Template Letter to Primary Care from Specialist Following Initiation of Rivaroxaban For

Template letter to Primary Care from Specialist following initiation of rivaroxaban for stroke prevention in AF

Dear Dr

Your patient has today been started on rivaroxaban to prevent stroke associated with non-valvular atrial fibrillation. The decision to do so instead of using warfarin has been made on the basis of: predicted to be difficult to maintain the therapeutic range on warfarin because of the need for variable interacting medications e.g. recurrent antibiotics with known excess use of ethanol (but patient is judged as likely to comply with treatment)

domicillary testing would be required with warfarin a very high stroke risk e.g. CHADS2 score > 3, and rapid anticoagulation is considered clinically necessary, and with no absolute or relative contraindication to rivaroxaban. A previous hypersensitivity or serious side effect to warfarin which has lead to discontinuation in the past Previous demonstrated resistance to warfarin TTR <65% after >3months taking warfarin, despite good compliance History of stroke or TIA whilst taking warfarin despite good compliance

CHADS2 = % annual stroke HASBLED = % annual bleed risk risk CrCl Hb Platelets

Your patient has been prescribed: Rivaroxaban 20mg od Rivaroxaban 15mg od

Your patient has:  Been counselled about the safe use of rivaroxaban  Been supplied with the attached frequently asked questions sheet  Signed the attached patient agreement (discretionary document) Yes / No  Been supplied with an alert card (produced by the manufacturer)

The following monitoring is recommended for patients on rivaroxaban  Renal function 12 monthly check, more frequently if unstable  FBC 12 monthly, to check for signs of bleeding

Annual review  History of any stroke/ TIA or bleeding in the last year  Recheck HASBLED and review renal function & FBC

If at any point the CrCl drops below 15ml/min, stop rivaroxaban and recheck HASBLED score. Change to aspirin if the risks of anticoagulation are considered to outweigh the benefits. If anticoagulation is still indicated, swap to warfarin and/or refer to specialist. If HASBLED rises, or bleeding events or a fall in Hb occur, consider whether anticoagulation is still indicated and/or consider referral to a specialist. RIVAROXABAN KEY POINTS for clinicians

 It does not require blood tests to monitor anticoagulant effect (INR monitoring)

 Regular blood tests are needed to monitor kidney function and look for signs of bleeding

 It must be stopped if kidney function declines so that the CrCl <15ml/min

 In patients with liver disease associated with clotting problems and clinically significant bleeding risk, including those with cirrhosis, rivaroxaban should not be prescribed

 Rivaroxaban levels drop by half in 5-9 hours in young patients and 11- 13 hours in elderly patients. Taking the tablets on a regular basis is therefore very important, and protection from stroke will be lost if only one dose is missed (the effect of warfarin lasts longer).

 In the event of surgery or procedures, rivaroxaban should be stopped 24 hours prior to the intervention. See product SPC for details: http://www.medicines.org.uk/EMC/medicine/25586/SPC/Xarelto+20mg +film-coated+tablets/#POSOLOGY

 Rivaroxaban should not be used with the following drugs because of interactions:

Systemic azole antifungals: ketoconazole, voriconazole, itraconazole, posaconazole, HIV protease inhibitors, rifampicin, phenytoin, carbamazepine, Phenobarbital, St. John’s wort and dronedarone.

 Rivaroxaban causes an increase principally in prothrombin, but this is not a measure of degree of anticoagulation

 There is no established method to reverse the effect of rivaroxaban.

For further information or advice please contact , the local Trust contact who will be able to answer any further questions you may have.

Signature of specialist