Safe and effective anticoagulation use: Case studies in anticoagulation stewardship

Abstract

Anticoagulant use is prevalent and associated with significant potential for harm. Anticoagulation stewardship practice has emerged to address care gaps and promote safe, effective, and cost-conscious anticoagulation use across health care systems. Here we present 4 patient cases describing common challenges in anticoagulation management: inappropriate dosing of direct oral anticoagulants (DOACs), the diagnosis and management of heparin-induced thrombocytopenia (HIT), periprocedural anticoagulation management, and heavy menstrual bleeding on anticoagulation. We discuss available examples of successful stewardship programs that can address the challenges of each case, demonstrating how an investment in anticoagulation stewardship can improve patient outcomes.

Introduction:

Anticoagulants are the leading class of agents resulting in emergency department (ED) visits for adverse drug events (ADEs), accounting for approximately 14.9% (95% CI, 10.7–19.1) of all ADE visits, followed by prescription opioids (11.0%; 95% CI, 9.4–12.5) and diabetes agents (9.9%; 95% CI, 8.7–11.1) in 2017–2019.¹ Furthermore, the percentage of anticoagulant-related ED visits continues to rise (Figure 1).

Figure 1:

United States Emergency Department visits for medication harms

Abbreviation: ADE, adverse drug events; ED, emergency department

Data collected from Budnitz et al¹ and Shehab et al.³ Figure modified from Burnett et al² with permission.

*Estimates from 2017–2019 include ED visits for medication harms from therapeutic use only, while all subsequent time periods include ED visits for medication harms overall.

Anticoagulation stewardship is an emerging model designed to improve anticoagulation efficacy and decrease harm and costs. Anticoagulation stewardship is defined as, “coordinated, efficient, and sustainable system-level initiatives designed to achieve optimal anticoagulant-related health outcomes and minimize avoidable ADEs through (i) the application of optimal evidence-based care; (ii) appropriate prescribing, dispensing, and administration of anticoagulants and related agents; and (iii) provision of appropriate patient monitoring and clinical responsiveness.”² The concept is modeled after antimicrobial stewardship, which has been widely adopted and successful, as demonstrated in part by the decline in the proportion of ED visits for ADEs due to antibiotics (Figure 1).^1,3

The Anticoagulation Forum, a multidisciplinary non-profit organization, published the Core Elements of Anticoagulation Stewardship Programs in 2019 with funding from the United States (US) Food and Drug Administration (FDA).⁴ This group subsequently developed an implementation guide in conjunction with the National Quality Forum in 2022,⁵ while also working with the American Society of Health-System Pharmacists to develop a post-graduate year 2 residency in Thrombosis and Hemostasis Management. These efforts are all working toward a goal of establishing anticoagulation stewardship programs as the new standard of care.

Herein, we present 4 cases to illustrate how anticoagulation stewardship programs can positively impact the care of individuals receiving anticoagulation, with an overview of the cases presented in Figure 2. We focus on 4 common scenarios associated with anticoagulation-related harm: inappropriate dosing of direct oral anticoagulants (DOACs), diagnosis and management of heparin-induced thrombocytopenia (HIT), periprocedural anticoagulation management, and heavy menstrual bleeding (HMB) on anticoagulation. In each case, we present specific examples of stewardship efforts to address the care gap, illustrating how anticoagulation stewardship can prevent harm and increase care quality.

Figure 2:

Overview of the four case topics, the care problem the case represents, and examples of anticoagulation stewardship to improve care

DTI, direct thrombin inhibitor; IV, intravenous

Case 1:

A 62-year-old, 72 kg female presents with a new ischemic stroke. She has a history of coronary artery disease (CAD) status post drug eluting stent placement 6 years prior, chronic kidney disease (serum creatinine 1.6 mg/dL, creatinine clearance 35mL/min) and atrial fibrillation. She has been taking apixaban 2.5mg twice daily for primary stroke prevention. Her new stroke is deemed a “failure” of apixaban, so she is switched to warfarin. Low-dose daily aspirin (ASA) is also added given her CAD history. Four weeks later, she presents with fatigue and dark stools, requiring admission for an acute upper gastrointestinal bleed.

1.1. Safe and effective use of direct oral anticoagulants (DOACs):

It is well-accepted that warfarin use necessitates strict oversight due to the requirement for therapeutic monitoring. The comparative simplicity of DOACs may drive an assumption that dedicated oversight is not needed, but as illustrated in Figure 1, anticoagulation-related ADEs continue to rise.¹ With the ever-expanding list of FDA-approved indications for different DOAC regimens (Table 1), the complexity of DOACs should not be underestimated.

Table 1:

Direct oral anticoagulation (DOAC) dose and indications for use per the United States Food and Drug Administration

DOAC & dose	Indication(s) for use
	VTE	AF	CAD or PAD
Apixaban
10mg BID	1. Acute VTE (for first 7 days)	x	x
5mg BID	1. Acute VTE (after 7 days of 10mg BID) 2. Secondary prevention of VTE	1. AF	x
2.5mg BID	1. Primary prevention of VTE after THA/TKA 2. Secondary prevention of VTE (after 6 months of 5mg BID)	1. AF if 2 of 3 criteria met: SCr ≥1.5mg/dL, age ≥80, weight ≤60kg	x
Dabigatran
75mg BID	x	1. AF, CrCl 15–30mL/min	x
150mg BID	1. Acute VTE (after 5–10 days parenteral anticoagulation) 2. Secondary prevention of VTE	1. AF, CrCl >30mL/min	x
220mg daily	1. Primary prevention of VTE after THA t	x	x
Edoxaban
30mg daily	1. Acute VTE (after 5–10 days parenteral anticoagulation), CrCl >50 to ≤95 mL/min or ≤60kg or certain P-gp inhibitors	1. AF, CrCl 15–50mL/min	x
60mg daily	1. Acute VTE (after 5–10 days parenteral anticoagulation)	1. AF, CrCl >50 to ≤95 mL/min	x
Rivaroxaban
15mg daily	x	1. AF, CrCl ≤50 mL/min
15mg BID	1. Acute VTE (for first 21days)	x	x
20mg daily	1. Acute VTE (after 21 days of 15mg BID) 2. Secondary prevention of VTE	1. AF, CrCl >50 mL/min	x
10mg daily	1. Primary prevention of VTE after THA/TKA 2. Primary prevention of VTE in acutely ill medical patients (total duration 31–39 days) 3. Secondary prevention of VTE (after 6 months of 5mg BID)	x	x
2.5mg BID	x	x	1. CAD or PAD, with aspirin (75–100mg) once daily

x = dose not used for this indication

AF, atrial fibrillation; BID, twice daily; CAD, coronary artery disease; CrCl, creatinine clearance; PAD, peripheral artery disease; THA, total hip arthroplasty; TKA, total knee arthroplasty; SCr, serum creatinine; VTE, venous thromboembolism

Inappropriate DOAC dosing is common, with approximately a quarter of individuals with atrial fibrillation receiving an off-label dose.^6–8 Underdosing of DOACs is most common, with resultant increased risk of hospitalization, stroke, and death in individuals receiving DOACs for atrial fibrillation, and increased risk of recurrence in individuals receiving DOACs for venous thromboembolism (VTE).^9–11 Overdosing also occurs and is associated with increased risk of major bleeding, stroke or systemic embolism, hospitalization, and mortality.^9,10

In addition, inappropriate co-prescribing of antiplatelet therapy occurs in more than one-third of individuals receiving anticoagulation.^12,13 Patients frequently have multiple comorbidities that may independently require anticoagulation or antiplatelet therapy, but when combined, anticoagulation monotherapy is often preferred. For example, there is no role for the addition of aspirin for the primary prevention of atherosclerotic events in patients on anticoagulation.¹⁴ In individuals on anticoagulation with known cardiovascular disease that undergo drug-eluting stent placement, guidelines consistently favor limited use of “triple therapy” (anticoagulation + aspirin + P2Y12 inhibitor) and finite duration of antiplatelet therapy (6–12 months), supporting anticoagulation monotherapy for long term secondary prevention.¹⁵ When co-prescribing is indicated, gastroprotection with a proton pump inhibitor (PPI) is encouraged.¹⁶

1.2. Anticoagulation stewardship for DOACs:

Anticoagulation services were initially developed to ensure safe and effective use of warfarin. Such services have been reimagined to optimize DOAC use with activities including agent/dose selection, patient and caregiver education, periprocedural management, addressing medication persistence/adherence, and regular reassessment of the therapeutic risk and benefit.^17,18 At a minimum, closer oversight is advisable for high-risk populations such as those with cancer, renal or hepatic impairment, polypharmacy, and history/risk of medication nonadherence.¹⁹ Targeted anticoagulation stewardship efforts like aspirin de-escalation have also been shown to significantly reduce harms associated with anticoagulation therapy.²⁰ Stewardship efforts have proven successful in the hospital setting, with one study reporting that their stewardship program identified an opportunity to optimize DOAC use (including dose change, antiplatelet therapy de-prescription, or other DOAC therapy management issue) in one-third of individuals on these therapies.²¹

The development of digital dashboards provides the promise of a more efficient platform for DOAC oversight. The Veterans Health Administration (VHA) created the DOAC Population Management Tool, which captures all patients prescribed DOACs across >170 medical centers and >1000 outpatient clinics. This tool has allowed the VHA to transition from one-on-one provider-to-patient anticoagulation monitoring to a population-based management approach.^22,23 By responding to clinical “flags” for at-risk patients, providers are able to focus efforts on individuals requiring intervention for DOAC optimization, which has significantly improved practice efficiency and decreased inappropriate DOAC dosing. Barriers to system-level dashboard development and implementation include data quality, tool usability, perceived value to end-users and leadership, and – most notably – the lack of a regulatory mandate for anticoagulation stewardship.²⁴

1.3. Return to Case 1:

In this case, a cardioembolic stroke occurred in the setting of inappropriate under-dosing of apixaban at 2.5mg twice daily. Rather than correct the apixaban dose to 5mg twice daily, warfarin was prescribed, which is associated with an increased risk of bleeding. Aspirin was also inappropriately added, and there was no consideration of a PPI once added. As a likely collective result of these changes, a bleeding event occurred. If anticoagulation stewardship efforts had been in place, such as a dashboard monitoring DOAC prescribing, the patient’s initial apixaban dose could have been corrected and potentially avoided these subsequent complications.

Case 2:

A 52-year-old female with diffuse large B-cell lymphoma receiving chemotherapy was admitted for febrile neutropenia. On admission, her platelet count was 210×10⁹/L, hemoglobin 8.8 g/dL, white blood cell count 0.8×10⁹/L, and absolute neutrophil count 350/uL. She was started on antibiotics as well as VTE prophylaxis with enoxaparin 40mg once daily. She had not been exposed to heparin in the past 3 months. On hospital day 2, platelets declined to 109×10⁹/L. The patient’s providers were concerned for HIT, so they ordered a screening immunoassay and switched from enoxaparin prophylaxis to therapeutic intravenous bivalirudin while awaiting the results. The immunoassay was reported as positive (optical density 0.7), so a confirmatory serotonin release assay (SRA) was sent and bivalirudin continued. Two days later, while awaiting the SRA result, the patient developed hemorrhagic shock from a retroperitoneal bleed. The SRA subsequently returned negative.

2.1. Diagnosis and management of heparin- induced thrombocytopenia (HIT):

HIT is an immune-mediated adverse drug event that occurs when antibodies develop against the platelet factor 4 (PF4)/heparin complex resulting in platelet activation and consumption as well as potentially life-threatening thromboses.²⁵ Although HIT is a rare complication of heparin exposure, the large population of hospitalized patients treated with heparin and the severity of untreated HIT makes prompt and accurate diagnosis a common challenge.

HIT diagnosis requires a stepwise approach that includes an initial assessment of the pre-test probability with a standardized scoring tool, most often the 4Ts Score. If the 4Ts Score indicates an intermediate or high risk of HIT, an immunoassay is the recommended next step to detect the presence of anti-PF4/heparin antibodies. If positive, a functional assay is then used to confirm the ability of the anti-PF4/heparin antibody to activate platelets.²⁶ This stepwise diagnostic algorithm exists due to the limitations of laboratory testing; immunoassays are sensitive but not specific while functional assays are specific but often require multiple days to obtain results from an external reference laboratory.

In addition to this diagnostic complexity, anticoagulation management introduces additional challenges in HIT care. For example, if a 4Ts Score indicates an intermediate or high risk of HIT, guidelines recommend initiation of non-heparin anticoagulation while laboratory results are pending (example anticoagulants include intravenous (IV) direct thrombin inhibitors (DTIs), oral factor Xa or thrombin inhibitors, or fondaparinux).²⁶ For patients with a high bleeding risk previously on prophylactic dose anticoagulation, transitioning to full dose anticoagulation will further increase the risk of bleeding. In addition, for patients awaiting complex surgery or cardiovascular procedures requiring heparin, management may require procedural delay, use of an alternative anticoagulant intraoperatively, and/or the use of adjunctive therapies such as plasma exchange and/or potent antiplatelet agents.

2.2. Anticoagulation stewardship for suspected and confirmed HIT:

Due to the complexity of HIT diagnosis and management, clinicians have attempted a range of stewardship interventions to optimize care, but making durable improvement has proven difficult.²⁷ Example interventions range from the development of electronic clinical decision support tools²⁸ to consultation on patients with suspected HIT in real time.^29–31 Stewardship programs have also targeted different steps along the timeline of HIT; some at the time of assay ordering,³² some at the time of screening assay positivity,^31,33 and some at the time of DTI ordering.^29,30 McGowan and colleagues even attempted to decrease HIT incidence by decreasing unnecessary exposure to heparin hospital-wide.³⁴

Anticoagulation stewardship programs have demonstrated meaningful care improvement of both suspected and confirmed HIT. For example, one institution reported how the use of a stewardship service successfully decreased the use of IV DTIs.^29,35 Stewardship pharmacists reviewed all screening assays to facilitate timely cessation of DTIs after a negative result. Also, the pharmacists promoted timely transition from IV DTIs to oral anticoagulation for individuals with confirmed HIT. In addition to decreasing potential harm related to IV DTIs, this intervention led to an estimated $225–250,000 annualized cost savings. Other programs have similarly demonstrated decreased overall DTI use, and median length of hospitalization in patients with confirmed HIT.^31,36

2.3. Return to Case 2:

The patient had a 4Ts Score of 1, indicating a low risk of HIT, so laboratory evaluation was not required. Nevertheless, the screening assay was obtained and raised concern for HIT. Because of the long turn-around time of the SRA, the patient was continued on unnecessary therapeutic IV DTI for multiple days, which contributed to a catastrophic bleeding event. If anticoagulation stewardship efforts had been in place, unnecessary HIT testing could have been cancelled or a pharmacist-led oversight of DTI use could have prompted a recommendation to stop this anticoagulant, with both actions potentially avoiding this patient’s bleeding complication.

Case 3:

A 65-year-old male with atrial fibrillation (CHA₂DS_2-VASc score 3) on warfarin for the past 5 years is due for a screening colonoscopy. He is deemed to be at average risk of colon cancer, with negative screening colonoscopies at ages 45 and 55, neither requiring polypectomy. The periprocedural anticoagulation plan was to hold warfarin for 5 days and bridge with therapeutic enoxaparin (1mg/kg twice daily) before and after the procedure. The patient developed a nosebleed 1 day prior to the colonoscopy, requiring an ED visit and resultant delay of his procedure.

3.1. Periprocedural management of anticoagulation:

Amongst individuals on oral anticoagulation, approximately 10% require surgery or invasive procedures each year.³⁷ Expert periprocedural anticoagulation management attempts to optimize the balance of thrombotic and bleeding risk by considering risk features unique to the patient, the procedure, and the anticoagulant.

Periprocedural management of warfarin requires specific consideration of the role for “bridging,” a term that refers to the use of an alternative anticoagulant during the period of warfarin cessation. The role for bridging has been debated for many years in the medical literature, but evidence-based guidelines increasingly recommend against bridging except in rare scenarios including some individuals with mechanical heart valves, or a recent thromboembolic event.¹⁵

Periprocedural management of DOACs is much simpler, as their rapid onset, shorter half-life, and lack of a prothrombotic initiation period avoids the question of the need for bridging. However, barriers to DOAC use remain and warfarin use is still prevalent.³⁸ In addition, warfarin remains the preferred anticoagulant in specific patient populations, including those with mechanical heart valves, antiphospholipid syndrome, and atrial fibrillation in the setting of rheumatic heart disease. Therefore, knowledgeable periprocedural management of warfarin remains an essential part of clinical practice.

Importantly, not all procedures require anticoagulation cessation. Guidelines recommend continuing anticoagulation uninterrupted for low-risk endoscopic procedures (including diagnostic colonoscopy),^39,40 although this recommendation is not consistently followed due to concern of the potential need for a second procedure if an intra-procedural finding requires a higher bleeding risk intervention. Examples of other minor procedures that do not require anticoagulation interruption include dental (e.g., tooth extractions), dermatologic (e.g., excision of basal and squamous cell skin cancers), ophthalmologic (e.g., cataract procedures), and pacemaker/internal cardiac defibrillator implantation.⁴⁰

3.2. Anticoagulation stewardship in periprocedural anticoagulation management:

While many individuals on warfarin are managed within a dedicated anticoagulation clinic, not all are directly managed during the periprocedural timeframe, and most clinics do not include care for individuals on DOACs.⁴¹ In addition, deviation from guideline-based periprocedural warfarin management is common.⁴² One multi-center study reported the use of bridging during warfarin hold times to be misaligned with guideline recommendations 68.2% of the time.⁴³ The simplicity of DOACs was expected to ease the burden of complex periprocedural decision-making, but studies continue to show variation from evidence-based practice in as many as 65% of cases.⁴⁴

Implementation of periprocedural management within anticoagulation clinics has been shown to improve patient safety by reducing deviation from guidelines, providing consistent patient education and messaging, increasing process efficiency, and decreasing cost by reduced ED visits/hospitalizations and procedural delays.⁴⁵ Alternative approaches to the traditional clinic model have also been reported to promote appropriate periprocedural anticoagulation management. The incorporation of telehealth allowed one center to increase access to anticoagulation stewardship expertise without the time, travel, and cost burdens of a traditional in-person visit.⁴⁶ Others have reported the successful development of clinical decision support tools, which can facilitate guideline-based care without requiring contact with a provider with anticoagulation management expertise.^45,47

3.3. Return to Case 3:

Given that a screening colonoscopy is a low bleeding risk procedure, interruption of anticoagulation was not clearly needed. If warfarin was continued and full reversal was deemed necessary, guideline-based care would not have included periprocedural bridging. Therefore, involvement of a guideline-driven anticoagulation stewardship program may have avoided a bleeding complication and procedural delay. Additionally, consultation with an experienced anticoagulation provider may have prompted a transition from warfarin to a DOAC, which could have simplified the periprocedural period, shortened the interruption window, and decreased the patient’s long-term risk of bleeding.

Case 4:

A 27-year-old female presents to clinic for evaluation 1 month after diagnosis of left lower extremity deep vein thrombosis (DVT). She had started a combined hormonal contraceptive (CHC) 3 months prior to her DVT diagnosis. In the ED, her care team discontinued her CHCs and prescribed rivaroxaban. Three days after her diagnosis, she began having a very heavy period, which lasted 2 weeks. Today, her hemoglobin is 7 g/dL with a mean corpuscular volume of 72 fL and a ferritin of 5 ng/mL.

4.1. Menstrual bleeding in individuals on anticoagulation:

CHCs are a known risk factor for VTE, increasing the baseline risk of VTE 2–4-fold. However, they have a plethora of benefits, the most well-known of which include contraception and management of heavy or otherwise abnormal uterine bleeding. As a result, the proportion of patients presenting with CHC-associated VTE who have a history of heavy menstrual bleeding (HMB) is likely higher than the 30% rate in the general population. Among individuals on anticoagulation, prevalence of HMB skyrockets to 70%. Unsurprisingly, a history of HMB is a risk factor for anticoagulation-associated HMB.^48,49

HMB is associated with a number of adverse outcomes including decreased quality of life and iron deficiency with or without anemia, and can be extreme enough to require transfusion or surgical intervention.^50–52 One study of individuals experiencing HMB on rivaroxaban also demonstrated a 5-fold increased risk of recurrent VTE.⁵³ The etiology of this is unclear, but one hypothesis is that individuals hold or skip anticoagulant doses during days of heavy bleeding, leaving them inadequately protected from their underlying thrombotic risk.

A variety of factors can contribute to the risk of HMB in anticoagulated individuals, in addition to a history of HMB as discussed above. This can include choice of anticoagulant, as risk of HMB with rivaroxaban is approximately twice the risk with warfarin or apixaban, while the risk with dabigatran is approximately 30% less than that with warfarin or apixaban.^54,55 Additionally, the common practice of discontinuing CHCs at the same time as initiating anticoagulation results in withdrawal bleeding and reverses the positive impact of the CHCs on menstrual blood losses. Unfortunately, discontinuation often occurs due to provider concern for ongoing thrombotic risk from the CHC, although data support the safety of continuation of CHCs along with anticoagulation.⁵⁶ Furthermore, discontinuation of contraception increases risk of pregnancy in the immediate post-VTE setting, something which most experts recommend against due to the increased risk of VTE/recurrent VTE in pregnancy and the postpartum period.

Unfortunately, failure to assess, or at least document assessment of, menstrual bleeding is common in anticoagulated individuals at risk for HMB.⁴⁹

4.2. Anticoagulation stewardship in menstrual bleeding:

There has unfortunately been a systemic lack of attention to increased menstrual bleeding with anticoagulation, and there is great opportunity to improve care by incorporating consideration of menstrual bleeding into anticoagulation stewardship programs.

The first and easiest stewardship effort to implement, in many places, is inclusion of a prespecified series of questions related to menstruation in history taking at clinic and/or anticoagulation service visits. An example series of questions used by one of the authors is included in Table 2, which can be easily converted into a template for electronic medical record documentation. The most modern definition of/diagnostic criteria for HMB is, “excessive menstrual blood loss that interferes with… quality of life.”⁵⁷ Thus, we incorporate quality of life questions into our assessment. In terms of objective criteria, menses lasting longer than 7 days, changing a pad/tampon more often than every 2 hours, and clots larger than 1 inch (otherwise known as the 7–2-1 rule) are predictive of losses >80mL, the objective definition of HMB.⁵⁸

Table 2:

Template for a complete menstrual bleeding history

Question	Response options
Patient reported heaviness	Amenorrheic/Moderate/Heavy/ Very Heavy
Regular	YES/NO/NA
Average cycle length	*** days
Average days of bleeding	*** days
Intermenstrual bleeding	YES/NO
Preferred menstrual product	Disposable pads/disposable tampons/menstrual cup/menstrual disc/period underwear/adult diapers (add text for absorbency e.g. ultra tampons, overnight pads etc.)
Frequency of changing preferred product	Every *** hours
Doubling up on protection?	YES/NO/NA
Getting up to change protection at night?	YES/NO/NA
Clots larger than an inch/quarter?	YES/NO/NA
History of iron deficiency?	YES/NO
History of anemia?	YES/NO
Does bleeding interfere with work/school?	YES/NO/NA
Does bleeding interfere with social activities?	YES/NO/NA
Do your periods negatively impact your quality of life?	YES/NO/NA
Currently using anything to manage periods	No/Combined hormonal contraceptives/Levonorgestrel IUD/progesterone only pills/Etonogestrel implant/Tranexamic acid/Procedural intervention/Other

Such questioning to identify HMB must also be accompanied by some guidance/management strategies. In many cases, referral to a gynecologist is the most practical intervention, although data support the use of tranexamic acid or switch to dabigatran as potential interventions.⁵⁹ Each institution or center should consider which strategy (treatment or referral) makes the most sense for their patient population and implement this approach for all individuals reporting symptoms of HMB.

Finally, education for patients and providers on reproductive implications of VTE and anticoagulation is a critical component of anticoagulation stewardship. Discussion points include the impact of anticoagulation on expected menstrual losses; what constitutes excessive menstrual losses; potential teratogenicity of anticoagulants; importance of effective contraceptive/pregnancy prevention strategies, particularly in the first 3 months after a VTE event; and the need to resume anticoagulation in the setting of future pregnancy for individuals who discontinue anticoagulation. There is opportunity to build clinical decision support to facilitate these discussions and ensure appropriate management is selected for each patient.

4.3. Return to Case 4:

Multiple factors led to this unnecessary increase in menstrual bleeding and resultant iron deficiency anemia, including the selection of rivaroxaban for anticoagulation and the discontinuation of CHCs at the same time. With an educational intervention from an anticoagulation stewardship program, a complete menstrual bleeding history could have been collected at the time of VTE diagnosis. Furthermore, an alternative anticoagulant could have been selected, and the CHC continued until appropriate follow-up with a gynecologist could be arranged to discuss alternative contraceptive and menstrual bleeding management options.

Conclusion:

In conclusion, anticoagulation stewardship is necessary to address the current and growing risk of medication-related harm associated with anticoagulation use. The 4 presented cases highlight the breadth of challenges anticoagulant-prescribed individuals may face, and how stewardship programs must adapt to address each need. Importantly, these examples are only a small sampling of the opportunities for stewardship, with many other published successes reported in the literature.⁶⁰ With adoption and expansion across health systems, anticoagulation stewardship programs can ensure optimal care for the sizeable anticoagulated population.

Table 3:

Published examples of anticoagulation stewardship, focused on either a specific anticoagulant or a specific clinical scenario

		Example anticoagulation stewardship effort
By anticoagulant	Warfarin	Daily pharmacist consultation with warfarin initiation in hospitalized patiets61
	DOACs	Centralized DOAC clinic18,62,63 and order review21,64
		Creation of “digital dashboards”24,65,66
	IV DTIs	Centralized review of IV DTI orders29–31
	Heparins	Hospital-wide efforts to decrease unnecessary UFH use34
		Nurse-managed heparin infusions (with EMR-based dose calculator) with regular audits to identify areas for improvement67
	Concurrent antithrombotic therapy	Centralized screening for inappropriate aspirin in patients on anticoagulation20
	Hemostatic agents	Creation of criteria for use and revised dosing strategy for antithrombin concentrate67,68
		Centralized approval of all PCC orders69
By scenario	Periprocedural	Clinical decision support tools45,47
	Anticoagulation reversal	Pharmacist-led anticoagulation reversal program, available 24/770,71
		Fixed-dose PCC for warfarin and DOAC reversal67
	Care transitions	Pharmacist-led anticoagulation transition at hospital discharge72

DTI, direct thrombin inhibitor; DOAC, direct oral anticoagulant; EMR, electronic medical record; IV, intravenous; PCC, prothrombin complex concentrate; UFH, unfractionated heparin