QUEST FOR THE IDEAL ANTICOAGULANT: A PATIENT-CENTERED APPROACH TO TREATMENT

Transcription

1 QUEST FOR THE IDEAL ANTICOAGULANT: A PATIENT-CENTERED APPROACH TO TREATMENT SATURDAY/11:30AM-12:30PM ACPE UAN: L01-T 0.1 CEU/1.0 hr Activity Type: Knowledge-Based Learning Objectives for Pharmacy Technicians: Upon completion of this CPE activity participants should be able to: 1. Explain the characteristics of the "ideal anticoagulant". 2. Distinguish between the various classes of anticoagulation medications. 3. Compare the pros and cons of the currently available anticoagulation medications. 4. Identify resources for patients who need financial assistance to pay for their anticoagulation medication. Speaker: Emily Neddermeyer, PharmD Emily Neddermeyer received her Doctor of Pharmacy degree from the University of Rhode Island College of Pharmacy. She completed a PGY1 Pharmacy Practice Residency with an ambulatory care focus at the University of Iowa Hospitals and Clinics in As a PGY2 Ambulatory Care Resident, Emily is continuing to develop her professional interest areas of academia, transitions of care, health disparities, and chronic disease state management. As an adjunct faculty member of the University of Iowa College of Pharmacy, she has enjoyed the opportunity to incorporate active learning in the classroom and precept students on their ambulatory care rotation. She spends the majority of her time managing chronic disease states in a variety of clinic settings and occasionally staffing in the outpatient Discharge Pharmacy at UIHC. As a native of Sioux City, Iowa, she is enjoying the opportunity to practice pharmacy in her home state. Speaker Disclosure: Emily Neddermeyer reports no actual or potential conflicts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation.

2 Quest for the Ideal Anticoagulant A patient-centered approach to treatment Emily Neddermeyer, PharmD PGY2 Ambulatory Care Pharmacy Resident University of Iowa Hospitals and Clinics Disclosure Emily Neddermeyer, PharmD reports no actual or potential conflicts of interest associated with this presentation 1

3 Learning Objectives Upon successful completion of this activity, participants should be able to: Explain the characteristics of the ideal anticoagulant Distinguish between the various classes of anticoagulation medications Compare the pros and cons of the currently available anticoagulation medications Identify resources for patients who need financial assistance to pay for their anticoagulation medication. Let the quest for the ideal anticoagulant begin! 2

4 Safe Low risk of bleeding Tolerable The Ideal Anticoagulant Limited toxicities and other side effects Oral Taken by mouth Antidote Quick reversibility Lack of Lab Monitoring Does not require regular lab monitoring Lack of Interactions (Drug-Drug) Lack of Interactions (Drug-Food) Effective for All Indications Safe Low risk of bleeding Tolerable The Ideal Anticoagulant Limited toxicities and other side effects Oral Taken by mouth Antidote Quick reversibility Lack of Lab Monitoring Does not require regular lab monitoring Lack of Interactions (Drug-Drug) Lack of Interactions (Drug-Food) Effective for All Indications 3

5 2/5/18 Indications Atrial Fibrillation (A. Fib) Pulmonary Embolism (PE) Deep Vein Thrombosis (DVT) Thrombophilia Heart Valve Replacement Left Ventricular Assist Device (LVAD) Medication Classes Parenteral Anticoagulants Vitamin K Antagonists Direct-Acting Oral Anticoagulants 4

6 Parenteral Anticoagulants Parenteral Anticoagulants Unfractionated heparin Low molecular weight heparin - Enoxaparin (Lovenox ), dalteparin (Fragmin ), tinzaparin (Innohep ) Fondaparinux (Arixtra ) Argatroban DRUGDEX System (electronic version). Truven Health Analytics, Greenwood Village, Colorado, USA. Available at: (cited: 12/17/17) 5

7 2/5/18 Parenteral Anticoagulants Pros Effective for numerous indications Large amount of clinical experience with medications Reversible (or semireversible) Cons Injectable Dosed multiple times per day Cost Risk of bleeding Is it the ideal anticoagulant? Safe Tolerable Oral Antidote Lack of Lab Monitoring Lack of Interactions (Drug-Drug) Lack of Interactions (Drug-Food) Effective for All Indications 6

8 2/5/18 Vitamin K Antagonists Warfarin Dosing is personalized - INR (International Normalized Ratio) monitoring - Clinicians focus on weekly dose Dietary consistency - Vitamin K containing foods Warfarin package insert. Bridewater, NJ: Amneal Pharmaceuticals: 2017 August. 7

9 Major Drug-Drug Interactions with Warfarin Clarithromycin Moxifloxacin Ciprofloxacin Levofloxacin Cefdinir Fluconazole Voriconazole Amoxicillin Bactrim Metronidazole Linezolid Amiodarone Mirtazapine Dapsone Entacapone Paroxetine Tamoxifen Prednisone Sertraline Citalopram Fluoxetine Valproic Acid Venlafaxine Escitalopram Methotrexate Carboplatin Desferasirox Fenofibrate Ibuprofen Aspirin Naproxen Clopidogrel Ticagrelor Cyclophpsphamide Cobicistat Nilotinib Efavirenz Elvategravir Orlistat Abiciximab Aprepitant Fish Oil Merceptopurine DRUGDEX System (electronic version). Truven Health Analytics, Greenwood Village, Colorado, USA. Available at: (cited: 12/17/17) Warfarin Pros Oral dosage form Approved for numerous indications Lab monitoring Long-acting Low Cost Cons Lab monitoring Dietary considerations Risk of bleeding Drug-drug interactions 8

10 2/5/18 Is warfarin the ideal anticoagulant? Safe Tolerable Oral Antidote Lack of Lab Monitoring Lack of Interactions (Drug-Drug) Lack of Interactions (Drug-Food) Effective for All Indications Direct-Acting Oral Anticoagulants 9

11 Direct-Acting Oral Anticoagulants (DOACs) DOACs Dabigatran (Pradaxa ) Apixaban (Eliquis ) Rivaroxaban (Xarelto ) Edoxaban (Savaysa ) 10

12 Dosing: DOACs - Dabigatran (Pradaxa ) twice daily - Apixaban (Eliquis ) twice daily - Rivaroxaban (Xarelto ) once or twice daily with food - Edoxaban (Savaysa ) once daily More information needed for some patients and disease states Must avoid missed doses! DRUGDEX System (electronic version). Truven Health Analytics, Greenwood Village, Colorado, USA. Available at: (cited: 12/17/17) DOACs Pros Few drug-drug interactions Limited drug-food interactions No required lab monitoring Cons Cost (all brand name) Limited indications Short half-life Risk of bleeding Twice daily dosing Rivaroxaban (Xarelto ) must be taken with a meal 11

13 Surely, this is the ideal anticoagulant. Right? Safe Tolerable Oral Antidote Lack of Lab Monitoring Lack of Interactions (Drug-Drug) Lack of Interactions (Drug-Food) Effective for All Indications Medication Cost Patient Preference Clinical Judgement Medication Selection Cost & Insurance Coverage 12

14 Iowa Medicaid preferred: - Enoxaparin - Warfarin - Dabigatran (Pradaxa ) - Apixaban (Eliquis ) - Rivaroxaban (Xarelto ) Medication Cost Iowa Medicaid Preferred Drug List (Updated:1/1/18) Medication Cost Warfarin is on the Walmart $4 list Co-pay cards - Rivaroxaban (Xarelto ) - $0 - Apixaban (Eliquis ) - $10 - Dabigatran (Pradaxa ) varies - Edoxaban (Savaysa ) - $4 13

15 Let s Practice! H.F. is a 75 y/o male who was recently diagnosed with atrial fibrillation. From your previous experience with H.F., you know that he struggles with medication adherence and doesn t have much of an appetite anymore. Which anticoagulant might be the best choice for H.F.? Take Home Points The ideal anticoagulant is not yet available. Patient-specific treatment is needed for best results. Understanding the differences with each medication can help technicians encourage adherence. Ensuring that patients can afford these life-saving medications is key. 14

16 Questions? Emily Neddermeyer, PharmD 15