aS pHaRMaCISTS BegIN TO pLay aN INCReaSINgLy pROaCTIve
ROLe IN aNTICOaguLaNT MaNageMeNT SeRvICeS, pIF LOOKS aT WHaT’S HappeNINg IN THe WORLD OF aNTICOaguLaTION…
ANTICOAGULANTS: vital role for pharmacy
a
nticoagulants are medicines that are used to treat and prevent blood clots that occur
in blood vessels.
Blood clots can block blood vessels such as arteries or veins. When this happens, blood and oxygen is prevented from reach parts of the body – the heart, brain or lungs, for example. If this occurs, the tissue that is supplied by a blocked artery becomes damaged or dies and this results in serious conditions such as heart attacks and strokes.
anticoagulants work by interrupting the process involved in the formation of clots. While some people refer to them as ‘blood thinners’, this is actually a misnomer since they don’t actually thin the blood. Blood simply does not clot as easily while an anticoagulant is being taken.
Why anticoagulants are prescribed anticoagulants are prescribed for patients, who have blood clots. In
40 - pHaRMaCy IN FOCuS
most cases the cause of the clot is a deep vein thrombosis (DvT) and/or a clot on the lung called a pulmonary embolus (pe). In such cases the anticoagulants prevent the clot from getting bigger.
The other main reason for anticoagulants to be prescribed is if a patient is at risk of having a blood clot, ie, for prevention purposes. The main reasons for a patient being at risk of having a blood clot are:
• Atrial fibrillation: atrial fibrillation (aF) is a fast, irregular heartbeat and is one of the most common reasons for taking an anticoagulant. aF is the most common type of cardiac arrhythmia and affects around two per cent of the population worldwide. The presence of aF is associated with a five times higher risk of stroke, three times higher risk of heart failure and increased mortality.
• A mechanical heart valve
• Certain blood disorders that affect how blood clots (eg, thrombophilia, antiphospholipid syndrome)
• Infection of the inside of the heart (mitral stenosis)
Types of anticoagulants The most commonly prescribed anticoagulant is warfarin. For over 50 years, warfarin was the only oral anticoagulant available for preventing aF-related strokes. While warfarin is an effective way of significantly reducing the risk of strokes, it requires frequent blood tests and careful monitoring. It also has a number of drug-drug and drug-food interactions.
In 2014, the National Institute for Health and Care excellence (NICe) produced a guideline on aF to ensure that many more patients at risk of stroke were taking anticoagulants. In order to achieve this increase in patients, NICe recommended that a new class of anticoagulant drugs –
initially known as novel oral anticoagulants (NOaCs) but now renamed direct oral anticoagulants (DOaCs) - should be considered as first-line therapy along with warfarin.
These DOaCs, which include: rivaroxaban (xarelto), dabigatran (pradaxa), acenocoumarol (Sinthrome), phenindione (Dindevan), apixaban (eliquis) and edoxaban (Lixiana), have offered patients an additional treatment option with some practical advantages. unlike warfarin, this new class of anticoagulant drugs have few drug interactions, produce a predictable therapeutic response and have no requirement for coagulation monitoring. They do, however, lack a clinically approved agent to reverse bleeding. DOaCs are also more expensive than warfarin, even when the frequent blood testing associated with warfarin is taken into account. It is expected, however, that as doctors become more comfortable prescribing them, the price will decrease.
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