Category: Federal Forum Posters
Purpose: This project evaluated the medication selection process for veterans weighing greater than 120 kg who were initiated on anticoagulation therapy in the pharmacy anticoagulation clinic within the VA Nebraska-Western Iowa Health Care System. Direct oral anticoagulants (DOACs) are indicated for treatment and prevention of venous thromboembolism (VTE) and the prevention of stroke in nonvalvular atrial fibrillation. There is little evidence evaluating the safety and efficacy of DOACs in individuals weighing greater than 120 kg and BMI greater than 40 kg/m2. Accordingly, in 2016 the International Society on Thrombosis and Haemostasis (ISTH) made the recommendation to avoid DOACs in these patients.
Methods: This quality improvement project is retrospective and reviewed patients greater than 120 kg who were started on anticoagulation therapy between January 1, 2017 and December 31, 2017. An existing local report was used to identify patient records for review that met search criteria. Data was collected via computerized patient record system (CPRS) chart reviews. No patient identifiable information was recorded during the chart review. The primary endpoint was the determination of anticoagulation therapy selected for veterans greater than 120 kg. The secondary endpoints were the rate of documented patient education regarding the lack of evidence supporting DOAC use in patients greater than 120 kg, the rate of anticoagulation medication started privately prior to veteran being assessed by clinical pharmacy, and the determination of the need to educate clinical pharmacists regarding the ISTH recommendation if there is a lack of documentation noted.
Results: Data collection is still being completed. A total of 42 patients have been reviewed. Of these, 19 patients (45.2 percent) were started on rivaroxaban, 16 patients (38.1 percent) were started on apixaban, 7 patients (16.7 percent) were started on warfarin, and zero patients were started on dabigatran. Of the 35 DOAC agents, 10 patients (28.6 percent) were counseled regarding the lack of evidence supporting DOAC use in patients weighing greater than 120 kg.
Conclusion: Early results show the need to further educate clinical pharmacists on the importance of providing patient education regarding the risk vs. the benefits of using a DOAC medication in patients weighing greater than 120 kg. Rivaroxaban has the most safety and efficacy evidence for use in obese patients and should therefore be considered the preferred DOAC agent in this patient population. Rivaroxaban has been the most prescribed DOAC agent to date which is a positive finding given that current safety and efficacy data points to its levels not being influenced by extremes in body weight.
Remington Wade– PGY1 Pharmacy Resident, VA Nebraska-Western Iowa Health Care System, Grand Island, NE