intolerable side-effects, he/she can be referred back to the GP in accordance with the service specification.

The NMS provides an opportunity to ensurethat patients are aware that they must carrywith them at all times an anticoagulation alertcard and tell other healthcare professionals that they are on an anticoagulant, particularlywhere they may be having an invasiveprocedure. A discussion around compliance and how a patient plans to fit the medicines into his/her daily routine is also beneficial.

ConclusionThere is a need to embed the NMS and MURservices into care pathways that enablecommunity pharmacists to supportanticoagulated patients. The importance ofmaintaining persistent adherence months andyears after being initiated on oral anticoagulanttherapy is particularly important with DOACs,and community pharmacists have an importantrole in supporting this patient group. Whereproblems arise with side-effects, bleeding or a patient’s own beliefs regarding theirmedication, community pharmacists cansignpost appropriately.

CPD MODULE

PULL OUT AND KEEP THIS CPD MODULE PLUS PRE-TEST AND POST-TEST IS ONLINE AT PHARMACYMAGAZINE.CO.UK PHARMACY MAGAZINE JANUARY 2016 CPD vii

Pharmacy Magazine’s CPD modules are available on Cegedim Rx’s PMR systems, PharmacyManager and Nexphase. Just click on the ‘Professional Information & Articles’ button withinPharmacy KnowledgeBase and search by therapy area. Please call the Cegedim Rx helpdesk on 0844 630 2002 for further information.

Community pharmacists can complete a post-graduate certificate in non-medical independent prescribing. As thesecourses offered by some universities are often oversubscribed, priority may be given to applicants who highlight howtheir independent prescribing service may improve patient safety. Pharmacists would normally need to identify and develop skills and knowledge required to underpin their intended

scope of practice prior to securing a place on a non-medical prescribing course. It is usual for a pharmacist to identify a therapeutic area – stroke prevention with or without AF would be considered an appropriate scope of practice. Theirassociated drugs list would normally include up to three classes of drugs and these could include oral anticoagulants.All students must identify a qualified medical practitioner who can support them through the course and who will act

as their designated medical practitioner (DMP). Students have to complete 12 days in practice in order to demonstrateprescribing competencies. Days in practice would normally be completed alongside their DMP and not in thecommunity pharmacy setting. Past experience suggests that community pharmacists who develop anticoagulation therapy as their scope of practice

would be expected to work closely with their local GPs and anticoagulant services.

�

Community pharmacists as anticoagulation independent prescribers?

How many of your patients prescribed DOACs have had a NMS? Discuss with the local anticoagulant leadpharmacist how you can develop or improve the referralpathway should any problems occur.

�


Initiation• Consent• Indication• Duration• Side-effects• Compliance• Alert card• Notification of other health-care professionals

• Opportunistic advice onhealthy living / publichealth topics

• Organise time and date ofintervention

OR • Complete GP notificationform on concerns relatingto a newly prescribedanticoagulant

• Update pharmacy record

Follow-up• Indication• Duration• Side-effects (bleedingrelated)

• Side-effects (non-bleedingrelated)

• Compliance • Alert card• Notification of other health-care professionals

• Advise end of NMS processand consider MUR whenappropriate

OR• Complete GP notificationform of concerns relating to a newly prescribedanticoagulant


Intervention• Confirm consent• Indication• Duration• Side-effects (bleedingrelated)

• Side-effects (non-bleedingrelated)

• Compliance• Alert card• Notification of other health-care professionals

• Organise time and date of follow-up

OR• Complete GP notificationform of concerns relating to a newly prescribedanticoagulant


�

Figure 1: NMS structured review of direct oral anticoagulant use


�

MEDICINES OPTIMISATION IN ANTICOAGULATION

1. Which of the following is not a DOAC?

a. Apixabanb. Acenocoumarolc. Edoxaban d. Rivaroxaban

2. Find the TRUE statementregarding DOACs:

a. They have a direct action onthe clotting cascade

b. If one causes a specific side-effect, so will all of the others

c. If a patient has renalimpairment, one DOAC maybe safer than another

d. DOACs are licensed to treatsecondary stroke preventionin all types of atrialfibrillation

3. Patients prescribedwarfarin should have theirtreatment reviewed if inthe past six months:

a. Three INR values have beenhigher than 5

b. Two INR values have beenhigher than 8

c. INR values have been lessthan 1.5

d. Time-in-therapeutic-range isless than 65 per cent

4. Which is NOT a licenseduse of dabigatran?

a. Primary prevention of avenous thromboembolic eventin adults who have undergoneelective knee replacementsurgery

b. Prevention of stroke andsystemic embolism in adultswith atrial fibrillation

c. Treatment of deep veinthrombosis and pulmonaryembolism in adults

d. Prevention of recurrent DVTand pulmonary embolism inadults

5. The acidic coating ofwhich anticoagulant can cause intolerable GI discomfort?

a. Rivaroxabanb. Dabigatranc. Apixaband. Edoxaban

6. Which statement isFALSE?

a. Anticoagulation should beconsidered for men who havea CHA2DS2-VASc score of 1

b. Edoxaban inhibits Factor Xac. Apixaban has once daily

dosingd. Warfarin has a half-life of

40 hours

7. Which of the followingissues does NOT have to be considered whendiscussing DOACtreatment options with patients?

a. GI symptomsb. Concerns that there is no

antidote availablec. Monitoring renal functiond. Ability to cope with a three-

time-a-day dosing regimen

8. Which of the followingdoes not require urgentmedical attention inpatients on anticoagulants?

a. Nosebleeds lasting less thanfive minutes

b. Blood in vomitc. Passing blood in the urine

or faecesd. Unusual headaches

CPD record

* If as a result of completing your evaluation you have identified another new learning objective, start a new cycle. This will enable you to start at Reflect and then go on to Plan, Act and Evaluate.This form can be photocopied to avoid having to cut this page out of the module. You can also

complete the module atwww.pharmacymagazine.co.uk and record on your personal learning log

January2016

Pharmacy Magazine


viii CPD OCTOBER 2015 PHARMACY MAGAZINE LEARNING SCENARIOS FOR THIS MODULE AT WWW.PHARMACYMAGAZINE.CO.UK PULL OUT AND KEEP

Activity completed. (Describe what you did to increase your learning. Be specific)(ACT)

Date: Time taken to complete activity:

What did I learn that was new in terms of developing my skills, knowledge and behaviours? Have my learning objectives been met?*(EVALUATE)

Do I need to learn anything else in this area? (List your learning action points. How do you intend tomeet these action points?)(REFLECT & PLAN)

How have I put this into practice? (Give an example of how you applied your learning). Why did it benefit my practice? (How did your learning affect outcomes?)(EVALUATE)

Use this form to record your learning and action points from this module on MedicinesOptimisation in Anticoagulation or record on your personal learning log atpharmacymagazine.co.uk. You must be registered on the site to do this. Any training, learning ordevelopment activities that you undertake for CPD can also be recorded as evidence as part ofyour RPS Faculty practice-based portfolio when preparing for Faculty membership. So start yourRPS Faculty journey today by accessing the portfolio and tools at www.rpharms.com/Faculty.

You can also record in your personal learning log at pharmacymagazine.co.uk 8

viii CPD OCTOBER 2015 PHARMACY MAGAZINE LEARNING SCENARIOS FOR THIS MODULE AT WWW.PHARMACYMAGAZINE.CO.UK PULL OUT AND KEEP

Now enter your answers onlineYou no longer have to send your answers away to be marked. Once you areregistered on our website, you can complete the pre- and post-test free ofcharge and record your learning outcomes in your personal learning log.

On

desktop,

mobile and

tablet

REGISTER AT: www.pharmacymagazine.co.uk

24_Module_MCQs PM_0116_rtQ8.qxp:24_PM_0116 08/01/2016 11:54 Page 1

17-23 CPD Module PM 0116 rtQ8.qxp:00-00 PM 0116 … module pull out and keep this cpd module plus pre-test and post-test is online at pharmacymagazine.co.uk pharmacy magazine january

Documents