A Guide to

Anticoagulation for AF Please use the following codes for Warfarin reviews: 66Q2 and 42QE2

Written by: Dr J Birch (GP ST1) & Dr A Latif (GP) v3 July 2017

NICE guidance on anticoagulation for AF (CG180): Anticoagulation Options:

Use CHA2DS2-VASc score to calculate risk Warfarin
No anticoagulation is needed if score is 0 for males, or 1 for females Once daily dosing
Treat all patients who have a score of 2 or more (consider in males who score 1) Regular INR monitoring needed
Use theHAS-BLEDscore to assess bleeding risk, although patients should be advised that for most
people the benefit of anticoagulation outweighs the bleeding risk
Low Molecular Weight Heparin (LMWH)
If on Warfarin, review for signs of poor anticoagulation control: Once daily injection
2INR values higher than 5, or 1INR value higher than 8 within the past 6months No monitoring needed
2INR values less than 1.5 within the past 6months
TTR less than 65% Apixaban (Factor Xa inhibitor)
DOACs are NOT suitable for patients with mitral stenosis or mechanical heart valves
Twice daily dosing
Lower incidence of bleeding (esp GI)
Some specific scenarios for AF: Starting a DOAC: DOAC that is least renally excreted
Standard dose: 5mg BD
Renal failure: Warfarin if CrCl <30ml/min Measure weight/height
Reduced dose: 2.5mg BD
Previous ICH: DOAC have lower risk of ICH than Warfarin Calculate CrCl
Extra-cranial bleeding: antidotes for Warfarin/Dabigatran Bloods: FBC, U&E, LFTs
Edoxaban (Factor Xa inhibitor)
GI bleeding: Dabigatran may increase GI bleed risk If 1st treatment, needs clotting screen
Once daily dosing
Menorrhagia: may be increased by Rivaroxaban If switching, only need an INR
Lower incidence of bleeding
Polypharmacy: DOACs have less interactions If switching from Warfarin, start when:
Standard dose: 60mg OD
Ischaemic Heart Disease: avoid Dabigatran INR <3 for Rivaroxaban
Reduced dose: 30mg OD
Weight over 120kg: must use Warfarin INR <2.5 for Edoxaban
Not first line (cost, see CCG guide)
Poor compliance: Warfarin may be better (longer half-life) INR <2.0 for Apixaban/Dabigatran
Rivaroxaban (Factor Xa inhibitor)
Contra-indications for DOACs: When stopping Warfarin, you MUST email: Once daily dosing
Weight over 120kg ac.service@nhs.net May reduce risk of ACS
Severe renal impairment (CrCl < 15) Standard dose: 20mg OD
For Dabigatran stop if CrCl < 30 Reduced dose: 15mg OD
Unsure what to do next?
Hepatic impairment Keele decision support tool:
Derranged clotting, ascites, encephalopathy, etc Dabigatran (Direct Thrombin inhibitor)
http://www.anticoagulation-dst.co.uk
Elevated liver enzymes > 2x ULN Twice daily dosing
Email advice: doacsupport.ox@nhs.net
Intolerance/allergy Best reduction in ischaemic stroke
Indication, age, weight, blood results,
Interacting drugs Do not use if eGFR below 30
medications, alcohol intake, dosette box
All DOACs: Ritonavir, Ketoconazole & other azoles Standard dose: 150mg BD
Anticoagulation Pharmacist
Dabigatran only: Tacrolimus & Ciclosporin Reduced dose: 110mg BD
Bleep 4177 (OUH switchboard)
 Comparison of DOACs

Apixaban Dabigatran Rivaroxaban

Standard Dose 5mg BD 150mg BD 20mg OD

Reduced Dose 2.5mg BD 110mg BD 15mg OD

Reasons to Reduce Two of more of: 80yrs old, 60kg or less, Cr 80yrs old, on verapamil, CrCl 30-50, or high
CrCl 15-49
133 or more risk GI bleeding

Renal Impairment
Reduce dose if CrCl 15 - 29. Stop below 15. Reduce dose if CrCl 30-50, Stop below 30. Reduce dose if CrCl 15 - 29. Stop below 15.

Monitoring
Repeat FBC, renal function, LFTs at least once a year if normal renal function
Every six months if the person has a CrCl between 3060 mL/min
Every three months if the person has a CrCl between 1530 mL/min
Consider monitoring more closely if intercurrent illness or concerns with frailty or renal function

Switching Warfarin to DOAC Stop Warfarin, Commence once INR < 2.0
Stop Warfarin, Commence once INR < 2.0 Stop Warfarin, Commence once INR < 3.0
(day after if <2.5)

Switching DOAC to Warfarin

Inform Warfarin clinic to support switching
Give both, check INR on day 3 and give together until INR therapeutic, then stop DOAC

Switching DOAC to DOAC or LMWH

Stop DOAC, give dose of DOAC/LMWH at same time next dose due

Specific Points Can go in a dossette box CANT go in a dossette box, but special Can go in a dossette box
Crushable and dispersible dosette boxes are available from the company Crushable and dispersible
OUH preference as this is the least renally Cannot be crushed/dispersed
cleared DOAC Dyspepsia is a common (10%)
Only DOAC with reversal agent

References and useful links:

OCCG/OUH guide on DOACs for AF: http://www.oxfordshireccg.nhs.uk/professional-resources/documents/clinical-guidelines/cardiovascular/prescriber-

decision-support-for-DOACs-in-atrial-fibrillation.pdf
OCCG/OUH guide on DOACs for VTE: http://www.oxfordshireccg.nhs.uk/professional-resources/documents/clinical-guidelines/cardiovascular/primary-
care-guidelines-for-DOACs-in-the-treatment-and-secondary-prevention-of-VTE.pdf
NICE CG180 AF: https://www.nice.org.uk/guidance/cg180
Guide on options: https://academic.oup.com/eurheartj/article/38/12/860/2966902/Choosing-a-particular-oral-anticoagulant-and-dose