Standardized anticoagulation counseling reduces patient harm

Pharmacists' role in patients on anticoagulation therapy

Anticoagulation medications often include complex dosing schedules and require close monitoring and patient compliance. Designed to prevent and treat thrombosis, traditional anticoagulants such as warfarin and heparin have been associated with an increased risk of adverse effects. With several novel anticoagulants recently approved by FDA and the Joint Commission calling for patient education on anticoagulation therapy, the pharmacist’s role in anticoagulation management is more important than ever before.

When it comes to monitoring patients on anticoagulant drug therapy, pharmacists “are dealing with two extremes,” said James Groce, PharmD, CACP, Clinical Pharmacy Specialist in Anticoagulation at the Moses Cone Health System in Greensboro, NC. “We may see the patient either die of an embolic event or die from bleeding. We have to keep the patient exactly in the middle for successful treatment.”

Patient education

The 2013 National Patient Safety Goal (NPSG) focused on anticoagulation therapy (NPSG.03.05.01) provides eight elements of performance and highlights patient education, including face-to-face interaction, as a vital component to achieving better outcomes.

“The hospital pharmacist is in a perfect position as the drug therapy expert to facilitate this patient-centric education before the patient leaves the hospital,” said Groce, who is also a Professor at the Campbell University College of Pharmacy and Health Sciences in Buies Creek, NC. He believes that patient education is a continuing process, from conducting the initial visit at the bedside of an acutely ill patient to helping patients manage their ongoing anticoagulation therapy in an outpatient setting.

There are several anticoagulation management clinics supervised by clinical pharmacists within the Moses Cone Health System, including internal medicine, family medicine, cardiology, and oncology outpatient clinics. The pharmacists at each of these clinics are guided by the elements of performance outlined in NPSG.03.05.01.

Groce and his team counsel patients about the indication, the type of anticoagulant, and the monitoring process, with a focus on recurrence of the disease or bleeding as the endpoints of efficacy and safety. “The use of standardized practices, which is an expectation of the Joint Commission, remains the mainstay of our efforts to reduce the likelihood of patient harm for all of these drugs,” Groce added.

Novel agents

FDA recently approved three novel anticoagulants—rivaroxaban (Xarelto—Janssen), apixaban (Eliquis—Bristol-Myers Sqiubb, Pfizer), and dabigatran (Pradaxa—Boehringer Ingelheim)—that have been shown to be as safe as warfarin and heparin, but without the need for routine monitoring. “Hospital pharmacists must be familiar with these new agents and be prepared to screen directly for drug–drug/drug–disease state modifications,” said Groce.

Although routine international normalized ratio monitoring is not necessary with the new agents, the patients taking them still have a disease, noted Groce. As part of their patient education efforts, pharmacists should “be able to effectively communicate the absolute importance of [adherence] to these new agents, monitor for adverse events, and … determine if any dose adjustment is necessary relative to the patient’s renal function,” he added.

In light of these new anticoagulants and increased attention on educating patients about their disease state and medications, Groce believes that pharmacists will continue to be relevant members of the health care team. “Our role remains not only to improve patient outcomes, which can go a long way in our effort to subvert the potential for unnecessary readmissions to hospital, but [to improve] safety as well, which can reduce the likelihood of increased financial risk that can drain dollars from our health care systems if therapeutic misadventure were to occur,” said Groce. “These efforts pay off in every way—we improve patient outcomes, we improve safety, [and] we decrease the potential for readmission to our hospitals.”