Provisional (working title):
Optimizing the prescribing and monitoring of
Direct Oral anti-coagulant (DOAc’s) in primary care. Is there a safe and
effective process?
Methodology: A systematic review.
The
review uses: To identify if there are robust policies in
place for monitoring of Direct anti-coagulant medications in primary care.
The
key words: Direct anticoagulation, monitoring,
optimizing, primary care.
The
focus of the project: The focus of the project is to identify if
there is a robust protocol for monitoring and optimizing the dose of Direct
anti-coagulant medications in primary care.
Rationale:
Systematic review of primary research articles
based on the research question regarding monitoring and optimization the dose
of DOACs.
Subject
area:
Direct Oral Anti-coagulants have a narrow
therapeutic index resulting in harmful side effects. The trend of prescribing
Direct anti-coagulant in primary are has increased in recent times. However
there is no robust process for monitoring and optimization of dose in primary
care. Monitoring of DOAC’s is important as it helps to ensure that patients are
prescribed the right dose in order to minimize the harmful effects like
bleeding complications.
The risk of falls, trips and bleeding are few
of the possible side effects of insufficient DOAC monitoring. Direct
anti-coagulation dose is dependent on renal function which prioritizes the
importance of monitoring to adjust dose. Most of the prescriptions are done in
primary care and the importance of monitoring DOAC’s in primary care is crucial
to improve patient safety and improve patient outcomes.
DOAc’s are dose dependent on renal function as
they are primarily eliminated via kidneys. Dose adjustments are to be made especially in
patients with poor renal function and elderly. Failure to adjust dose in
patients with reduced renal function can result in accumulation of the drug
resulting in increased risk of bleeding. Also other factors like age, weight
and other medications are also important in order to make dose adjustments to
optimize efficacy and safety. Monitoring helps to assess patient’s adherence as
non-adherence can result in increased risk of thromboembolic events and reduced
effectiveness of treatment.
Direct Oral antic-coagulant medication can have
potential interactions with other medications. Following a strict protocol for
monitoring can minimize drug drug interactions and improve clinical outcomes by
dose adjustments or considering other alternatives if needed.
Effective monitoring and optimizing the dose of
DOAc’s can help reduce health care costs by minimizing adverse events like bleeding complications or recurrent
thromboembolic events leading to hospital admissions.
In summary, monitoring and optimizing the dose
of DOAC medications in primary care settings are essential for ensuring patient
safety, maximizing efficacy, and minimizing adverse events. It allows for
individualized treatment based on patient characteristics, improves adherence,
and ultimately leads to better clinical outcomes.
Defining
the parameter: I would like to look at the research in the
last 5 years within the UK but if there is not enough research in the UK I
would like to look into research in other countries which are relevant to this literature
review.
The
gap in current knowledge:
Although Direct Oral Anticoagulants (DOACs)
have gained significant popularity in recent times due to their efficacy and
safety profile compared to traditional anticoagulants like warfarin, there are still
some gaps in the current knowledge regarding the monitoring and optimization of
DOAC therapy.
Warfarin is a well-established medication which
has International Normalized ratio (INR) test for monitoring. DOAc’s lack a
universally accepted assays for monitoring. While specific tests exist for
Direct Oral anticoagulation monitoring like anti Xa assay for direct factor Xa
inhibitors like Rivaroxaban and Apixaban, these tests are not widely available
in primary care. There is no standard protocol for monitoring which makes it
hard to DOAc levels especially in emergency situations or assessing adherence.
Doac’s can interfere with common coagulation
tests which are primarily used in primary care like prothrombin time and
activated partial thromboplastin time (aPTT). This can lead to false
interpretation of coagulation status which makes it difficult to assess DOAc
effects accurately.
Also there are lack of validated reversal
agents available in the primary care. While there are specific reversal agents
like idarucizumab for dabigatran there are not easily available and expensive
resulting in challenges managing bleeding complications or urgent surgeries in
patients taking DOAc. There is limited research on therapeutic drug monitoring
in order to optimize dosing of DOAc and this increases the requirement for more
research. The impact of patient specific factors like renal function, age, body
weight, other medications is not fully understood and this increases scope of
further investigations.
Identifying the gaps in knowledge is essential
to help optimize dose regimens and reduce side effects.
Aim: The aim of this project is to explore DOAc prescribing trends in general
practice, improve the prescribing and monitoring protocols in primary care in
order to improve patient safety, efficacy, minimize side effects and improve
patient outcomes by improving the overall management of Direct anti-coagulant
medication.
Objectives:
The objectives are to evaluate current
prescribing practices of DOACs within primary care, including dosage,
indication and frequency of prescribing DOAC’s. Review if there are any existing
monitoring processes in place for patients on DOAc medication and identify any
areas for improvement. Is there any evidence based protocols for prescribing
and monitoring of DOACs in primary care and developed updated protocols. Is there any educational trainings to improve
understanding of DOAcs including prescribing, monitoring and management of side
effects? IS there updated guidelines and protocols for the prescribing and
monitoring of DOACs in primary care, based on evidence-based best practices and
clinical guidelines and a process of regular audit of DOAc prescribing and
monitoring and improve patient outcomes and safety. Is there a protocol in place to manage side
effects like thromboembolic events, bleeding complications and improving
patient safety with anti-coagulant therapy?
https://bmjopenquality.bmj.com/content/12/2/e002216
https://www.proquest.com/docview/2712734554?accountid=8318&pq-origsite=primo
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10347456/
https://link.springer.com/article/10.1007/s12325-023-02544-8
https://link.springer.com/article/10.1007/s11239-022-02743-https://www.hindawi.com/journals/ah/2020/3890706/
https://www.sciencedirect.com/science/article/pii/S0149291822003253
https://go.gale.com/ps/i.do?p=AONE&u=anglia_itw&id=GALE%7CA763707284&v=2.1&it=r&aty=sso%3A+shibboleth
https://link.springer.com/article/10.1007/s10557-021-07211-0
https://link.springer.com/article/10.1007/s11606-023-08315-z
https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.15106
https://link.springer.com/article/10.1007/s00392-013-0560-7
https://go.gale.com/ps/i.do?p=AONE&u=anglia_itw&id=GALE|A577888931&v=2.1&it=r
https://go.gale.com/ps/i.do?p=AONE&u=anglia_itw&id=GALE|A749007162&v=2.1&it=r
https://link.springer.com/article/10.1007/s11239-020-02223-3
https://link.springer.com/article/10.1007/s00392-013-0560-7
https://www.tandfonline.com/doi/full/10.1080/03007995.2022.2078100
https://go.gale.com/ps/i.do?p=AONE&u=anglia_itw&id=GALE|A738478624&v=2.1&it=r
I have included an example of how it should look like.
