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Christine Clark BSc, MSc, PhD,
The results of trials of new oral anticoagulants (NOACs) have shown that
they are effective in stroke prevention in patients with atrial fibrillation (AF) and they are likely to be granted marketing authorisations for this indication in the near future. The impact of this development will depend on the pricing of these agents. If it is economically advantageous to use NOACs in place of warfarin for stroke prevention in AF then the patient pathway will change dramatically. Instead of months or years of warfarin monitoring and the associated demands for rigorous adherence to treatment and control of diet and alcohol intake, patients will simply take a tablet and get on with life in the normal way. Anticoagulation clinics will shrink and laboratory time will be liberated. This assumes everything is working like clockwork now but in reality many patients who should be receiving preventive treatment do not. Moreover, some who do receive treatment are poorly controlled because of poor adherence. If all of these patients were to be treated effectively with NOACs, the health gains could be considerable. Economic evaluations will need to take into account the increased acquisition costs for the NOACs and the reduced monitoring costs compared with warfarin (or other vitamin K antagonists).
The UKCPA is to be congratulated on its timely publication of a position statement (see p.70) that helps to clarify some of the issues in this area. Pharmacists with expertise in cardiology and anticoagulation have collaborated to produce a clear list
of recommendations regarding the appropriate use of warfarin and NOACs in stroke prevention to serve as interim guidance until national guidance is published in the coming months.
There are several important things here: first, clinical pharmacists are providing advice on which patients should be treated and the risk assessment measure that should be used – in this case the CHADS2 or CHA2DS2VASc score. They have also stated the situations in which NOACs should be considered as alternatives to warfarin. Importantly, they have clearly said that aspirin is not suitable for most patients as it offers much less protection against stroke than warfarin. Such unambiguous statements are welcome. This position statement is a good example of pharmacists taking a lead in providing good quality, evidence-based advice to the healthcare community.
The story does not end here. Most importantly, the authors of the statement have also considered who should be involved in making decisions both in primary and secondary care. Stakeholders should include cardiologists, haematologists, family doctors, medical and pharmaceutical prescribing advisers, specialist clinical pharmacists, service managers and local cardiac and stroke networks. Stroke prevention in AF is a long-term undertaking, requiring input and support from many parties. If NOACs become the agents of choice then pharmacy anticoagulation services will need to shift their activities from warfarin counselling and international normalised ratio monitoring to the provision of advice on adherence and lifestyle matters.