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MODULE 2


DOACs an antidote only exists for dabigatran. Management of a bleeding event in all other cases must take place in secondary care and consists of stopping treatment and general haemostatic measures. These include mechanical compression and surgical haemostasis with bleeding control procedures, fluid replacement and haemodynamic support, blood products or platelets. One product used in such situations, often in hospital protocols, is PCC or Prothrombin Complex Concentrate. 11


Patients taking warfarin are well- versed in carrying information about their anticoagulant therapy, to alert any healthcare provider about their treatment. It is equally important that those treated with DOACs carry details of their therapy too, and indeed the respective manufacturers provide such alert cards in each of their cartons of medication. [It is a recommendation of the ESC that a card of uniform design be adopted instead.] 12


.


It is critically important to educate patients at every point of contact possible with a healthcare professional, about their dosage regime, whether once daily or twice daily, the importance of presence of food (as with rivaroxaban 10mg/15mg/20mg), etc. It is important to reinforce the importance of strict adherence to the prescribed dosing regime, how to deal with any lapse in dosing, and to be careful not to leave medication behind when travelling.13


. That said, evidence from


RCTs and RWD suggests that many patients on DOACs often need less monitoring due to the reduction in intracranial haemorrhage and other major bleeds. 14


Strict adherence to DOAC intake is crucial as its anticoagulant effect wanes within 12-24 hours after last intake. 15


.


It is critically important to educate patients at every point of contact possible with a healthcare professional, about their dosage regime


. DOAC plasma levels as well


as general coagulation tests cannot be considered as tools to monitor adherence since they only reflect intake over the last 24(-48) hours and the measured level is heavily dependent on the time between last intake and sampling. The absence of a need for routine plasma level monitoring (some kind of equivalent to INR measuring) means that DOAC patients are likely to be less frequently seen for follow-up compared with warfarin patients. However there are arguments in favour of regular follow- up assessments for patients on DOACs, particularly in case of


relevant comorbidities such as renal failure, older age, multiple comorbidities or frailty. 16


.


People taking any anticoagulant should be advised:- • To seek immediate medical advice if spontaneous bleeding occurs and does not stop, or recurs. This includes bruising, bleeding gums, nosebleeds, prolonged bleeding from cuts, blood in urine or stools, haemoptysis, subconjunctival haemorrhage, and vaginal bleeding in postmenopausal women.


• To seek medical advice if they get sudden severe back pain, which may indicate spontaneous retroperitoneal bleeding.


• Not to take, or apply, over-the- counter medicines such as non- steroidal anti-inflammatory drugs.


• What to do if there has been a missed dose or if a double dose had been taken. 17


.


There is a very clear role for the community pharmacist in the care of anticoagulated patients. We are all very familiar with how that looks and sounds when the anticoagulant is warfarin, but perhaps less so when it’s one of the DOACs.


Here are some suggested actions:- • Reinforce dosage and regime with each new supply of DOAC.18


. • Must take rivaroxaban with food,


otherwise there’s a 66% reduction in absorption, hence under- coagulation. 19


.


• Open discussion on patient’s experience of missed doses and how to proceed if that should happen in the future.


• Check if they have had any experience of unusual and/or uncontrolled bleeding and how they have dealt with that.


• Ensure they know what signs they are looking for indicating a hidden bleed eg urine, stools, back pain.


• Reinforce that, should they have an accident and hit their head, do report to ED, with medication card, and they will be fast-tracked through to examination and scanning. 20


. > PHARMACY IN FOCUS - 19


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