Drug Status Key

  • Preferred
  • On Formulary
  • Specialist Initiation
  • Shared Care
  • Hospital Only
  • Under Review
  • New on System

2.8.2 Oral anticoagulants

  1. Phenindione may be used exceptionally when warfarin is not appropriate. (Licensed indications differ).
  2. Nurse Specialist, Haemostasis and Thrombolysis, available at EDGH and Conquest for
    expert advice on request.
  3. All prescribers have a responsibility to ensure awareness of any existing medications the patient may be taking (including over the counter and herbal medicines) and the potential for interaction when prescribing anticoagulants. All prescribers should ensure that their practice is compliant with the recommendations of the NPSA Patient Safety Alert No.18: Actions that can make anticoagulant therapy safer
  4. The formulary status of the oral thrombin inhibitors is dependent on the indication it is being used for – see table below.
  5. For appropriate dosing in renal impairment please consult the appropriate summary of product characteristics for dabigatran, rivaroxaban, apixaban and edoxaban
  6. Prophylaxis of venous thromboembolic events after elective hip and knee surgery
    Apixaban, Dabigatran and Rivaroxaban are all approved by NICE for the prophylaxis of venous thromboembolic events after elective hip and knee surgery as an alternative to low molecular weight heparins. No therapeutic monitoring is required. Patients are discharged with the full course of treatment.
  7. Prevention of stroke and systemic embolism in adults with non-valvular atrial fibrillation Apixaban, Dabigatran, Edoxaban and Rivaroxaban are now licensed and approved by NICE to prevent stroke in patients with atrial fibrillation with a CHA2DS2-VASC score of ≥2 or in males with a CHA2DS2-VASC score ≥ 1. Prescribing should be in accordance with the approved treatment pathway below.
  8. Acute DVT & PE treatment and VTE prophylaxis
    Rivaroxaban is approved by NICE as a treatment option for the treatment of acute DVT or PE and prevention of recurrent DVT and PE.
    Dabigatran is approved by NICE as a treatment option for treatment and secondary prevention of DVT and PE
    Apixaban is approved by NICE as a treatment option for treatment and secondary prevention of DVT and PE
    Edoxaban is approved by NICE as a treatment option for treatment and secondary prevention of DVT and PE
  9. Prevention of atherothrombotic events in acute coronary syndrome
    Rivaroxaban in combination with aspirin and clopidogrel or aspirin alone is approved by NICE as a treatment option for preventing further atherothrombotic events in patients with ACS. Prescribing responsibility will remain with the cardiologists.
  10. The MHRA drug Safety Update July 2012 gives updated advice on contraindications and warnings for dabigatran and on switching treatment to and from dabigatran.
    Dabigatran is contraindicated in clinical conditions associated with a significant risk of bleeding, such as:
      current or recent gastrointestinal ulceration
      oesophageal varices
      malignant neoplasms
      arteriovenous malformations
      recent brain or spinal injury
      vascular aneurysms
      recent brain, spinal or ophthalmic surgery
      major intraspinal or intracerebral vascular abnormalities
      recent intracranial haemorrhage
  11. The benefits and risks of starting dabigatran should also be considered carefully for patients who may have other conditions that put them at an increased risk of major bleeding (but in whom treatment with dabigatran is not contraindicated)
  12. The above has since been extended to include ALL new oral anticoagulants (apixaban, dabigatran and rivaroxaban in MHRA Drug Safety update (October 2013)
  13. Use of dabigatran is contraindicated with dronedarone, and with other anticoagulants, except when switching treatment to or from dabigatran, or with the use of unfractionated heparin for maintenance of venous or arterial catheter patency
  14. Concomitant use of antiplatelet agents increases the risk of major bleeding with dabigatran approximately two-fold, therefore a careful benefit-risk assessment should be made prior to initiation of treatment
  15. Pradaxa® (dabigatran) is now contraindicated in patients with prosthetic heart valve requiring anti-coagulant treatment. related to their valve surgery. This is regardless of the length of time elapsed since valve replacement took place. The contraindication is based on clinical trial data which showed an increased frequency of thromboembolic and bleeding events in the group of patients treated with dabigatran, compared with warfarin. See Boehringer Ingelheim letter January 2013 and MHRA Drug Safety Update March 2013

Please note, sample information has been entered into Chapters 1 and 2 only and although fairly clinically accurate, it is not guaranteed. The information was entered during April and May 2017 and drugs will have subsequently been randomly added during telephone demonstrations.

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