Steven A. Rothman, MD - AFib Treatment: General Population - Figure 33

Expanding the Role of the Anticoagulation Service

Finally, what about follow-up of anticoagulation patients? We are used to our anticoagulation patient and the anticoagulation clinics that take care of our warfarin monitoring, and there has been hope that perhaps we can really minimize these services with the switch to the NOACs. I think, however, that having some sort of an anticoagulation protocol in place is still an important consideration for all practices.

Any patient on oral anticoagulant needs to be educated to both improve their compliance and decrease any adverse events.
The clinic should be responsible for managing the interruptions in therapy, and for monitoring drug interactions in these patients.
Warfarin patients require a significant amount of monitoring of drug levels and dose adjustments to maintain warfarin within the narrow therapeutic INR range of 2 – 3
Patients have to be monitored to avoid gaps in drug therapy and monitored to maximize the time in therapeutic range (TTR).

The emphasis on tracking patients is useful, because now patients who really have a low time in therapeutic range can be switched to one of the NOACs and maintain better anticoagulant efficacy. Any patients on a NOAC with moderate renal dysfunction, periodic monitoring of renal function will be required, and any transitions to or from warfarin or between NOACs will require attention to anticoagulation efficacy. And finally, of course, patient education is important, and physicians need to be aware of ways to assess compliance in these patients.

Rothman SA. Am J Med 2013; 126: 00-00.