Decentralized vs Centralized
Pharmacist Treatment of Patients With
Atrial Fibrillation Managed With Direct
Oral Anticoagulants
Cristina Elgin, PharmD, BCPS; and Veldana Nuhi, PharmD, BCPS
Centralization of pharmacy services for anticoagulants increased access
to care without impacting adherence or adverse events.
In the U.S. about 2. 7 to 6.1 million people have atrial fibrillation (AF).1 This condition affects the rhythm of the heart, causes blood in the
heart to become stagnant, and puts
patients at high risk for developing
a systemic embolism, particularly a
stroke.1 Recent studies have shown
that AF accounts for at least 15% of
all strokes in the U.S. and 36% of
strokes in people aged > 80 years. 2
For patients aged > 60 years, the
gold standard of long-term anticoagulation for reducing the risk of
stroke has been oral vitamin K antagonist (warfarin) therapy. 2 Although
overwhelming evidence exists that
supports the use of warfarin in these
patients, warfarin is a narrow therapeutic index medication that requires
frequent laboratory monitoring of international normalized ratio (INR)
for dose titration guidance. There is
also strong evidence that pharmacist-run anticoagulation clinics have improved patient-centered outcomes in
patients prescribed warfarin. 3-5
Direct oral anticoagulants
(DOACs) are recently approved
oral medications used as alternatives to warfarin for anticoagulation
in AF. Direct oral anticoagulants do
not require INR monitoring or any
laboratory test for efficacy. In 2010,
the FDA approved the first DOAC,
dabigatran, for use in patients with
AF. In 2011, rivaroxaban received
approval for the same indication.
One potential drawback of these
new agents relative to warfarin is
the lack of availability of a reversal
agent that can be used in the event
of a life-threatening bleeding event.
Dabigatran is the only DOAC with
an FDA-approved available reversal agent. In both 2011 and 2012,
dabigatran, warfarin, and other anticoagulants topped the Institute for
Safe Medicine Practice list of suspect drugs related to adverse events
(AEs). These data prompted the Joint
Commission to incorporate anticoagulation into the 2017 National Hospital Patient Safety Goals to improve
patient outcomes and reduce harm
from use of anticoagulants. 6
In early 2011, the VHA pro-
duced national guidance on the
treatment of patients who receive
DOACs; this guidance was updated
most recently in September 2016.7
Patients who were receiving DOACs
at the Ralph H. Johnson VAMC
(RHJVAMC) were initially monitored
by 12 primary care pharmacists at
the main hospital or at community-
based outpatient clinics (CBOCs).
Ambulatory care pharmacists at
RHJVAMC work under a scope of
practice to prescribe and adjust
certain classes of medications to
provide the highest level of care to
more than 65,000 veterans in South
Carolina and Georgia. Historically at
RHJVAMC, warfarin has been the
anticoagulant most commonly used
for AF, though dabigatran and riva-
roxaban have gained in popularity
after being added to the national VA
formulary.
In November 2012, for better
monitoring of patient outcomes, improved efficiency of the primary care
pharmacist clinics, and increased
access to care in these clinics, treatment of patients prescribed DOACs
was shifted to a centralized model
that involved 3 anticoagulation clinical pharmacy specialists.
Dr. Elgin is an ambulatory care clinical pharmacy
specialist, and Dr. Nuhi is an ambulatory care
pharmacy supervisor, both at Ralph H. Johnson
VAMC in Charleston, South Carolina.
