Watch for New DOAC Guidance in Your Anticoagulation Policies

You'll see more focus on maximizing safe use of direct oral anticoagulants (DOACs)...apixaban (Eliquis), etc.

The Joint Commission is expanding the anticoagulation National Patient Safety Goal (NPSG) starting July 1, 2019. The biggest change will be the addition of the DOACs.

Verify your policy addresses DOAC dosing, monitoring, interactions, etc...similar to what you have for warfarin and injectable anticoagulants.

And consider these safety strategies when using DOACs.

Require an indication for DOAC orders and when documenting home DOACs in the EHR...so you can catch dosing errors.

Also ask about recent DOAC starts...to check the need for dose changes. For example, ensure a patient started on rivaroxaban 15 mg BID for VTE gets switched to a 20 mg/day maintenance dose after 3 weeks.

Outline DOAC monitoring criteria, such as requiring serum creatinine and CBC within the first 24 hours...and at least weekly.

But don't routinely check thrombin time, anti-Xa, or similar assays for DOACs. They're hard to interpret and require local calibration.

Continue to avoid rifampin, phenytoin, or carbamazepine with DOACs. But lay out a plan for managing less clear-cut interactions.

For instance, try not to combine rivaroxaban with a moderate CYP3A4 and P-glycoprotein inhibitor (diltiazem, etc) in patients with other bleeding risks...such as renal dysfunction or age over 75 years.

Define DOAC hold times around surgery or regional anesthesia. For example, consider stopping apixaban at least 48 hours before CABG or another high-bleeding-risk surgery...or longer in patients who also have renal dysfunction, such as at least 72 hours if CrCl less than 30 mL/min.

Determine criteria for treating major DOAC bleeds with agents such as 4-factor PCC (Kcentra) or idarucizumab (Praxbind). Be aware that some hospitals are still debating the need for the newest agent, Andexxa...due to limited outcome data, long prep time, and cost of up to $50,000/dose.

At discharge, emphasize adherence due to the DOAC's short half-life. Verify patients know who's managing their outpatient anticoagulation...and document the DOAC indication and duration for that prescriber.

Look for other new requirements with this NPSG...such as reversal protocols and peri-op management for all anticoagulants.

Prepare yourself by using our Safe Use of Anticoagulants toolbox.

Key References

  • www.jointcommission.org/assets/1/18/R3_19_Anticoagulant_therapy_FINAL2.PDF
  • Jt Comm J Qual Patient Saf 2018;44(11):630-40
  • J Thromb Thrombolysis 2016;41(1):206-32
  • J Am Coll Cardiol 2017;70(24):3042-67
Hospital Pharmacist's Letter. Feb 2019, No. 350217



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