Table 2.
Rationale for pharmacist interventions
| Intervention category | Subcategory | Reasons for intervention | n (%) | Examples of interventions made by pharmacists |
|---|---|---|---|---|
| Quantity of drug, 26.5%, n = 182 | Dose change | Age | 38 (16.7) |
Rivaroxaban dose reduced to 15 mg OD as recorded GFR 29 (CrCl 49) Edoxaban dose increased to 60 mg OD as eGFR improved (GFR 62, CrCl > 50 ml/min) Changed from dabigatran 150 mg to 110 mg to match medicines reconciliation |
| Renal function | 67 (29.4) | |||
| Weight | 41 (18.0) | |||
| Adverse effect (bleeding) | 2 (0.9) | |||
| Pre-admission dose | 9 (3.9) | |||
| Indication/per guidelines | 30 (13.2) | |||
| To match medicine reconciliation | 10 (4.4) | |||
| Not specified | 31 (13.6) | |||
| Total | 228* | |||
| Change schedule | Total | 1 | Apixaban timings altered so patient wouldn’t miss a day of treatment | |
| Change duration of treatment | Per guidelines | 7 (46.7) | Apixaban duration of loading dose corrected to 7 days | |
| Not specified | 8 (53.3) | |||
| Total | 15 | |||
| Pharmacological strategy, 38.1%, n = 262 | Drug change | Interaction | 7 (12.7) |
Interaction between voriconazole and apixaban. Patient to be switched to warfarin Advised doctor that apixaban less effective if weight > 120 kg, warfarin more suitable Apixaban switched to enoxaparin due to swallowing issues Tinzaparin switched to edoxaban to improve compliance post-discharge |
| Surgery | 3 (5.5) | |||
| More effective option available | 2 (3.6) | |||
| Renal function | 7 (12.7) | |||
| Per history (Hx) | 6 (10.9) | |||
| Dysphagia | 2 (3.6) | |||
| Aid compliance | 1 (1.8) | |||
| Not specified | 27 (49.1) | |||
| Total | 55 | |||
| Change administration | Dysphagia | 4 (66.7) | Rivaroxaban paused due to dysphagia. Advised that the patient could continue, crush and disperse in water | |
| Other | 2 (33.3) | |||
| Total | 6 | |||
| Start/restart medication | Pre-admission | 25 (18.5) |
Proposed pre-admission dabigatran Proposed rivaroxaban to start 72 h post-surgery as per procedure Newly diagnosed AF. Team to consider starting apixaban + anticoagulation referral |
|
| Discharge | 30 (22.2) | |||
| Post-procedure | 9 (6.7) | |||
| Diagnosis | 10 (7.4) | |||
| Post-scan | 4 (3.0) | |||
| Not specified | 57 (42.2) | |||
| Total | 135 | |||
| Medication paused | Surgery | 9 (31.0) |
Advised to stop edoxaban for 24-48 h prior to surgery Apixaban was being withheld as patient has a subdural haematoma Patient at high risk of falling—apixaban paused |
|
| Reduced renal function | 5 (17.2) | |||
| Active bleeding | 3 (10.3) | |||
| Fall risk | 2 (6.9) | |||
| Vomiting | 1 (3.4) | |||
| Not specified | 9 (31.0) | |||
| Total | 29 | |||
| Discontinue medication | Interaction | 1 (3.4) |
Asked doctor to remove Ibuprofen from TTO due to high risk of bleeding with Apixaban Apixaban stopped due to small subarachnoid haemorrhage Rivaroxaban stopped due to risk of falls |
|
| Duplicate therapy | 3 (10.3) | |||
| Active bleeding | 4 (13.8) | |||
| Bleeding risk | 2 (6.9) | |||
| Fall risk | 1 (3.4) | |||
| Renal impairment | 3 (10.3) | |||
| Not indicated | 3 (10.3) | |||
| Not specified | 12 (41.4) | |||
| Total | 29 | |||
| Monitoring | Interaction | 3 (37.5) |
Apixaban needs reviewing, patient’s LFTs not within range – Doctor to monitor Advised GP to review renal function in one week’s time to check GFR |
|
| Liver impairment | 1 (12.5) | |||
| Monitor renal function | 1 (12.5) | |||
| Intolerance | 1 (12.5) | |||
| Other | 2 (25.0) | |||
| Total | 8 | |||
| Patient education, 14.5%, n = 100 | Enhance compliance | Change dosing regime | 1 (50.0) | Advised to see if switching from apixaban 10 mg OD to rivaroxaban is an option to help with compliance without imposing a risk |
| Patient refusal to take medicine | 1 (50.0) | |||
| Total | 2 | |||
| Newly initiated | Diagnosis | 3 (15.8) | Conversation with patient about change from apixaban to edoxaban, patient thought 60 mg (edoxaban) was too high a dose in comparison to 5 mg (apixaban) | |
| Drug change | 2 (10.5) | |||
| Not specified | 14 (73.7) | |||
| Total | 19 | |||
| General counselling | Total | 79 | ||
| Documentation, 9.7%, n = 67 | Update drug record | Document end date | 1 (6.3) | Informed doctor of patient’s regular medications to be charted, including apixaban |
| Amend drug | 2 (12.5) | |||
| Amend dose | 4 (25.0) | |||
| Drug missing from chart | 5 (31.3) | |||
| Other | 4 (25.0) | |||
| Total | 16 | |||
| Update discharge letter | Drug change | 4 (30.8) | Discharge letter needed to be updated to include that warfarin has been switched to apixaban | |
| Amend dose | 3 (23.1) | |||
| Other | 6 (46.2) | |||
| Total | 13 | |||
| Indication | Total | 23 | Confirmed indication for apixaban as not clearly documented in the discharge letter | |
| Thrombosis assessment update | Total | 15 | Thrombosis assessment—contraindication to enoxaparin as patient on rivaroxaban | |
| Other, 11.2%, n = 77 | Book follow-up appointment | Total | 5 | Advised doctor that the patient was new to apixaban and will need anticoagulation appointment referral on discharge |
| Check dose | Doesn’t comply with guidelines | 4 (18.2) | Queried why lower dose of apixaban prescribed as patient did not meet criteria for dose reduction in AF | |
| Subtherapeutic | 7 (31.8) | |||
| Renal function | 4 (18.2) | |||
| Other | 7 (31.8) | |||
| Total | 22 | |||
| Consult prescriber | Rational for drug change | 2 (4.0) |
Queried with the doctor about restarting rivaroxaban as bleeding has settled Discussed with doctor about restarting apixaban—renal function shows slight improvement |
|
| When to restart drug | 14 (28.0) | |||
| Rational for drug choice | 4 (8.0) | |||
| Rational for drug discontinuation | 3 (6.0) | |||
| Rational for duplicate therapy | 12 (24.0) | |||
| Query drug duration | 1 (2.0) | |||
| Review plan | 14 (28.0) | |||
| Total | 50 |
*The total number of reasons for dose change does not equal the number of dose change intervention cases (n = 166) due to multifactorial rationale (i.e., dose change for one patient due to both age and weight); AF atrial fibrillation, GFR glomerular filtration rate, GP general practitioner, LFTs liver function test, OD once daily’ TTO to take out (prescriptions)