Checklist
| Assessment |
Recommendation |
| Is anticoagulation still appropriate and required |
For example, can anticoagulant therapy be stopped in patients with prior DVT / PE, where the risk of recurrence is now considered low seek specialist advice if necessary |
| Is patient's condition suitable for DOAC switch |
DOACs are only licensed for the prevention of atrial fibrillation (AF)-related stroke in people with non-valvular AF and for the treatment and secondary prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) there is little data on DOACs for patients with venous thrombosis at unusual sites (e.g. portal vein thrombosis) and these patients should be discussed with an anticoagulation specialist DOACs should not be considered for patients
|
| Does patient require a higher INR than the standard INR range of 2.0 – 3.0 | DOACs are not suitable |
| Does patient have a severe renal impairment | Not recommended in patients with Creatinine Clearance (CrCl) < 15ml/min |
| Check interacting medications |
Click here for information about DOAC interactions check with HIV drug interactions website at https://www.hiv-druginteractions.org/ some antiepileptics- phenytoin, carbamazepine, phenobarbitone or rifampicin are likely to reduce DOAC levels so should be discussed with an anticoagulation specialist on triple therapy (dual antiplatelet therapy plus warfarin) without discussing with an anticoagulant specialist or cardiologist |
| Extremes of bodyweight < 50kg or > 120kg |
When calculating CrCl for these patients in primary care: adjusted BW for >120kg and actual BW for <50kg Usually unsuitable for DOAC |
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CHADVASC score |
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Creatinine clearance |
Reduce dose if CrCL< 50 CrCl dosing |
For patients in whom DOACs are suitable
If all above is suitable and the decision is made to switch to a DOAC then you will need to
- Choose appropriate DOAC for choosing the right DOAC click here
- Choose the correct dose for DOAC doses click on this link
- Plan the switch for switching from warfarin to a DOAC click here
- Ensure patent understands everything about the switch for a checklist of counselling points for the patient click here
For patients in whom DOACs are NOT suitable
- is self-testing of INR with a CoaguChek self-testing meter a possibility? There are limited supplies of Coaguchek self-testing meters available in the UK but, where available, these should be used for appropriate patients continuing warfarin therapy.
- assess if Low Molecular Weight Heparin (LMWH) is suitable - Whenever possible, patients with mechanical heart valves should remain on warfarin, however if monitoring is impossible then a brief period of LMWH could be considered if the patient can be taught to self-inject or a family member that lives with them can administer the injection; Dosing recommendations should be provided by the patient’s current anticoagulation service provider by phone or electronically. See https://www.nice.org.uk/guidance/dg14
