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April 22, 2015
Pharmacists Improve Anticoagulant Adherence for Atrial Fibrillation Patients

Palo Alto, CA—Atrial fibrillation patients are more likely to take a target-specific oral anticoagulant (TSOAC) regularly and correctly when pharmacists are actively involved in their medication management.

That’s according to a new study published recently in the Journal of the American Medical Association. It found that Veterans Health Administration (VHA) patients were 80% more likely to adhere to medication guidelines if they were provided patient education when they first received a prescription for dabigatran and then were monitored by pharmacists than those who only were managed by physicians and nurses.

The study team was led by researchers at the Veterans Affairs Palo Alto Health Care System and Stanford University.

“The new oral anticoagulants, such as dabigatran, represent the biggest medical change in in the delivery of care for a-fib patients,” said senior author Mintu Turakhia, MD, of the Palo Alto VA and Stanford. “Before, the only option we had for patients was warfarin, which is cumbersome and requires blood testing once or more per month.”

Because the new drugs, typically taken twice daily, come in fixed doses and do not require regular blood tests, healthcare professionals assumed they would not require monitoring, according to Turakhia, who emphasized that the new study suggests otherwise.

An unintended consequence of having atrial fibrillation patients switch to the new drugs may have been poorer adherence to drug regimens because they no longer regularly visited anticoagulation clinics for monitoring, he said.

“This finding challenges the entire framework of health-care delivery of these new agents,” Turakhia pointed out. “These medicines were pitched as easier for patients and for health-care providers.”

Yet, most physician offices do not have a fail-safe system in place to verify how well patients take their medication and to anticipate refills and get patients their refills promptly before medications run out.

“Although pharmacist-led management of these new drugs is uncommon in the U.S., the findings make the case that it is still important and can ultimately impact clinical outcomes,” he added.

The first of the TSOACs was approved by the FDA in 2010, and, over the last 5 years, the blood thinners have increasingly been prescribed in lieu of warfarin, which has been in use for half a century. The drugs not only require fewer blood tests but also have been shown to cause less bleeding than warfarin.

Proper usage is critical, however, according to Turakhia, who noted, “This is important because even missing a few doses can lead to acute events such as stroke. How well you take the new drugs largely determines your treatment benefit.”

With those concerns about adherence, the researchers looked at 67 VHA sites with 20 or more patients filling dabigatran prescriptions between 2010 and 2012 for nonvalvular atrial fibrillation—4,863 total patients—and also included in-depth telephone interviews with 47 pharmacists from 41 eligible sites.

According to the results, the median proportion of patients who were adherent to dabigatran was 74%. The principal finding of the study was that appropriate patient selection was associated with better dabigatran adherence but that a modifiable variable—monitoring by pharmacists—also made a big difference.

“Surprisingly, we found that treatment adherence varied not by individual, but by site,” said Turakhia.

The study found that at the sites with the highest patient adherence, a pharmacist typically was actively educating patients on medication adherence, reviewing any possible drug interactions, and following up to make sure patients were taking the medication when they were supposed to and that prescriptions were being refilled on time.

“We're suggesting that greater structured management of these patients, beyond the doctor just prescribing medications for them, is a good idea,” Turakhia said.

“These findings suggest that such site-level practices provide modifiable targets to improve patient adherence to dabigatran as opposed to patient characteristics that frequently cannot be modified,” the authors conclude.
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