direct oral anticoagulant (doac) playbook
TRANSCRIPT
Webinar
Direct Oral Anticoagulant (DOAC) Playbookcreated by the Anticoagulation Forum
Wednesday | May 5, 2021 | 12:00 - 1:00pm EST
Presenters:Arthur Allen, PharmD, CACP | Jack Ansell, MD, MACP
Sara Vazquez, PharmD, BCPS, CACP | Diane Wirth, ANP, CACP
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PresentersArthur Allen, PharmD, CACP• Anticoagulation Program Manager,
VA Salt Lake City Health Care System
Sara Vazquez, PharmD, BCPS, CACP• Clinical Pharmacist, University of
Utah Hospital
Jack Ansell, MD, MACP• Professor of Medicine,
Hofstra/Northwell School of Medicine
• Founder, AC Forum
Diane Wirth, ANP CACP• Adult Nurse Practitioner, Grady
Memorial Hospital• Manager Heart Failure Program,
Grady Memorial Hospital
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Disclosures & Notification of SupportAcknowledgement of Financial Commercial Support:Support for this project provided by Janssen Pharmaceuticals Inc. This content was developed independently by the AC Forum.
________________________________________________________________________________________________________________________________________________________
The speakers have the following relevant financial relationships with commercial interests:
Arthur Allen, PharmD, CACPAlexion Pharmaceuticals | BMS/Pfizer Alliance | Boehringer-Ingelheim Pharmaceuticals | Janssen PharmaceuticalsRoche Diagnostics
Jack Ansell, MD, MACPAMAG Pharmaceuticals | Perosphere Technology, Inc
Sara Vazquez, PharmD, BCPS, CACPUpToDate, Inc
Diane Wirth, ANP CACPJanssen Pharmaceuticals
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How to Claim Credit
1) Go to: http://acf.cmecertificateonline.com/2) Select “New Clinical Guide for Managing Direct Oral Anticoagulants (DOACs)”3) Evaluate the program4) Print certificate for your records
Claim Credit:http://acf.cmecertificateonline.com/
This program is accredited for Providers, Pharmacists, and Nurses for 1.0 hour
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What is the DOAC PlaybookGuidance document for managing patients on DOACs Incorporates both evidenced based and expert clinic consensus on
the management of clinical situations encountered by cliniciansGoal of the playbook was to develop a concise, easily accessible tool
for providers to utilize in daily practice
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DOAC Information Table1
Mechanism of action Indications Half Life Clearance Mechanism Special instructions
Table 2 Contraindications Dosing in renal and hepatic impairment Body weight guidance
Table 3 Pharmacokinetics Pharmacodynamics
Table 4 Dosage sizes Dosages by indications Directions for use
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Patient Selection Review of bleeding risk factors Populations to avoid DOAC use in Contraindication for DOAC use by population
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Case Study
KP is a 70 year old morbidly obese (BMI=37) female with recent diagnosis of Atrial Fibrillation PMH- TTE shows normal EF with mild aortic stenosis, HTN, DM, OA of
knees, walks with cane, 1 fall in the past 6 months without injuryMedications: Lisinopril 10 mg daily, Glucophage 1000 mg bid,
naproxen 220 mg bid, MVI daily Labs: Hgb 10.4 g/dl, HCT 33, Creatinine 1.2mg/dl
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Switching to DOACs
Reasons to switch between anticoagulantsHow to transition between anticoagulants
• DOAC to warfarin• Warfarin to DOAC• LMWH to DOAC• UFH to DOAC
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Case Study
TS is a 55 year old male recently diagnosed with colon cancer who presents to your service for guidance on when to stop Xarelto before colon resection
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DOAC30 d overall
Bleed / High Risk Patients
Arterial TE
Apixaban 1.35% / 2.96% 0.16%
Rivaroxaban 1.85% / 2.95% 0.37%
Dabigatran 0.9% 0.6%
PAUSE TrialPerioperative management of patients
with AF receiving a DOACJAMA Intern Med 2019;179:1469
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Laboratory Monitoring
Indications where lab monitoring of DOAC may be beneficial Description of labs test needed for the different DOACWhat is needed to perform DOAC lab testing
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Case Study RW is a 100 kg 50 year old male that presents to ER at 2 AM for
severe abdominal pain. CT of abdomen shows perforated bowel. Surgery is needed and you are asked to determine when it may be safest to proceed. PMH- Afib, HTN, Diverticulitis, GoutMedication: Apixaban 5 mg bid Toprol XL 100 mg daily, Lisinopril 20
mg daily. Last dose of all medications was 9 PM previous evening Labs: Hgb 12 g/dl, Hct 36, Creatinine 1.3 mg/dl
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Managing Drug-Drug Interactions
PK/PD Table of drugs that potentially can interact List of drugs that may require dose adjustment if patient must take
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Case Study MK is a 38 year old female that presented to the ER with acute onset
CP and SOB PMH- DVT 10 years ago after surgery, treated for 6 months with
warfarin, HIV, HTNMedications- MVI daily, abacavir-lamivudine 600-300 mg daily,
darunavir 800 mg daily, Ritonavir 100 mg daily, Amlodipine 5 mg daily Labs- HGB 14.7 g/dl HCT 42.3, Creatinine 1.0 mg/dl, D-Dimer
4180ng/dl Imaging- Duplex US of LE negative for DVT, CT PE- positive for bilateral
PE, no RH strain noted on CT, TTE negative for RV dilation
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Managing DOAC-associated Bleeding
Supporting your patient during a DOAC bleed Determining if reversal is necessaryWhat is the severity of the bleed Do you need a drug level Reversal agents, dosing, and administrationWhat co-morbidities could contribute to decision to reverse or notWhen to resume DOAC after a bleed
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Case Study CN is a 70 kg 73 year-old female that presents to ER after GLF in
which she hit her head and is complaining of severe headache and weakness on her left side PMH: PE 12 months ago, unprovoked, hyperlipidemia, CAD, MI 5
years agoMedications: dabigatran 150 mg bid, atorvastatin 40 mg daily, Toprol
xl 150 mg daily, asa 81 mg daily Labs: Hgb 13 g/dl, HCT 40, Creatinine 1.2 mg/dl CT of head ordered
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Managing Transitions of Care
Hospital to homeHospital to SNFHospital ward to OR Discharge check list
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Patient and Family Education Joint Commission National Patient Safety Goal Centers of Excellence Resource Center (excellence.acforum.org)
• Shared decision making• Management of DOAC• Drug Information• Systems of Care• Order Sets• Disease Management• Side Effect Management• Medication Management
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Download theAC Forum DOAC Playbook,
February 2021
excellence.acforum.org
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How to Claim Credit
1) Go to: http://acf.cmecertificateonline.com/2) Select “New Clinical Guide for Managing Direct Oral Anticoagulants (DOACs)”3) Evaluate the program4) Print certificate for your records
Claim Credit:http://acf.cmecertificateonline.com/
This program is accredited for Providers, Pharmacists, and Nurses for 1.0 hour
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Register Now for Our Upcoming Webinar:Effectiveness and Safety of DOACs versus Warfarin in Patients
with Valvular Atrial FibrillationTuesday | May 25, 2021| 12:00pm ET
Presenters: Arthur Allen, PharmD, CACP| Geoffrey Barnes, MD, MSc | Adam Cuker, MD, MS Ghadeer Dawwas, PhD, MSc, MBA | Diane Wirth, ANP, CACP
Register at www.acforum.org/education-webinars
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2021 National ConferenceOctober 28th-30th 2021 | San Francisco, CA
Hybrid Model In-Person in San Francisco & Broadcast Virtually
Session Highlights: Covid-19 Lessons Learned Addressing Health Disparities in Your Practice High Dose vs. Low Dose: Duration of Therapy Debate DOACs, End Stage Renal Disease, and the Very Elderly
Early Registration Deadline June 15, 2021
Standard Registration Deadline September 1, 2021
Visit our website to view the full program & learn more: acforum.org/2021
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This webinar is brought to you, in part, by the support of the following companies:
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