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Ensuring the pharmacy profession has the knowledge and skills to manage patients receiving anticoagulation

Stephane Steurbaut, PharmD, PhD [email protected]

On behalf of the iPACT working group Disclosure

Consultancy work performed in the past for Bayer Travel grants received in the past from Bayer

2 EAHP2018 Background Indications to receive anticoagulation/ therapy: ○ Prevention of (recurrent) venous thromboembolism (VTE) ○ Treatment of VTE (deep vein thrombosis & ) ○ Stroke prevention in atrial fibrillation (AF) ○ Secondary prevention after acute coronary syndrome ○ Secondary cardiovascular prevention in carotid/peripheral artery disease ○ …

Molecules used in anticoagulation therapy: ○ Low molecular weight (LMWH): dalteparin, enoxaparin, nadroparin, tinzaparin, bemiparin, … ○ antagonists (VKA) : , , , , … ○ Direct oral (DOAC): , , , , …

3 EAHP2018 Some facts & figures Global Burden of Atrial Fibrillation (AF) and Venous Thromboembolism (VTE) ATRIAL VENOUS FIBRILLATION THROMBOEMBOLISM

4 EAHP2018 Background

Problems with DOAC prescriptions/use:

○ Incorrect dosing according to indication ○ Incorrect dosing according to renal function ○ Incorrect dosing according to age ○ Incorrect dosing according to weight ○ Incorrect dosing according to co-

○ Incorrect dosing according to CHA2DS2-VASc & HAS-BLED score ○ Non-adherence to the therapy ○ Bleedings ○ ...

5 EAHP2018 Example incorrect dosing

6 EAHP2018 Increased complexity

↑ number of patients ↑ number of

Pharmacist? ↑ number of indications ↑ need for follow-up for antithrombotics of patients/therapy

7 EAHP2018 Wordwide survey among pharmacists

Aims & objectives:

To identify self-reported gaps in competences and confidence among practicing pharmacists in the area of anticoagulation and to identify variances in confidence levels between different countries. ○ To identify demographic-related trends in confidence levels ○ To compare confidence levels of pharmacists between different countries ○ To identify therapeutic areas for additional education ○ To determine preferred method of education delivery

8 EAHP2018 Needs Assessment Survey

6 demographic questions: - Gender, age, country, years of work experience, level of education, and practice setting

9 survey questions: - Confidence with counselling VKA, LMWH and DOAC - Confidence with individual counselling points (benefit, indication, adverse events, missed doses, switching agents) Demographics - Type of reference used in practice Confidence Levels - Interest in additional education Needs Assessment - Preferred topic areas for additional education Required Educational Tools - Preferred method of education delivery - Interest in having a quick reference or pocket guide

9 EAHP2018 Results: Participating countries

SLOVAKIA

10 EAHP2018 Results: Demographics

♀ = 3,045 (72%); ♂ = 1,167 (28%)

Community pharmacists n = 2,852 (68%)

Hospital pharmacists n = 1,157 (27%)

Others n = 203 (5%)

11 EAHP2018 Results: Education-Based Trends (1)

Confidence level Confidence level Confidence level counselling on VKA counselling on LMWH counselling on DOACs PhD PhD BSc BSc PharmD MSc PharmD PhD MSc BSc

1.7x 0.5x 0.4x 0.4x PhDs 1.7x more likely to be 1.5x 1.8x 2.8x confident vs. BSc PharmD PhD MSc Confidence level BSc monitoring INR/ warfarin dosing recommendations n = 1,165 1.5x 2.8x 12 EAHP2018 3.4x Results: Education-Based Trends (2)

Community Hospital pharmacists vs. pharmacists

In general, hospital pharmacists displayed higher confidence levels compared to community pharmacists (p < 0.001) • might be due to higher degree of specialization • country specific differences were observed

13 EAHP2018 Results: Aggregate Confidence Levels Confidence level of pharmacists when providing necessary information to patients about VKAs and DOACs (n = 1,165)

p < 0.0001

14 EAHP2018 Results: Confidence Levels by Country Counselling on VKA Counselling on DOACs

15 EAHP2018 Results: Counselling Distribution of pharmacists’ confidence by counselling item 1 > 2 were not confident in discussing switching agents, INR monitoring and management of bleeding

16 EAHP2018 Results: Preferred sources of information 56%

52%

43%

30%

17 EAHP2018 Results: Pharmacists’ educational needs

Bleeding Risk Indications Assessment (50%) (61%)

Switching Bleeding Personalized Therapy 92% Management e-learning (66%) (68%)

Adverse Effects 92% of all surveyed Drug or Food Interactions (58%) pharmacists said they would Method (70%) like to receive additional preferred education in the area of by ~60% 18 EAHP2018 anticoagulation E-learning DOAC: Correct dosing and indication

19 EAHP2018 E-learning DOAC: Correct dosing and indication

20 EAHP2018 E-learning DOAC: Correct dosing and indication

21 EAHP2018 E-learning DOAC: Correct dosing and indication

22 EAHP2018 E-learning DOAC: Correct dosing and indication

23 EAHP2018 E-learning DOAC: Correct dosing and indication

24 EAHP2018 Conclusions & Key Findings (1)

>than 50% switching agents

as well as area of practice

25 EAHP2018 Conclusions & Key Findings (2)

Knowledge about anticoagulation therapy is anticipated to improve through e-learning

To improve skills regarding anticoagulation therapy e.g. to increase patient adherence probably more practical trainings are needed as well as more research to evaluate what works best

26 EAHP2018 References

• http://circ.ahajournals.org/content/129/8/837 • http://www.healthline.com/health/living-with-atrial-fibrillation/facts-statistics-infographic • https://www.nature.com/articles/nrcardio.2015.83 • https://pharmastore.informa.com/product/venous-thromboembolism-market-forecast- analysis-2024/ • https://pharmastore.informa.com/product/savaysa/

27 EAHP2018 THANK YOU FOR YOUR ATTENTION !

ACKNOWLEDGEMENTS

All iPACT collaborators involved in this study and especially Filipa Alves da Costa, Sotiris Antoniou, Fabio De Rango, Nadir Kheir, Katerina Ladova, Maria Dolores Murillo, John Papastergiou, Silas Rydant and Reka Viola