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

SATURDAY/11:30AM-12:30PM

ACPE UAN: 0107-9999-17-237-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 2017. 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.

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QuestfortheIdealAnticoagulant

Apatient-centeredapproachtotreatment

Emily Neddermeyer, PharmDPGY2 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

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LearningObjectives

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.

Letthequestfortheidealanticoagulantbegin!

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TheIdealAnticoagulant

• Low risk of bleeding

Safe

• Limited toxicities and other side effects

Tolerable

• Taken by mouth

Oral

• Quick reversibility

Antidote

• Does not require regular lab monitoring

Lack of Lab Monitoring

Lack of Interactions (Drug-Drug)Lack of Interactions (Drug-Food)Effective for All Indications

TheIdealAnticoagulant

• Low risk of bleeding

Safe

• Limited toxicities and other side effects

Tolerable

• Taken by mouth

Oral

• Quick reversibility

Antidote

• Does not require regular lab monitoring

Lack of Lab Monitoring

Lack of Interactions (Drug-Drug)Lack of Interactions (Drug-Food)Effective for All Indications

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IndicationsAtrial Fibrillation

(A. Fib)

Pulmonary Embolism (PE)

Heart Valve Replacement

Deep Vein Thrombosis (DVT)

Thrombophilia

Left Ventricular Assist Device (LVAD)

MedicationClasses

• Parenteral Anticoagulants

• Vitamin K Antagonists

• Direct-Acting Oral Anticoagulants

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ParenteralAnticoagulants

ParenteralAnticoagulants

• Unfractionated heparin

• Low molecular weight heparin- Enoxaparin (Lovenox®), dalteparin (Fragmin®),

tinzaparin (Innohep®)

• Fondaparinux (Arixtra®)

• Argatroban

DRUGDEX®System(electronicversion).Truven HealthAnalytics,GreenwoodVillage,Colorado,USA.Availableat:http://www.micromedexsolutions.com/(cited: 12/17/17)

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Pros

• Effective for numerous indications

• Large amount of clinical experience with medications

• Reversible (or semi-reversible)

• Injectable• Dosed multiple times

per day• Cost• Risk of bleeding

Cons

ParenteralAnticoagulants

Isittheidealanticoagulant?

Safe

Tolerable

Oral

Antidote

Lack of Lab Monitoring

Lack of Interactions (Drug-Drug)

Lack of Interactions (Drug-Food)

Effective for All Indications

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VitaminKAntagonists

Warfarin

• Dosing is personalized- INR (International Normalized Ratio) monitoring- Clinicians focus on weekly dose

• Dietary consistency- Vitamin K containing foods

Warfarinpackageinsert.Bridewater,NJ:Amneal Pharmaceuticals:2017August.

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MajorDrug-DrugInteractionswithWarfarin

• 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(electronicversion).Truven HealthAnalytics,GreenwoodVillage,Colorado,USA.Availableat:http://www.micromedexsolutions.com/(cited: 12/17/17)

Pros

• Oral dosage form • Approved for numerous

indications• Lab monitoring• Long-acting• Low Cost

• Lab monitoring• Dietary considerations• Risk of bleeding• Drug-drug interactions

Cons

Warfarin

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Iswarfarintheidealanticoagulant?

Safe

Tolerable

Oral

Antidote

Lack of Lab Monitoring

Lack of Interactions (Drug-Drug)

Lack of Interactions (Drug-Food)

Effective for All Indications

Direct-ActingOralAnticoagulants

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Direct-ActingOralAnticoagulants

(DOACs)

DOACs

• Dabigatran (Pradaxa®)

• Apixaban (Eliquis®)

• Rivaroxaban (Xarelto®)

• Edoxaban (Savaysa®)

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DOACs

• Dosing:- 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(electronicversion).Truven HealthAnalytics,GreenwoodVillage,Colorado,USA.Availableat:http://www.micromedexsolutions.com/(cited: 12/17/17)

Pros

• Few drug-drug interactions

• Limited drug-food interactions

• No required lab monitoring

• Cost (all brand name)• Limited indications• Short half-life• Risk of bleeding• Twice daily dosing• Rivaroxaban (Xarelto®)

must be taken with a meal

Cons

DOACs

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Surely,thisistheidealanticoagulant.Right?

Safe

Tolerable

Oral

Antidote

Lack of Lab Monitoring

Lack of Interactions (Drug-Drug)

Lack of Interactions (Drug-Food)

Effective for All Indications

MedicationCost

PatientPreference

ClinicalJudgement

Cost&InsuranceCoverage

MedicationSelection

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MedicationCost

• Iowa Medicaid preferred:- Enoxaparin - Warfarin- Dabigatran (Pradaxa®)- Apixaban (Eliquis®)- Rivaroxaban (Xarelto®)

IowaMedicaidPreferredDrugList(Updated:1/1/18)

MedicationCost

• Warfarin is on the Walmart $4 list

• Co-pay cards- Rivaroxaban (Xarelto®) - $0- Apixaban (Eliquis®) - $10- Dabigatran (Pradaxa®) – varies- Edoxaban (Savaysa®) - $4

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Let’sPractice!

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.?

TakeHomePoints

• 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.

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Questions?

Emily Neddermeyer, PharmDemily-neddermeyer@uiowa.edu