Novel Oral Anticoagulants
Please click on the links below to view the newly developed documents to support prescribers in making clinical decisions about the appropriate use of NOACs. These documents have been developed in conjunction with secondary care clinicians and pharmacists.
NOAC is the term used to describe new drug treatments that are alternatives to warfarin, namely: dabigatran, rivaroxaban and apixaban. All three are the subject of NICE technology appraisal guidance and their licensed indications are referred to in the linked information.
Atrial Fibrillation (AF)
This is a link to the joint formulary.
Under each drug it has the clinical decision aid called Medicines for stroke prevention in AF. Patients and GPs can use to determine which oral anticoagulant option is most appropriate for an individual patient. It is important that patients make informed decisions about which medicine may be the best for them. Whilst NOACs are available to be prescribed as per NICE guidance, warfarin remains the first line treatment option; Clinicians should consider, with patients, the individual’s and collectively the whole CCG’s benefits and costs of using warfarin or a NOAC.
Pathway for new presentation of VTE - this is guidance for GPs about how to manage patients who newly present with VTE and what the treatment options are.
Pathway for long term VTE anticoagulant treatment - this is guidance on how to manage patients who are already established on long term VTE prophylaxis and documents what factors to consider when reviewing treatment and what triggers there might be for initiating alternatives and when.
Choices in AF
There are pros and cons of all treatments, and inevitably new treatments are more expensive than established ones. Significant numbers of patients changing from warfarin to a NOAC would have a material impact on prescribing costs and lead to the need to limit commissioning of other services or treatments. Many patients will be established on warfarin and have good control and not need to change: NICE guidance states that for a patient who is already established on warfarin, the risks and benefits of switching should be considered in the light of their INR. So there would need to be a very strong additional reason to switch well controlled patients to a NOAC.
Some patients, despite good compliance, fail to achieve good warfarin control: such patients may have better control of anticoagulation and therefore of stroke prevention on a NOAC. Patients with poor warfarin control due to poor compliance however are less likely to benefit from a NOAC and may have worse control of anticoagulation and stroke prevention on a NOAC than warfarin.
Patients and clinicians need to be aware of the cost implications to the NHS as a whole from choosing a NOAC for long term use before they have tried warfarin (where both are treatment options) and of the relative clinical inexperience of the NOACs compared with warfarin. The black triangle status of dabigatran has recently been removed: that of rivaroxaban and apixaban remain. It is regrettable that none of the manufacturers of the NOACs have signed up to the All Trials Petition so doctors and the public cannot be sure of the risks and benfits of these drugs over established treatment.
We hope that this is useful information. Further patient information for VTE prophylaxis is under development. The above documents are available on the York and Scarborough Joint Formulary. If you have questions or comments about these documents or their application in practice, then please do not hesitate to contact on the RxLine Email Address.