Clinical Decision Making Tool for Embolism Prophylaxis for Patients with Non-Valvular Permanent

Clinical decision making tool for embolism prophylaxis for patients with non-valvular atrial fibrillation

CHA2DS2-VASc≥2
Congestive heart failure (inc LVD) / 1
Hypertension / 1
Aged 75 or more / 2
Diabetes / 1
Stroke/TIA/thromboembolism / 2
Vascular disease
(prior MI, PAD or aortic plaque) / 1
Aged 65-74 / 1
Sex category: female / 1

Is patient due for direct current cardioversion (DCCV)? See guidelines for use of dabigatran for patients undergoing DCCV.

For GP pathway only

Assessing Adherence

The patient’s adherence to therapy is an important consideration in the pathway and must be thoroughly assessed.

Indicators of adherence include:

Patient has described few episodes of missed or incorrect doses.
Few episodes of DNA at clinic. (<10%)
Patient indicates an understanding of the importance of taking the correct dose.
Patient is a resident in a care home.
Patient is well supported /accompanied at clinic by informal or formal carers

Indicators of non-adherence include:

Patient has been in range in the past and current poor control is unexplained
Unmodified alcohol intake above national guideline amounts
Patients describes episodes of missed or incorrect doses at >50% of clinic visits.
Anticoagulant clinic has sent two or more DNA letters to the GP in the last 6 months.
Information received from other healthcare professionals on the patient’s adherence.
Patient requires assistance with medicines from carers in their own home.
Previous history of adverse event which was the result of non-adherence.
Chaotic drug use/drug abuse.
Reduced cognitive ability/ understanding unmitigated by assistance form carers

Prescribing notes:

There are no specific storage requirements for rivaroxaban therefore it is suitable for administration in compliance aids.
Rivaroxaban will be the agent of choice with dabigatran or apixaban reserved for those who have a contra-indication to, or intolerant of rivaroxaban or where the prescriber feels dabigatran or apixaban will be more appropriate than rivaroxaban.

Drug interactions

Interactions with other medicinal products affecting haemostasis
Anticoagulants

Unfractionated heparins, low molecular weight heparins (e.g. enoxaparin, Dalteparin), heparin derivatives (e.g. fondaparinux)
Oral anticoagulants e.g. warfarin, rivaroxaban, dabigatran

/ Concomitant use of rivaroxabanwith any other anticoagulant agent is contraindicated, except under the circumstances of switching therapy to or from rivaroxaban or when unfractionated heparin is given at doses necessary to maintain a patent central venous or arterial catheter
Platelet aggregation inhibitors and NSAIDs including Acetylsalicylic acid (ASA) and platelet aggregation inhibitors / Care is to be taken if patients are treated concomitantly with non-steroidal anti-inflammatory drugs (NSAIDs), including ASA and platelet aggregation inhibitors because these medicinal products typically increase the bleeding risk. For patients at risk of ulceratice gastrointestinal disease an appropriate prophylactic treatment may be considered.
Concomitant use with strong inhibitors of both CYP3A4 and P-gp, such as azole-antimycotics (e.g. ketoconazole, itraconazole, voriconazole and posaconazole) and HIV protease inhibitors (e.g.ritonavir) / The use of rivaroxaban is not recommended
Dronedarone / Co-administration with rivaroxaban should be avoided
Concomitant use with strong CYP3A4 inducers (e.g. rifampicin, phenytoin, carbamazepine, phenobarbital or St. John’s Wort) / Use with caution as may lead to reduced rivaroxaban concentrations

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