Implementation of pharmacist-managed anticoagulation in patients receiving newer anticoagulants

Warfarin has been the mainstay of oral anticoagulant therapy since the 1940s.1 One of the most significant challenges with warfarin is the complexity of its management, including the need for education, International Normalized Ratio (INR) monitoring, and dosage adjustments. In many clinical settings, pharmacists have played a central role in providing anticoagulation management services because of their expertise in dosage management, drug interactions, and patient counseling.2,–4 The complexity of warfarin management is compounded by the frequency and severity of hemorrhagic complications, even when the therapy is well managed, including high rates of major bleeding,5,6 adverse drug reactions (ADRs),7 and ADR-related admissions.7 Over the past several years, new anticoagulants have been developed, such as dabigatran, rivaroxaban, apixaban, and edoxaban. Three of these agents have received Food and Drug Administration (FDA)-approved labeling—dabigatran and apixaban for the prevention of atrial fibrillation (AF)-associated stroke,8 and rivaroxaban, for the prevention of AF-associated stroke, prevention of venous thromboembolism (VTE) during hip- and knee-replacement surgeries, and treatment of VTE.9 Theoretical advantages of these new agents include the use of fixed-dose regimens, eliminating the need for dosage adjustments and routine INR monitoring. Also, because these anticoagulants have a direct-acting, target-specific mechanism of action, they do not interact with foods containing phytonadione.