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An Age-Old Question: Warfarin or a Direct Oral Anticoagulant in Frail Adults?

It is now uncommon to see warfarin therapy initiated for stroke prevention. However, quality patient care is never a “one-size-fits-all” approach.  New evidence from the FRAIL-AF trial suggests that some of our most vulnerable older adults might be better off maintained on a vitamin K antagonist rather than (automatically) switched to a direct oral anticoagulation (DOAC).  

Guest Author:  Matthew Cantrell, PharmD, BCPS

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Weighing Options: Comparing Oral Anticoagulants for Patients at Various BMIs

Direct oral anticoagulants (DOACs) are the standard of care for stroke prevention in most patients with nonvalvular atrial fibrillation (NVAF). Data on the safety and efficacy of DOACS in patients with obesity are limited and, at times, contradictory.  What would you recommend for a patient with a BMI>40: warfarin, which requires periodic monitoring and dose adjustments, or a DOAC, which may not be as effective?

Guest Authors: Taylor M. Benavides, PharmD, BCPS and Elizabeth B. Hearn, PharmD, BCACP

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Could a DOAC Replace Warfarin to Treat the Thrombotic Antiphospholipid Syndrome?

The thrombotic antiphospholipid syndrome (TAPS) is associated with atypical thromboembolic events and/or recurrent pregnancy loss. Patients with TAPS are at very high risk of recurrent thrombotic events and require indefinite therapy.  Warfarin therapy is very challenging to manage in this patient population and requires frequent monitoring.  Thus a direct oral anticoagulant would be a welcomed alternative to warfarin by many patients with TAPS.  But are they effective?

Guest Authors: Leslie Walters, PharmD, BCACP  and Jennifer Carie, PharmD, BCACP, BC-ADM

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Using shared decision-making tools: Are they worth it?

There’s no denying that shared decision making (SDM) is an effective communication approach for making patient-centered medical decisions across a variety of health conditions. However, while tools for SDM are often useful during patient visits with practitioners, studies have yielded mixed results with regard to patient outcomes.  A new study explores the impact of a SDM tool for anticoagulation selection in patients with atrial fibrillation compared to standard care.

Guest Authors:  Ashley Meredith, PharmD, BCACP, BCPS, CDCES and Chandler Howell, PharmD

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Will Riva Be Defeated By It’s (Long-Standing) Nemesis, Apixa?

Do we finally have enough evidence to establish a preferred direct-acting oral anticoagulant (DOAC) for stroke prevention in patients with atrial fibrillation? The use of DOACs for a-fib has rapidly increased due to their ease of use and favorable safety profile. The AHA/ACC/HRS and CHEST guidelines now recommend DOACs over warfarin for stroke prevention in a-fib, but do not state a preference for one DOAC over another. Factor Xa inhibitors, specifically apixaban and rivaroxaban, are the most commonly prescribed DOACs suggesting they are preferred by clinicians in real-world practice but is one better than the other?

Guest Authors: Amy D. Robertson, PharmD, BCACP and Michelle Balli, PharmD, BCACP

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Secondary Stroke Prevention in A-Fib: Do DOACs PROSPER in High-Risk Patients?

Several guidelines now recommend direct oral anticoagulants (DOACs) as the preferred anticoagulants for patients with non-valvular atrial fibrillation (a-fib). However, the landmark clinical trials focused largely on the primary prevention of stroke.  Moreover, real-world data using DOACs for secondary prevention is lacking. Many have argued that warfarin might be a better choice in these high-risk patients because it requires routine monitoring and increases the patient’s contact with the healthcare system. Does the choice of anticoagulant make a difference in preventing recurrent stroke?

Guest Authors: Blaire White, PharmD; Amber Cizmic, PharmD, BCACP; and Tish Smith, PharmD, BCACP

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Top Ten Things Every Clinician Should Know About the 2018 Antithrombotic Therapy Atrial Fibrillation Guidelines

The American College of Chest Physicians (ACCP) recently updated their guideline recommendations for the use of antithrombotics for the prevention of stroke in patients with atrial fibrillation (aka the Chest Guidelines).  Find out what's new, who shouldn't receive treatment based on the CHA₂DS₂-VASc score, and why the guideline panel recommends calculating a patient's SAME-TTR score.

Guest Author:  Dylan Lindsay, PharmD

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Stop the Shots: Edoxaban vs Dalteparin in Cancer-Associated VTE Treatment

For the treatment of cancer-associated VTE, LMWHs are recommended over warfarin (Grade 2B) and DOACs (all Grade 2C).  Warfarin therapy in cancer-associated VTE is often made more difficult by wildly fluctuating international normalized ratios, procedure-related interruptions, as well as numerous drug-drug and drug-food interactions.  While DOACs have been widely used in the treatment of VTE, there is very little data supporting their use in patients with active cancer until now with the publication of the Hokusai VTE Cancer study.

Guest Authors:  Elizabeth Scheffel, PharmD and Christa George, PharmD, BCPS, BCACP, CDE

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Where is the COMPASS Taking Us? Rivaroxaban, Aspirin, or Both for Stable CVD ?

Since the introduction of direct oral anticoagulants (DOACs) less than a decade ago, use of this class has expanded beyond the prevention and treatment of venous thromboembolism and stroke prevention in the setting of atrial fibrillation. The potential role of DOACs in the secondary prevention of coronary artery disease (CAD) has been of considerable interest. In the setting of CAD, warfarin has resulted in significant more major bleeding when given either alone or in combination with antiplatelet agents when compared to aspirin alone.  Therefore, clinicians have been reluctant to embrace the combination of an anticoagulant plus an antiplatelet agent. However, could DOACs have a role in stable CAD? The COMPASS trial aimed to find an answer.

Guest Authors:  Candyce Bryant, Pharm.D., Joy Hoffman, Pharm.D., and M. Shawn McFarland, Pharm.D.

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Validating HERDOO2 - When is it Safe to Stop Therapy After an Unprovoked VTE?

According to the 2016 CHEST VTE Guidelines, at least 3 months of therapy is recommended for an unprovoked DVT or PE (Grade 1B). Thereafter, the clinician is expected to weigh the risks and benefits to determine if extended therapy is appropriate. Balancing the risk of mortality from recurrent VTE versus major bleeding has been challenging.  A validated clinical decision tool is sorely needed!  Until recently, no risk assessment tool has been validated and therefore none have been widely adopted in practice.

Guest Author:  Carol Chan, Pharm.D.

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