New Roles for Anticoagulation Clinics in an Era of Non-Warfarin Options

The availability of several new direct oral anticoagulants (DOACs) does not render the system of anticoagulation clinics set up to support warfarin administration unnecessary, but rather provides the impetus to “reimagine” what those clinics can do to improve patient safety more broadly, according to one perspective.

A revamped anticoagulation clinic would have three central roles: selection of the most appropriate treatment regimen, reduction of serious bleeding risks, and enhancement of adherence, Geoffrey Barnes, MD (University of Michigan Medical School; Ann Arbor), and colleagues write in a perspective published online this week in Circulation: Cardiovascular Quality and Outcomes.

“Anticoagulation clinic support and consultation should be used to ensure safe, high-quality anticoagulation care,” they say.

More than 3,000 anticoagulation clinics are operating in the United States to support warfarin-treated patients with A-fib, venous thromboembolism, and mechanical valve replacement with ongoing laboratory monitoring and dose adjustments as needed. The system has been shown to prevent emergency department visits, hospitalizations, and thromboembolic complications.

Since 2009, four DOACs have been approved—dabigatran (Pradaxa; Boehringer Ingelheim), rivaroxaban (Xarelto; Janssen Pharmaceuticals), apixaban (Eliquis; Bristol-Myers Squibb), and edoxaban (Savaysa; Daiichi Sankyo). These drugs do not require INR monitoring and frequent dose adjustments, leading many to question the continued need for anticoagulation clinics, the authors write.

“However, rather than diminish the importance of anticoagulation clinics, we think the growing number of DOACs creates an urgent need for expanding the traditional role of the anticoagulation clinic,” they say.

A reimagined anticoagulation clinic could assist in deciding on the most appropriate drug and dose for a specific patient, tapping into the expertise of the specialized pharmacists and nurses who already work there, Barnes and colleagues say.

That same specialized knowledge could then be used during long-term monitoring to mitigate serious bleeding risks that may develop due to worsening renal function and to navigate the need to stop anticoagulation when patients require procedures. “The time needed to stop an anticoagulant before and after a procedure varies greatly depending on the medication, a patient’s renal function, and the bleeding risk of the proposed procedure,” the authors note.

And finally, the updated clinic could encourage adherence to the selected treatment regimen by serving as a hub for addressing patients’ questions and concerns on a continuous basis, they say.

Obstacles to Transition

Changing the role of anticoagulation clinics would require modifications to habitual practice patterns and potentially require a reworking of institutional policies “to empower specialist nurses and pharmacists to manage these specific clinical scenarios,” Barnes and colleagues point out.

But the primary challenge is a financial one. “With increasing utilization of DOACs, health systems and insurers may be tempted to discourage use of anticoagulation clinics and avoid paying for these services,” the authors write. “This is especially true because existing studies of cost-effectiveness for DOAC medications did not include the costs of anticoagulation clinic support.”

Overcoming that economic obstacle may depend on morphing anticoagulation clinics into broader medication safety clinics attending to a wider spectrum of patients with cardiovascular conditions treated with high-risk medications. That would include patients taking mineralocorticoid receptor antagonists for hypertension or heart failure or those taking amiodarone for arrhythmia control, for example.

“A medication safety clinic would leverage the existing anticoagulation clinic infrastructure of nurse and pharmacist experts designed for longitudinal medication monitoring to reduce complications from a variety of effective, yet potentially dangerous, cardiovascular medications,” the authors say. “In this manner, the business justification supporting a medication safety clinic would be even greater than that of a more narrowly focused anticoagulation clinic.”

Source: 
Barnes GD, Nallamothu BK, Sales AE, Froehlich JB. Reimagining anticoagulation clinics in the era of direct oral anticoagulants. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.

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