Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

Rahmanzade, Ramin; Diaz, Francisco Cabrera; Zaugg, Claudia; Schuetz, Philipp; Salili, Ali Reza

doi:10.1186/s12959-020-00227-w

Cited by 9 publications

(5 citation statements)

References 38 publications

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“…The MHRA safety alert on anticoagulation identified a “small number of patients” co-prescribed warfarin and a DOAC, but provided no further information on the scale of the problem. One Swiss hospital found 0.8% of its patients on anticoagulant therapy (121/15812) were co-prescribed two anticoagulants in a single year, 2017/2018 [18]. However, 88.7% of these cases involved co-prescription of DOACs and injectable low-weight molecular heparins, not included in our study.…”

Section: Discussionmentioning

confidence: 87%

OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England

Curtis

MacKenna

Walker

et al. 2020

Preprint

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BackgroundEarly in the COVID-19 pandemic the NHS recommended that appropriate patients anticoagulated with warfarin should be switched to direct acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately co-prescribed two anticoagulants following a medication change, and associated monitoring.ObjectiveTo describe which people were switched from warfarin to DOACs; identify potentially unsafe co-prescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.MethodsWorking on behalf of NHS England we conducted a population cohort based study using routine clinical data from >17 million adults in England.Results20,000 of 164,000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in co-prescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. INR testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).ConclusionsIncreased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people co-prescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

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Section: Discussionmentioning

confidence: 87%

OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England

Curtis

MacKenna

Walker

et al. 2020

Preprint

View full text Add to dashboard Cite

show abstract

“…One Swiss hospital found 0.8% of its patients on anticoagulant therapy (121/15812) were coprescribed two anticoagulants in a single year. 16 However, 88.7% of these cases involved coprescription of DOACs and low-molecular weight heparins, not included in our study. As regards INR tests, the MHRA reports appears to have been triggered by a root cause analysis from a single centre in London, 17 reporting that between 1 March and 17 April 2020, 0.9% (30/3214) of INRs were high (>8.0) compared with 0.1% (6/4079) the previous year.…”

Section: Discussionmentioning

confidence: 90%

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic

et al. 2021

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BackgroundEarly in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring.ObjectiveTo describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.MethodsWith the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England.Results20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50–100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).ConclusionsIncreased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

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“…The consequences of therapeutic duplication of anticoagulants have been studied previously, where 7.4% of cases led to a hemoglobin-relevant bleed. 40 In addition, our study found 3.4% of patients with an HAC linked to an anticoagulant resulted in hospital death. This further emphasizes the high-risk nature of anticoagulants and the need for concerted interventions to ensure their judicious and effective use.…”

Section: Discussionmentioning

confidence: 58%

The Effect of Digitization on the Safe Management of Anticoagulants

et al. 2022

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Background: Anticoagulants are high-risk medications and are a common cause of adverse events of hospitalised inpatients. The incidence of adverse events involving anticoagulants has remained relatively unchanged over the past two decades, suggesting novel approaches are required to address this persistent issue. Electronic medication management systems (eMMS) offer strategies to help reduce medication incidents and adverse drug events, yet poor system design can introduce new error types. Objective: To evaluate the effect of the introduction of an electronic medical record (EMR) on the quality and safety of therapeutic anticoagulation management. Methods: A retrospective, observational pre/post study was conducted, analysing real-world data across five hospital sites in a single health service. Four metrics were compared one year pre- and one year post-EMR implementation. They included clinician-reported medication incidents, toxic pathology results, hospital-acquired bleeding complications (HACs) and rate of heparin-induced thrombocytopenia. Further sub-analyses of patients experiencing HACs in the post-EMR period, identified key opportunities for intervention to maximise safety and quality of anticoagulation within an eMMS. Results: A significant reduction in HACs was observed in the post-EMR implementation period (mean (SD) =12.1 (4.4)/month, vs. mean (SD) =7.8 (3.5)/month; p=0.01). The categorisation of potential EMR design enhancements found that new automated clinical decision support or improved pathology result integration would be suitable to mitigate future HACs in an eMMS. There was no significant difference in the mean monthly clinician-reported incident rates for anticoagulants or the rate of toxic pathology results in the pre- versus post-EMR implementation period. A 62.5% reduction in the cases of heparin-induced thrombocytopenia were observed in the post-EMR implementation period. Conclusion: The implementation of an EMR improves clinical care outcomes for patients receiving anticoagulation. System design plays a significant role in mitigating the risks associated with anticoagulants and consideration must be given to optimising eMMS.

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Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

Cited by 9 publications

References 38 publications

OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England

OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic

The Effect of Digitization on the Safe Management of Anticoagulants

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