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Role of the pharmacist

questions on any aspect of their treatment. Pharmacists are ideally placed to address patients’ belief systems that result in intentional non-adherence, as well as resolve the specific barriers contributing to unintentional non- adherence, such as by providing oral dosage forms instead of injections.4 Such interaction between the patient and the pharmacist in pharmacist-led anticoagulation clinics has been shown to provide greater patient satisfaction than in conventional clinic settings,5


that patients have better treatment outcomes, are kept safer, and are less likely to be re-admitted to hospital to manage complications.

Monitoring treatment

The oral anticoagulant, warfarin, has been the mainstay of anticoagulation therapy for several decades. Its narrow therapeutic index, long half-life and significant food–drug and drug–drug interactions create a complex dosing schedule with doses being titrated against the measured INR reading, to ensure that the patient attains and maintains the target INR range for the duration of treatment. To help with this, the United Kingdom (UK) National Patient Safety Agency (NPSA) issued alert 18 to introduce a variety of measures to ensure safer prescribing, dispensing and administration of anticoagulants. The alert mandated clinicians to provide patients with a Yellow Book for recording their INR reading and latest dose. The book is to be completed by the prescriber in the clinic, and reviewed by the pharmacist at the point of dispensing.6 The Yellow Book scheme provides an excellent opportunity for patient education when they attend clinic, and for further counselling when they visit their community pharmacist to collect repeat supplies of warfarin.

The new class of direct-acting oral anticoagulants such as edoxaban, apixaban and rivaroxaban come with a promise of reduced need for anticoagulant monitoring, compared with warfarin, and the indirect-acting parenteral anticoagulants, such as danaparoid, fondaparinux and heparin.4

However, they 32

still require monitoring of other pharmacokinetic parameters such as renal and hepatic function. While they are adjudged to be as effective as warfarin, they are considered safer because of their reduced bleeding risk and the reduced requirement for blood samples to be taken

to monitor INR readings, and adjust doses. While non-attendance for INR monitoring may be an advantage with the direct acting anticoagulants, it presents a challenge for ensuring continued patient education and adherence to treatment. Pharmacists will need to ensure that they have a system of monitoring on-going adherence and counselling when this group of patients attend their pharmacy or hospital wards.

Multidisciplinary communication Sharing of vital information is critical to successful anticoagulation management. Pharmacists, working with other clinicians as part of the multidisciplinary team, have a duty to uphold the relevant guidelines, contribute to staff and patient education and ensure that the required records are completed contemporaneously and made available to share at each stage of the patient’s journey. Missed doses, non-attendance at clinics, non-performance of VTE risk assessment, significant interactions and side-effects, and other key considerations in anticoagulation therapy should be escalated. Pharmacists offer great value in providing structured patient education and standardised discharge reports for general practitioners.7

Discharge planning

Pharmacists offer patient counselling and provide addition supplies of medicines at the point of discharge. They are also involved in verifying the accuracy of the medicines’ section of discharge letters. That way, accurate information is transmitted to the general practitioner, and the patient can be monitored better in the community. Community-pharmacist led monitoring of INR has been part of the Community Pharmacy Agreement in New Zealand since 2012, and is being advocated in other parts of the world.8

This is made possible by the

use of Point-of-Care Testing (POCT), that is, performing the INR monitoring test at bedside, or near the patient, using portable testing devices. POCT involves taking a pin-prick blood sample, rather than the standard approach of venous sampling for a laboratory-based INR test. The results are instantly available, enabling the pharmacist to make adjustments to the patient’s dose while the patient is in attendance. This provides further opportunities for discussion and patient education. POCT supports prompt clinical decision-making and provides time and cost savings for the local economy. It is also more convenient for the patient and, as a result, will reduce

the probability of non-adherence.

Compliance auditing In addition to playing specific roles in the patient’s anticoagulation journey, pharmacists can perform an oversight function for anticoagulation in both the primary and secondary care settings.10 Commissioning of new services and reviewing the effectiveness of existing services are potential roles for pharmacists. As medication safety experts, pharmacists can be invited to investigate medication safety incidents and recommend preventive strategies. Furthermore, the pharmacist can monitor audits of compliance with prescribing guidelines, and ensure their organisation meets national or regional targets intended to ensure safe use of anticoagulants.


Pharmacists are pivotal to the safe use of anticoagulants by clinicians and patients. They are involved at all stages of the patient’s anticoagulation journey, and can provide the necessary support and education to ensure optimal patient care. ●

References 1. Eradiri OL. VTE: a journey to meet that 90 percent goal. Pharmaceutical Journal 2011;286:411–12.

2. Lakshmi R, James E, Kirthivasan R. Study on impact of clinical pharmacist’s interventions in the optimal use of oral anticoagulants in stroke patients. Indian J Pharm Sci 2013;75(1):53–9.

3. Young S et al. Comparison of pharmacist managed anticoagulation with usual medical care in a family medicine clinic. BMC Family Practice 2011;12:88 doi:10.1186/1471-2296-12-88

4. Eradiri OL. Oral anticoagulants: the dawning of a brighter era. Hospital Pharmacy Europe 2014;74:14–15.

5. Makowski CT et al. The impact of pharmacist- directed patient education and anticoagulant care coordination on patient satisfaction. Ann Pharmacotherapy 2013;47(6):805–10.

6. National Patient Safety Agency. NPSA Patient Safety Alert 18: Actions that can make anticoagulant therapy safer. alerts-and-directives/alerts/anticoagulant/.

7. Vervacke A, Lorent S, Motte S. Pharmacist plays an important role in managing anticoagulation therapy. EJHP 2014;21:A60-61. doi:10.1136/ ejhpharm-2013-000436.149.

8. Community Pharmacist-Led Anticoagulation Management Service. British Columbia Pharmacy Association, Canada, 2013.

9. Perry DJ et al. Point-of-care testing in haemostasis. Br J Haematol 2010;150(5):501–14.

10. Eradiri OL. VTE prevention: how can pharmacists contribute? Hosp Pharm Eur 2011;57:57–9.

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