Management of Venous Thromboembolism: Recent Advances in Oral Anticoagulation Therapy

OBJECTIVE

To review clinical data on direct oral anticoagulants (DOACs) used in the acute treatment of venous thromboembolism (VTE) as well as practical considerations when using these products.

DATA SOURCES

Searches of PubMed and Google Scholar for VTE, deep vein thrombosis, pulmonary embolism, and relevant drug international nonproprietary names were conducted. Additional online searches were conducted for prescribing information.

STUDY SELECTION AND DATA EXTRACTION

Relevant articles on dabigatran, rivaroxaban, apixaban, and edoxaban for the management of VTE compared with oral vitamin K antagonists (VKAs; published between 1966 and December 2015) were reviewed and summarized, together with information on dosing, pharmacokinetics/pharmacodynamics, and drug-drug interactions.

DATA SYNTHESIS

The DOACs have the potential to circumvent many of the disadvantages of VKAs. At a minimum, they greatly increase the available therapeutic options, thus providing a greater opportunity for clinicians to select a management option that best fits the needs of individual patients. Despite the significant advance that DOACs represent, they are not without risk and require careful consideration of a number of clinical issues to optimize safety and efficacy.

CONCLUSIONS

The emergence of DOACs for the management of thromboembolic disorders represents a paradigm shift from oral VKAs. The DOACs provide similar efficacy and improved safety in selected patients as compared with VKAs. Clinicians treating VTE need to be familiar with the intricacies involved in using these agents, including the appropriate dose selection for the relevant indication, avoidance of drug-drug and drug-disease interactions, and consideration of dose adjustments in specific clinical situations, such as organ dysfunction.

Implementation of an order set to adhere to national patient safety goals for warfarin therapy

BACKGROUND

In 2009, The Joint Commission mandated full compliance with National Patient Safety Goal (NPSG) 03.05.01 to reduce the likelihood of patient harm associated with anticoagulant therapy.

METHODS

We conducted a retrospective chart review of inpatients receiving warfarin at Methodist Hospital pre and post implementation of a warfarin order set between January 2008 and July 2011. The primary endpoint of this study was overall adherence to laboratory monitoring. Secondary endpoints included compliance with individual laboratory parameters, percentage of patient educational sessions completed prior to discharge, and percentage of appropriate follow-up arrangements documented on discharge.

RESULTS

A total of 707 patients were assessed. Overall adherence to laboratory monitoring parameters significantly improved from 71.8% to 87.5% (odds ratio [OR], 2.76; 95% CI, 1.87- 4.07; P < .001). Additional improvements were seen in patient education prior to discharge, and appropriate follow-up arrangements were documented at discharge.

CONCLUSIONS

This analysis demonstrates that implementation of an order set assists in adherence to policies and procedures designed to address the NPSG 03.05.01. Additionally, pharmacy involvement in monitoring, educating, and arranging for follow-up may lead to successful completion of these parameters.