Changing from Warfarin

[nemisis2]

Thanks to all of you for coming back with all your feelings about changing from Warfarin to rivaroxaban, It seems that most people feel that it is a good change, my main problem is that I am so worried about leaving off warfarin for almost five days and thats the main reason, I suppose that it is something I have to cope with and I do feel I could have had more support from the doctor, but thanks for all your helpful comments.

[10gingercats]

There are times in life when there are gaps in taking anticoagulants.I have had a couple of them when mine had to be halted before surgery .....and like you I had a gap when I changed from Warfarin to Apixaban. Many of us have been in these situations so try and take courage from that.

[Hidden]

Suggest you click on the “Useful links for Newbies and Oldies” pinned post to the right of this page. Scroll down to Miscellaneous where you will find a link to anticoagulation. Click on scenario Rivaroxaban and scroll down and click on switching from Warfarin to Rivaroxaban. That will provide you with the NICE recommendations for making the change which appears to be at odds with what you have been told. The important thing to bear in mind that your Doctor may have good reasons for his recommendations but if I were you, I would seek clarification because it is important to get it right so don’t be put off by referring to the recommendations provided by NICE.

[Nan1]

I had an INR test one Wednesday and my reading was 2.6. Told by clinic not to take Warfarin that night and start Apixiban Thursday evening. Have to admit I was worried that was too soon but took it anyway.

[JaneChapple]

Hi Nemisis2

i think I have solved the riddle of why the Pharmacist was pushing you for a NOAC/DOAC.

How did you get on with your phone call to the GP? It does state that patients should be assessed individually and that they are not suitable for all AF Patients including people with a mechanical heart valve or those with moderate to severe mitral stenosis. A renal check should be undertaken too. It seems to be an international push for this which I cant understand as supposedly w e have left Europe? I wonder if we ever be allowed to make our own decisions about these types of matters!

Hope this helps.

JaneCxx

From: Pulse <[e-mail]>

Subject: Bayer PLC - Transitioning from warfarin to DOACs for eligible NVAF patient

Transitioning from warfarin to DOACs for eligible NVAF patients during COVID-19

Following the publication of guidance from NHS England, Dr Jim Moore, GPSI and President of the Primary Care Cardiovascular Society, discusses transitioning from warfarin to direct oral anticoagulants (DOACs) for patients with non-valvular atrial fibrillation (NVAF).

Many patients with NVAF (non-valvular atrial fibrillation) are prescribed warfarin to prevent stroke1 /systemic embolism (SE)2 - these patients require regular, ongoing clinical contact to monitor their international normalised ratio (INR), which, on average, takes place 13 times a year,3 though potentially more frequently for patients whose warfarin therapy is more difficult to control within an acceptable INR range.

But, these are extraordinary times. Patients with NVAF commonly have associated co-morbidities such as hypertension, cardiovascular disease, heart failure or diabetes which increase their risk of the most serious complications of COVID-19 infection and therefore it is particularly important they follow the UK government's guidance regarding social distancing and social isolation, or shielding where appropriate.4,5,6 In my experience, most patients wish to avoid direct contact with healthcare professionals or organisations at present unless it is absolutely necessary, and many areas have seen a reduction in nursing services available to conduct INR monitoring in the community during this pandemic.

It's important that whilst social distancing measures are in place, vulnerable NVAF patients still receive effective anticoagulation treatment, with minimal exposure to COVID-19, given the effectiveness of such therapy in reducing the risk of stroke.7

Recent guidance for the management of anticoagulant services during the pandemic

NHS England has published guidance with the recommendation that eligible patients with NVAF be considered for transitioning from warfarin to DOACs during the COVID-19 pandemic.8 Unlike warfarin, DOACs do not require monitoring of INR levels though will require monitoring of renal function,8 typically once or twice a year. Transitioning appropriate patients from warfarin to a DOAC will reduce clinic visits due to reduced INR monitoring, thereby decreasing the risk of exposure to COVID-19 for patients and frontline NHS staff. Appropriately managing the transition from warfarin to DOACs is important in order to ensure eligible NVAF patients remain appropriately anticoagulated whilst maintaining adequate social distancing.9

Compared with warfarin, DOACs are easier to use with fewer drug-drug interactions, no dietary restrictions (including alcohol) and the dose of DOAC is fixed.10 Moreover, DOACs have a favourable risk-benefit profile when compared to warfarin, with studies showing a similar significant reduction in strokes or systemic embolic events (RR 0.81, 95% CI 0.73-0.91, p<0.0001) and importantly around 50% fewer cases of intracranial haemorrhage (0.7% vs. 1.45% for those on DOACs and warfarin respectively; p<0.0001), however there is an associated increase in gastrointestinal bleeding (RR 1·25 95% CI 1·01-1·55), p=0.043).11There are also potential variabilities in dosing with warfarin, as it can be difficult to keep patients taking it within an acceptable INR therapeutic range.7,12

Though current NICE guidance suggests that either warfarin or DOACs be offered as first line therapy for stroke prevention in NVAF more recent international guidance (ESC and AHA) advises that DOACs should be considered as first-line therapy.7,13,14

Transitioning from warfarin to DOACs

In our practice we have followed current guidance, taking a phased/measured approach to transitioning in order to protect DOAC stocks. We initially reviewed the clinical records of patients with poor INR control, assessing their suitability for transitioning as they generate most potential contact with HCPs. We then reviewed patients who were due to come into the surgery for their regular INR monitoring, identifying those who may be eligible and discussing the possibility of transitioning from warfarin to a DOAC prior to their routine INR appointment. Such discussions are a good time to reinforce the importance of anticoagulation in reducing the risk of AF-related strokes given the poor outcomes associated with such events.15 Universally, patients have welcomed the opportunity to discuss transitioning and where appropriate are keen to do so.

DOACs are not suitable for all patients with AF and GPs should refer to the SmPC for each DOAC to assess suitability.16,17,18,19 In particular, we would not consider transitioning patients who have a mechanical heart valve, antiphospholipid syndrome or with moderate to severe mitral stenosis.20 A pragmatic guideline, authored by Helen Williams, NHS England's National Specialty Adviser for CVD prevention, was recently published, which concisely summarises how we might best identify and transition patients who are right for DOACs.20

We need to make sure it is appropriate to prescribe a DOAC and that the correct dose is prescribed for each patient. With both a recent assessment of renal function (in last three months) and a record of the patient's actual weight, we can calculate the estimated creatinine clearance (CrCl) which is central to deciding on the correct dose for that person.20 When you decide to make the transition and have the appropriate information needed, DOACs can generally be initiated straight away or within the next few days, depending on the patient's current INR levels.20

Randomised control trials comparing individual DOACs with warfarin have shown broadly similar favourable outcomes in the NVAF population, though evidence suggests that correct dosing is critical in achieving these outcomes.9,11 There are many possible considerations when choosing a DOAC but ease of use from both a healthcare practitioner and patient perspective is paramount not least in these extraordinary times. Simplicity, I believe, is key to accurate prescribing for HCPs, not least when DOAC dosing algorithms vary considerably in their complexity. Simplicity is equally important for patients where frequency of dosing and interactions with commonly prescribed medications may be important considerations.

Supporting patients when making the transition from warfarin to DOACs

Unlike warfarin, DOACs have a short half-life10 and therefore when counselling patients it is important to emphasise the importance of good compliance to maintain efficacy; and with some DOACs, there may be additional recommendations, such as the need to take with food. In some circumstances, it may be helpful and reassuring to include a relative or responsible person in those discussions, to reinforce these important messages with the aim of achieving as good compliance as possible. Pharmacists working both in the practice and in the community can also play an important role in supporting patients to make this transition, while encouraging good compliance in the longer term.

Importantly, the patient should only need face-to-face contact with a HCP on one occasion during transitioning, everything else can be done remotely, which is essential during these times.

A 'new normal' post COVID-19 - bringing forward the inevitable

At this critical time, we must ensure patients can follow government guidance and are put at minimal risk of exposure to COVID-19, while also protecting healthcare professionals providing care.

We do not know how long the current situation will last, or what lies ahead. But, regardless, we should continue speaking to patients with NVAF about anticoagulation, optimising stroke risk prevention while minimising risks.

Perhaps this difficult time presents the opportunity we need to bring forward the inevitable, improving care for NVAF patients and moving towards a 'new normal' when it comes to prescribing anticoagulation.

NHS England guidance

PCCS

References:

NHS. Atrial Fibrillation Treatment. Available at: nhs.uk/conditions/atrial-fi... [Last accessed May 2020]

Anderson, et al. Warfarin for the Prevention of Systemic Embolism in Patients With Non-Valvular Atrial Fibrillation: A Meta-Analysis. Heart 2008; 94(12): 1607-13

Anticoagulation UK. 'Out of Range: Audit of anticoagulation management in secondary care in England'. Available at: anticoagulationuk.org/promo... [Last accessed May 2020]

Guan W, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis. Eur Respir J. 2020. ncbi.nlm.nih.gov/pmc/articl... [Last accessed May 2020]

Zoni-Berisso, M., et al. Epidemiology of atrial fibrillation: European perspective. Clinical epidemiology 2014;6: 213-220. doi.org/10.2147/CLEP.S47385

GOV.UK. Coronavirus (COVID-19): what you need to do. Available at: gov.uk/coronavirus [Last accessed May 2020]

ESC. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016; 37:2893-2962. Available at: academic.oup.com/eurheartj/... [Last accessed May 2020]

NHS England. March 2020. Clinical guide for the management of anticoagulant services during the coronavirus pandemic. Available at: england.nhs.uk/coronavirus/... [Last accessed May 2020]

ESC. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Available at: academic.oup.com/eurheartj/... [Last accessed May 2020]

Julia S, James U. Direct Oral Anticoagulants: A Quick Guide. Eur Cardiol 2017; 12(1):40-5

Ruff CT, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014: 383(9921): 955-962.

Jaffer A, Bragg L. Practical tips for warfarin dosing and monitoring. Clev Clin J Med. 2003; 70(4): 361-71

NICE. 2014. Atrial fibrillation: management Clinical guideline [CG180]. Available at: nice.org.uk/guidance/cg180/... Recommendations [Last accessed May 2020]

January et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2019;140:e125-e151. DOI: 10.1161/CIR.0000000000000665

Linn J et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke 1996 27(10). Available at: ahajournals.org/doi/full/10... [Last accessed May 2020]

Rivaroxaban (NVAF) - Summary of Product Characteristics. Nov 2019. medicines.org.uk/emc/produc... [Last accessed May 2020]

Apixaban - Summary of Product Characteristics. Apr 2020. Available at: medicines.org.uk/emc/produc... [Last accessed May 2020]

Dabigatran - Summary of Product Characteristics. Jan 2020. Available at: medicines.org.uk/emc/produc... [Last accessed May 2020]

Edoxaban - Summary of Product Characteristics. Apr 2020. Available at: medicines.org.uk/emc/produc... [Last accessed May 2020]

Williams H. 2020. Guidance for the safe switching of warfarin to direct oral anticoagulants (DOACs) for patients with non-valvular AF and venous thromboembolism (DVT / PE) during the coronavirus pandemic. Available at: rpharms.com/Portals/0/RPS%2... accessed May 2020]

Commissioned and funded by Bayer PLC Ltd.

Xarelto▼ (rivaroxaban) prescribing information and adverse event reporting details can be found here.

Supporting materials on transitioning patients from warfarin to a DOAC are available here.

Report Adverse Events

Adverse events should be reported. Reporting forms and information can be found at yellowcard.mhra.gov.uk or search MHRA Yellow Card in Google Play or Apple App Store. Adverse events should also be reported to Bayer plc.

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Job number: PP-M_RIV-GB-0018

Date of preparation: June 2020

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[Wightbaby]

Well!!....I was phoned and simply told DO NOT come in for your INR check...because of COVID.....you must now take edoxaban.....leave off Warfarin for 3 days....(my INR's were always pretty stable). I was very worried about this......

On the 3rd day, in the morning, I took my first edoxaban, and all was OK.....and I logically thought that even if there was a trace of Warfarin left in my blood, it would soon be gone.....

I never had a pre change INR and have not been tested since to see how things are going with it!! Not really happy about that.....

There was no way I was leaving it 5 days.....I had a blood clot 7 years ago!!