Transcript Inpatient - Anticoagulation Centers of Excellence

NOACs vs. warfarin:
Pros and Cons for Patients and Providers to Consider
•
•
•
•
•
•
Advantages of NOACs
No INR monitoring required
No bridging required
Easier to manage around surgical
procedures
Convenient for rural patients or
those with other barriers to clinic
visits
Fewer drug/diet/disease
interactions
Potentially better efficacy & safety
for patients with poor INR control
on warfarin









Disadvantages of NOACs
Higher out-of-pocket costs and copays
No clear advantage over wellcontrolled warfarin
BID dosing may have negative impact
on compliance
Missed doses place a patient at higher
risk for adverse event due to short
half-life
No specific antidote
Higher incidence of G.I. side effects &
discontinuation rate
Possible increased incidence of heart
attacks with dabigatran
Lack of monitoring may foster noncompliance
Renal monitoring and dose adjustment
required
Dabigatran and Rivaroxaban
Formulary Recommendations:
Inpatient
• Add to UNMH inpatient formulary only for the purpose of
continuing the drug in patients on dabigatran prior to
admission that have been deemed to be good candidates for
the drug
 No initiation of dabigatran in-house
 If a patient with new onset non-valvular afib needs anticoagulation,
warfarin should be initiated
 If a provider wishes to ultimately switch the patient to dabigatran for
valid reasons (see outpatient criteria), this should be done in the
outpatient setting
 Other uses of dabigatran will be reviewed as a nonformulary
medication on a case-by-case basis
Dabigatran and Rivaroxaban
Formulary Recommendations:
Outpatient
• Add to UNMH outpatient formulary for patients with non-valvular atrial
fibrillation and at least one of the following:
 history of poor INR control on warfarin despite good compliance
 considerable barriers to routine monitoring, such as physical or
transportation issues
 documented warfarin allergy
 documented history of non-hemorrhagic adverse effects with
warfarin
 documented, confirmed warfarin failure such as an ischemic stroke
while consistently therapeutic on warfarin
• Reason for using dabigatran instead of warfarin should be clearly
documented in the medical record by the prescriber prior to initiation
of dabigatran therapy.
• Approval for dispensing dabigatran will need to be obtained from the
Director of Clinical Pharmacy or their designee for UNM Care patients
OR prior authorized by Molina Medical Director for SCI patients.
Dabigatran and Rivaroxaban
Formulary Recommendations
• In all cases where dabigatran will be
prescribed, providers will be responsible for
ensuring insurance coverage, obtaining prior
authorization, if required, and determining
patients ability to obtain dabigatran prior to
prescribing.
• Any prior authorization or approval need to
be documented in the patient’s medical
record.