MHRA advice: Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome (June 2019) (www.gov.uk).
MHRA advice: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents (June 2020) (www.gov.uk).
MHRA advice: Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic (October 2020) (www.gov.uk).

 

EDOXABAN

Important: Therapy notes

First line for atrial fibrillation
MHRA advice: Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic (October 2020) (www.gov.uk).

Important: Formulation and dosage details

Formulation:

Tablets 15mg, 30mg, 60mg

Dosage:

Embolism prophylaxis for patients with non-valvular atrial fibrillation

APIXABAN

Important: Therapy notes

Second line for atrial fibrillation
MHRA advice: Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic (October 2020) (www.gov.uk).

Important: Formulation and dosage details

Formulation:

Tablets 2·5mg, 5mg

Dosage:

Embolism prophylaxis for patients with non-valvular atrial fibrillation

Prophylaxis of venous thromboembolism following knee and hip replacement surgery, 2·5mg twice daily, refer to SPC.

Treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE): 10mg twice daily for the first 7 days then 5mg twice daily, refer to SPC, also refer to Clinical Decision Algorithm for Suspected Leg DVT.

DABIGATRAN

Important: Therapy notes

Second line for atrial fibrillation
MHRA advice: Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic (October 2020) (www.gov.uk).

Important: Formulation and dosage details

Formulation:

Capsules 110mg, 150mg

Dosage:

Embolism prophylaxis for patients with non-valvular atrial fibrillation

Prophylaxis of venous thromboembolism following knee and hip replacement surgery, 220mg once daily, refer to SPC.

Treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE): 150mg twice daily, refer to SPC, also refer to Clinical Decision Algorithm for Suspected Leg DVT

RIVAROXABAN

Important: Therapy notes

First line for prevention and treatment of DVT/PE

  • If rivaroxaban is contra-indicated: low molecular weight heparin (LMWH) overlapping with warfarin, is the second treatment of choice.
  • If both choices are contra-indicated then discuss further options with the Haematology Department.
  • Active cancer; patients receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment should be treated with LMWH, for at least the first 6 months of therapy. If treatment for longer than 6 months is required, it may be appropriate to switch to an alternative anticoagulant. Discuss with Haematology.

Second line for atrial fibrillation
MHRA advice: Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic (October 2020) (www.gov.uk).
MHRA advice: After transcatheter aortic valve replacement: increase in all-cause mortality, thromboembolic and bleeding events in a clinical trial (October 2018) (www.gov.uk).
MHRA advice: Rivaroxaban (Xarelto): reminder that 15mg and 20mg tablets should be taken with food (July 2019) (www.gov.uk).

Important: Formulation and dosage details

Formulation:

Tablets 10mg, 15mg, 20mg

Dosage:

Prophylaxis of venous thromboembolism following knee and hip replacement surgery, 10mg once daily, refer to SPC.

Treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE): Also see Clinical Decision Algorithm for Suspected Leg DVT. Dose is 15mg twice daily for 21 days followed by 20mg daily thereafter. Refer to SPC for dose adjustments, especially in reduced renal function.

Embolism prophylaxis for patients with non-valvular atrial fibrillation

Multiple myeloma to counteract the prothrombotic effect of immune modulating drugs (specialist haematology use only) off-label,10mg once daily.

Important: Formulation and dosage details

Formulation:

Tablets 2∙5mg (specialist initiation only as per CAD/PAD guideline)

Dosage:

CAD/PAD guideline

WARFARIN

Important: Therapy notes

Third line for atrial fibrillation
MHRA advice: Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic (October 2020) (www.gov.uk).

If commencing warfarin for treatment of VTE, low molecular weight heparin (LMWH) is usually administered for at least 5 days AND until adequate oral anticoagulation is established (INR in therapeutic range (>2·0) for 48 hours). 

Note: warfarin commenced at high dose has an initial pro-coagulant effect, so cover with LMWH is mandatory.

Rapid warfarin induction carries potential risks of over-anticoagulation and bleeding. Slow induction is preferable, commencing with 1 to 2mg daily. Refer to Warfarin anticoagulant advice for more detailed advice and recommended INR ranges for therapeutic control (usually 2·5, range 2·0 to 3·0 for DVT). Take into account patient circumstances (risk of falls, alcoholism, drug abuse etc) when deciding on appropriate range, and seek advice from Haematology, if unsure.

If LMWH is given for more than 5 days, assess renal function and alter dose if impaired. Check baseline platelet count and, if required, monitor for up to 14 days for heparin-induced thrombocytopenia.

INR must be monitored at the start of warfarin therapy, frequently in the initiation phase and regularly thereafter.

Refer to BNF for contraindications or complications.

  • There is a wide range of drug and dietary interactions with warfarin which should be carefully considered, refer to BNF.
  • Where antibiotics are required, note that many antibiotics interact with warfarin. Ideally patients should be advised and the INR should be checked at baseline and rechecked three days after starting a course of antibiotics, regardless of the length of the antibiotic course.
  • On discharge from hospital, to ensure that anticoagulant monitoring can be provided safely, information on the anticipated duration of anticoagulation, target INR, indication and current dose of warfarin must be provided. This information is contained in a form within the Immediate Discharge Document (IDD) system, eg IDL, and should be emailed to whoever is responsible for the ongoing management of the patient’s anticoagulation.

Important: Formulation and dosage details

Formulation:

Tablets 500 micrograms, 1mg, 3mg

Dosage:

Venous thromboembolism (VTE) and pulmonary embolism (PE), see warfarin anticoagulant guidance and for in-patients refer to additional guidance on the NHS Highland In-patient Oral Anticoagulant Prescription Chart (intranet access required)

Deep venous thrombosis (DVT) see Clinical Decision Algorithm for Suspected Leg DVT

Embolism prophylaxis for patients with non-valvular atrial fibrillation

Metal valves – refer to BCSH Guidelines on oral anticoagulation with warfarin – 4th edition

Important: Formulation and dosage details

Formulation:

Tablets 5mg (not recommended)

Dosage:

No longer recommended for the general population to avoid confusion with the 500 microgram (0·5mg) tablet. There may however be some patients whose risk/benefit is to continue to use the 5mg tablet.

Document Id: F022