St George’s Hospital in London runs an anticoagulation service with around 2,100 active patients. The hospital uses INRstar as its clinical decision support system and benefits from its new functionality which supports direct oral anticoagulants (DOACs) * and LMWH. Around 250 patients are currently on non-warfarin anticoagulants such as heparin, DOACs and Sinthrome.
The nurses running the clinics are highly skilled and manage patients and clinics effectively requesting consultant help when needed. We talked to Sherra Aynin, Anticoagulation Sister at St George’s about how they currently manage their patients, and how they are building in reviews for their DOAC patients.
“We run a range of clinics at the hospital, including a bi-weekly nurse-led dosing clinic using Point of Care testing and we offer bridging therapy. These clinics process around 300 INRs a week. Consultants run clinics twice a week, where complex patients and thrombosis cases are managed. We also have an open access clinic which runs every day. This clinic uses lab testing and also runs a postal service, which accounts for around 250 INRs a week.”
“We manage patients on both a short and long term basis. Our patients are referred from the wards within the hospital and/or by their GP and are reviewed four weeks after initial consultation. With the introduction of DOACs, we review patients after four weeks if they were initially prescribed dabigatran and after 3 weeks if they were initially prescribed rivaroxaban. If the patients do not report any side effects during this initial treatment period they will be prescribed the DOACs for another 2 months and – where agreements are in place, the prescribing is transferred over to the GPs. GPs may ask for consultant advice when needed. However, many GPs in the local area are not willing to do this and so we end up managing many patients for the whole term of their treatment.”
*Supported drugs are apixaban, dabigatran, rivaroxaban, edoxaban and dalteparin.
“It is critical that we review patients on a regular basis 1. Patients with acute thrombosis are seen every 3 weeks initially. When patients are prescribed DOACs we regularly review the kidney function, because the route of elimination of DOAC drugs is through the kidneys. A decline in kidney function would result in accumulation of the plasma concentration of the said DOAC and increase the risk of bleeding. In people with normal kidney function this may checked on a yearly basis, but in people with a decreased kidney function we would consider checking every 3/6 months. This is why we find the new DOAC functionality from INRstar so useful: reviewing and monitoring our patients is absolutely vital to our service and we are keen to have a means of reviewing patients on different medications in the one place.”
“Our anticoagulant clinics are exceedingly overbooked for INR monitoring. The introduction of DOACs that do not require INR monitoring should reduce our clinical workload, though the lack of an effective antidote is limiting patients’ acceptance. This is not a major obstacle for patients with newly diagnosed thrombosis, but patients who are asked to switch from warfarin to DOACs often say they do not feel in control of their management, as they do not have the same level of monitoring carried out. As healthcare providers, we read and update ourselves on the efficacy of DOACs as more and more clinical trials are published, but we understand that for many patients to accept the efficacy and the lack of monitoring of DOACs is a leap of faith. Nevertheless we hope to reduce the prescribing of warfarin and increase that of DOACs.”
1The European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation states “Patients should return on a regular basis for on-going review of their treatment, preferably every 3 months.”
Tags: apixaban, bridging therapy, dabigatran, dalteparin, Direct Oral Anticoagulant, DOAC, DOAC management, dose and post, edoxaban, INRstar, Newer/ Novel Oral Anticoagulant, NOAC, POCT, rivaroxaban, St George’s Hospital