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Primary Care Initiation of Direct Oral Anticoagulants (DOACs) for Stroke Prevention in Atrial Fibrillation (AF)

  

Guidance and information regarding initiation of DOACs


Primary Care Initiation of Direct Oral Anticoagulants (DOACs) for Stroke Prevention in Atrial Fibrillation (AF)

Guidance for the safe selection and prescribing of DOACs in primary care in consultation with UHCW Department of Cardiology Haematology and Area Prescribing Committee

Please use the following information in consultation with your patients to initiate preventative treatment

Refer to the following algorithm when Atrial Fibrillation is suspected clinically or on ECG

 

 

 

Primary Care Prescribing of DOACs

Consider the following steps before completion of selected DOAC checklist with patient

1) Renal Function (calculation of creatinine clearance)

It is essential to calculate the patient’s true creatinine clearance prior to initiating DOACs

Online Cockcroft Gault calculator which may be found at:

https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation or

https://www.kidney.org/professionals/KDOQI/gfr_calculatorCoc

Note SCr (serumcreatinine) = mg/dL

2) Assessment of stroke and bleeding risks for patients with NVAF (NICE guideline)

Use CHA2DS2-VASc stroke risk score with any of the following:

Symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
Atrial flutter
Continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm.
http://resources.hrsonline.org/chads2-vasc-calculator.html or https://www.chadsvasc.org/

oint Scoring: 1 – Congesti

0 score = LOW RISK may not require anticoagulation

1 score = LOW-MODERATE RISK should consider anticoagulation

2 score or greater = MODERATE-HIGH RISK and should be anticoagulated

 

 

Bleeding risk (NICE AF guidelines) HAS-BLED score

This should be used as a tool to identify factors that can be optimised or patients that need closer monitoring and not to deny appropriate patients from getting anticoagulation.

Offer modification and monitoring of the following risk factors:

  • Uncontrolled hypertension
  • Labile INRs
  • Concurrent medication eg aspirin or a non-steroidal anti-inflammatory drugs (NSAIDs)
  • Harmful alcohol consumption.

HAS-BLED Major Bleeding Risk Score

page2image1734124432HAS-BLED Notes:
  • Hypertension: systolic blood pressure >160 mm Hg.
  • Renal function: creatinine >200 or dialysis.
  • Liver function: chronic liver disease (beg. cirrhosis) or bilirubin >2x ULN +AST /ALP >3x upper limit normal).
  • Bleeding: previous bleeding, bleeding diathesis or unexplained anaemia.
  • Labile INRs: Time in Treatment Range <60%.
  • Drugs: concomitant use of drugs, e.g. antiplatelet agents and non-steroidal anti-inflammatory drugs.
  • Alcohol: excess alcohol

Low risk = 0-2

High risk = ≥ 3 (high risk suggests caution required and more frequent reviews are recommended)

3) Patient Factors

Renal Function
Compliance Aids / Dosette Box
Not suitable for Dabigatran – needs to be kept in original foil wrapper
Swallowing Difficulties / Feeding Tubes
Dabigatran CANNOT be crushed (all others can be)
Taken with food
Rivaroxaban to be taken WITH food to ensure absorption (others can be with or without)
Dabigatran – 10% reported to have dyspepsia
Antidote
Exists currently for Dabigatran
Compliance / Missed Doses
TWICE DAILY REGIMEN: missed dose can be taken up to 6 hours before next scheduled dose then continue as normal. If next dose is due a double dose can be taken.
ONCE DAILY REGIMEN: missed dose can be taken up to 12 hours before next scheduled dose. A DOUBLE DOSE SHOULD NOT BE TAKEN
Monitoring
Usually ANNUAL monitoring of compliance, adverse events and FBC LFTs Renal function
If ELDERLY or FRAIL 6 monthly
CrCl <= 60ml/min check intervals at intervals of CREAT CLEARANCE DIVIDED BY 10 in MONTHS eg CrCl 30 checks at 3 monthly intervals
Completion of DOAC Checklist with Patient
After consideration of the above factors complete the appropriate checklist WITH the patient and attach a copy to the NHS GP Medical Record.
In the absence of mental capacity an appropropriate Best Interests Meeting will be required
Explain when and how to seek medical help
Complete checklists below and right
Monitoring via Primary Care IT System Templates

From: Tomlinson Jagdish (05A) NHS Coventry & Rugby CCG On Behalf Of Contracting PC (05A) NHS Coventry & Rugby CCG
Sent: 17 March 2020 10:03
Subject: DOAC Initiation and Management Scheme – EMIS Template

Dear Colleague,

 RE: Recording and reporting of DOAC initiation management for EMIS practices. 

On 1st January 2020 CRCCG launched the new DOAC initiation and management contract within primary care. Alongside this, a template was created to record and report the activity in partnership with Vision. This process covers 2 elements:

  • Vision Outcomes Manager will run a report via Bluebay automatically at each reporting period.
  • The Template to offer guidance and record activity has also been made available to all practices. This can be found and named: ID1386 – AF with Anticoag Coventry and Rugby CCG

However, it has come to our attention that the template is not as readily accessible on all clinicians computers who are using EMIS and as a consequence many EMIS practices may be using the wrong template. EMIS systems are able to access the template devised by Vision by following the attached guidance. However, following conversations with practices,  the CCG recognise that this may not be practical for all practices and are working at re-creating the template on EMIS (with the support of Tim Morris) which will be shared once this is complete and tested. In the mean time, the below codes can be entered into the system so that the activity is recorded in the interim until the new template is made available.

Term Read Code Snomed Description Code
NOAC Prophylaxis 8B61 3317820016
Atrial Fibrillation Monitoring 662S 134377004

If you have any further questions please contact Yasser Din on yasserdin@warwickshire.gov.uk

Follow link for EMIS template (Link to follow)

Save as Download then import to EMIS from Template Manager

VISION Template Version shown below

 

 

 

EMIS Clinical Template

Follow link to EMIS template. Save to your Desktop and import to EMIS Template manager

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