Category: Federal Forum Posters
Purpose: Patients on warfarin therapy with low time in therapeutic range (TTR) or labile INRs are at risk for poor-outcomes, including bleeding and thromboembolic events. Direct oral anticoagulants (DOACs) have compelling evidence of non-inferiority to warfarin for nonvalvular atrial fibrillation and venous thromboembolism (VTE) treatment and prophylaxis, with lower bleed risk for certain agents, and have significantly fewer dietary considerations and less frequent laboratory monitoring. The purpose of this conversion project is to evaluate TTR, improve outcomes for patients with low TTR/labile INRs, and improve compliance.
Methods: Generate report on time in therapeutic range over past 106 days. Verify that patient’s TTR is 60% or less in Anti-Coagulation Management Tool (AMT). If patient’s TTR is greater than 60%, consider DOAC if compelling reasons (travel burden, consistently overdue for INRs, expression of personal preference, etc.). If no compelling reasons, continue warfarin and continue efforts to improve TTR and improve compliance, measured by refill history. If patient’s TTR is 60% or less, or compelling reasons for DOAC, evaluate patient for DOAC based on current inclusion and exclusion criteria per Phoenix Veterans Affairs Health Care System (PVAHCS) prior authorization drug review (PADR). If patient does not meet criteria, continue warfarin. If patient does meet criteria, select DOAC based on patient- and indication-specific factors. Contact patient to discuss conversion from warfarin to DOAC. If patient is not willing to switch to DOAC, continue warfarin and continue efforts to improve TTR and improve compliance. If patient is willing to switch, order DOAC and advise patient to remain on warfarin until education appointment. Select date and time for education call with patient and arrange INR to be obtained one business day prior to appointment.
Results: Not applicable
Conclusion: Not applicable
Grace Fenner– PGY1 Ambulatory Care Pharmacy Resident, Phoenix Veterans Affairs Health Care System, Phoenix, AZ