NHS Dudley Health Economy Medicines Formulary
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2.8.2 Oral anticoagulants

General guidance

For NHS Dudley Atrial Fibrillation (AF) Primary Care Diagnosis and Management Pathway click here

For National Patient Safety Agency (NPSA) Anticoagulation Therapy Guidance click here

For Dudley Briefing on New Oral Anticoagulants (NOACs) click here

  • Main indications for oral anticoagulation are atrial fibrillation and deep-vein thrombosis (DVT). Patients with pulmonary embolism should also be treated, as should those with atrial fibrillation who are at risk of embolisation, and those with mechanical prosthetic heart valves; an antiplatelet drug may also be useful in these patients.
  • The target recommended INRs are:
  • Recurrent DVT and pulmonary embolism (PE) whilst off anticoagulation: INR 2.5
  • Recurrent DVT and PE occurring whilst on anticoagulation: INR 3.5
  • Mechanical prosthetic heart valves: INR 3.5
  • All other indications: INR 2.5
  • Patients tend to be maintained on doses which can be achieved through the use of only the 3mg strength of warfarin tablets in order to reduce the potential for confusion.

Recommended drugs

Warfarin

& New Oral Anticoagulants (NOACs)

Apixaban

Dabigatran

Rivaroxaban

Edoxaban 

Prescribed within NICE guidance (see below) and also see Dudley Briefing on NOACs including referral form for initiation

Antiplatelet drugs - see seperate formulary section

 

Drug Traffic Light Key:

Green – On Formulary

Amber – Restricted use, see local guidelines      

Purple – Specialist use/initiation

Red – Non Formulary

 

Relative Costs Key (where indicated):

£££££ - high

£££ - moderate

£ - low

Atrial fibrillation - dabigatran etexilate - NICE TAG TA249

1.1 Dabigatran etexilate is recommended as an option for the prevention of stroke and systemic embolism within its licensed indication, that is, in people with nonvalvular atrial fibrillation with one or more of the following risk factors:

  • previous stroke, transient ischaemic attack or systemic embolism

  • left ventricular ejection fraction below 40%

  • symptomatic heart failure of New York Heart Association (NYHA) class 2 or above

  • age 75 years or older

  • age 65 years or older with one of the following: diabetes mellitus, coronary artery disease or hypertension.

1.2 The decision about whether to start treatment with dabigatran etexilate should be made after an informed discussion between the clinician and the person about the risks and benefits of dabigatran etexilate compared with warfarin. For people who are taking warfarin, the potential risks and benefits of switching to dabigatran etexilate should be considered in light of their level of international normalised ratio (INR) control.

 

https://www.nice.org.uk/guidance/TA249

Atrial fibrillation (stroke prevention) - rivaroxaban - NICE TAG TA256

1.1 Rivaroxaban is recommended as an option for the prevention of stroke and systemic embolism within its licensed indication, that is, in people with nonvalvular atrial fibrillation with one or more risk factors such as:

  • congestive heart failure

  • hypertension

  • age 75 years or older

  • diabetes mellitus,

  • prior stroke or transient ischaemic attack.

1.2 The decision about whether to start treatment with rivaroxaban should be made after an informed discussion between the clinician and the person about the risks and benefits of rivaroxaban compared with warfarin. For people who are taking warfarin, the potential risks and benefits of switching to rivaroxaban should be considered in light of their level of international normalised ratio (INR) control.

 

https://www.nice.org.uk/guidance/TA256

Pulmonary embolism and recurrent venous thromboembolism - rivaroxaban - NICE TAG TA287

1.1 Rivaroxaban is recommended as an option for treating pulmonary embolism and preventing recurrent deep vein thrombosis and
pulmonary embolism in adults.

https://www.nice.org.uk/guidance/TA287

Stroke and systemic embolism (prevention, non-valvular atrial fibrillation) - apixaban - NICE TAG TA275

1.1 Apixaban is recommended as an option for preventing stroke and systemic embolism within its marketing authorisation, that is, in people with nonvalvular atrial fibrillation with 1 or more risk factors such as:

  • prior stroke or transient ischaemic attack

  • age 75 years or older

  • hypertension

  • diabetes mellitus

  • symptomatic heart failure.

1.2 The decision about whether to start treatment with apixaban should be made after an informed discussion between the clinician and the person about the risks and benefits of apixaban compared with warfarin, dabigatran etexilate and rivaroxaban. For people who are taking warfarin, the potential risks and benefits of switching to apixaban should be considered in light of their level of international normalised ratio (INR) control.

https://www.nice.org.uk/guidance/TA275

Venous thromboembolism - dabigatran - NICE TAG TA157

1.1 Dabigatran etexilate, within its marketing authorisation, is recommended as an option for the primary prevention of venous thromboemolic events in adults who have undergone elective total hip replacement surgery or elective total knee replacement surgery.

https://www.nice.org.uk/guidance/TA157

Venous thromboembolism (hip and knee surgery) - apixaban - NICE TAG TA245

1.1 Apixaban is recommended as an option for the prevention of venous thromboembolism in adults after elective hip or knee replacement surgery.

https://www.nice.org.uk/guidance/TA245

Venous thromboembolism - rivaroxaban - NICE TAG TA170

1.1 Rivaroxaban, within its marketing authorisation, is recommended as an option for the prevention of venous thromboembolism in adults having elective total hip replacement surgery or elective total knee replacement surgery

https://www.nice.org.uk/guidance/TA170

Venous thromboembolism (treatment and long term secondary prevention) - rivaroxaban - NICE TAG TA261

1.1 Rivaroxaban is recommended as an option for treating deep vein thrombosis and preventing recurrent deep vein thrombosis and pulmonary embolism after a diagnosis of acute deep vein thrombosis in adults.

https://www.nice.org.uk/guidance/TA261

Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism - NICE TAG TA327

1.1 Dabigatran etexilate is recommended, within its marketing authorisation, as an option for treating and for preventing recurrent deep vein thrombosis and pulmonary embolism in adults.

https://www.nice.org.uk/guidance/TA327

Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome - NICE TAG TA335

1.1 Rivaroxaban is recommended as an option within its marketing authorisation, in combination with aspirin plus clopidogrel or aspirin alone, for preventing atherothrombotic events in people who have had an acute coronary syndrome with elevated cardiac biomarkers.

1.2 Clinicians should carefully assess the person's risk of bleeding before treatment with rivaroxaban is started. The decision to start treatment should be made after an informed discussion between the clinician and the patient about the benefits and risks of rivaroxaban in combination with aspirin plus clopidogrel or with aspirin alone, compared with aspirin plus clopidogrel or aspirin alone.

1.3 A decision on continuation of treatment should be taken no later than 12 months after starting treatment. Clinicians should regularly reassess the relative benefits and risks of continuing treatment with rivaroxaban and discuss them with the patient.

http://www.nice.org.uk/guidance/ta335 

Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism - NICE TAG TA341

1.1 Apixaban is recommended, within its marketing authorisation, as an option for treating and for preventing recurrent deep vein thrombosis and pulmonary embolism in adults.

http://www.nice.org.uk/guidance/ta341

Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation - NICE TAG TA355

1.1 Edoxaban is recommended, within its marketing authorisation, as an option for preventing stroke and systemic embolism in adults with non‑valvular atrial fibrillation with one or more risk factors, including:

  • congestive heart failure

  • hypertension

  • diabetes

  • prior stroke or transient ischaemic attack

  • age 75 years or older.

1.2 The decision about whether to start treatment with edoxaban should be made after an informed discussion between the clinician and the person about the risks and benefits of edoxaban compared with warfarin, apixaban, dabigatran etexilate and rivaroxaban. For people considering switching from warfarin, edoxaban's potential benefits should be considered against its potential risks, taking into account the person's level of international normalised ratio (INR) control.

http://www.nice.org.uk/guidance/ta355 

Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism - NICE TAG TA354

1.1 Edoxaban is recommended, within its marketing authorisation, as an option for treating and for preventing recurrent deep vein thrombosis and pulmonary embolism in adults.

http://www.nice.org.uk/guidance/ta354

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