MANAGEMENT PLAN FOLLOWING INITIATION OF DIRECT ORAL ANTICOAGULANTS (DOACs) APIXABAN/DABIGATRAN/EDOXABAN/RIVAROXABAN

CONSIDERATIONS AT TIME OF INITIATION  Confirm appropriateness of therapy  Obtain baseline labs (CBC/LFTs/SCr) and calculate creatinine clearance (CrCl) using Cockcroft-Gault  Conduct medication review to assess potential for drug interactions (see https://depts.washington.edu/anticoag)  Review indication for therapy and provide education to patient, supplemented by written materials

Apixaban for treatment of VTE: DOAC MONIITORING CHECKLIST change dose from 10mg bid (for 1 week ) to 5mg bid 1 1 Week Follow-Up FOR EACH FOLLOWUP VISIT

 Adherence (including Rx refills) Is patient experiencing Yes Take with food and full glass dyspepsia? of water  Thromboembolic events Consider PPI or H2 blocker  Bleeding events/risk factors Is patient experiencing Yes other adverse side effects? Treat any modifiable factors  Adverse effects and/or consider switching to No another agent  Medication review for potentially interacting drugs At 3 weeks Rivaroxaban for including ASA and NSAIDs (see treatment of VTE: change dose from https://depts.washington.edu/ 15mg bid (for 3 anticoag) weeks) to 20mg qday  Reassessment of appropriate- ness and duration of therapy At 3 Months

 Repeat CBC

 Repeat SCR/Calculate CrCl Any sign of medication

1 intolerance? Clinical judgment should be used to At 6 months determine frequency of monitoring based on patient’s overall health, compliance, and risk factors

Continuing Follow-up After 1st 6 Months

1. CrCl > 60 m/min: Checklist once yearly Any concerns? including annual LFTs

2. CrCl < 60 ml, age> 75, wt < 60kg or medically fragile: Checklist q6months and No Yes annual LFTs Continue routine scheduled  Reassess risk vs benefit follow-up  Adjust dose or switch to another anticoagulant  Increase frequency of monitoring for patients with renal or hepatic impairment or at risk for worsening renal or hepatic function

UW Medicine Anticoagulation Services June 2015