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The Anticoagulation Clinic of the Future. Edith Nutescu, PharmD Clinical Assistant Professor Director Antithrombosis Service The University of Illinois at Chicago College of Pharmacy & Medical Center. 1998 First commercially available DTI.

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The anticoagulation clinic of the future

The Anticoagulation Clinic of the Future

Edith Nutescu, PharmD

Clinical Assistant Professor

Director Antithrombosis Service

The University of Illinois at Chicago

College of Pharmacy & Medical Center


Advances in ac therapy in the united states

1998First commercially available DTI

2001First commercially available synthetic factor Xa inhibitor

1940sHeparin available commercially

1993First commercially available LMWH

I N J E C T A B L E A G E N T S

50 Years

1954Warfarin availablecommercially

2005First oral DTI

AC Management Services

Advances in AC Therapy in the United States

1930

1940

1950

1960

1970

1980

1990

2000

2005

O R A L A G E N T S

AC = anticoagulant; DTI = direct thrombin inhibitor; LMWH = low-molecular-weight heparin.


AC CLINICS

N = 1300

Registered


Ams vs usual care
AMS vs. Usual Care

Ansell, et al. Chest 2001; 119:22S-38S


Accp 2001 chapter on ams
ACCP 2001: Chapter on AMS

  • Reviews Models Of Care…Recommends Anticoagulation Clinics Over Usual Medical Care, Grade 1C

Ansell, et al. Managing Oral Anticoagulant Therapy. Chest 2001; 119:22S-38S


Medicolegal considerations ams
Medicolegal Considerations : AMS

“…there is little doubt that practitioners who use the “less effective” system are at higher risk of legal liability…and may be seen by a jury as not having exercised a level of diligence demanded by the risk …to the patient…it will be very difficult to mount a defense sufficient to overcome this charge.”

McIntyre K. Chest 2001; 119:342S (also 1998 Chest suppl)


Anticoagulation clinics affiliations
Anticoagulation Clinics: Affiliations

Ansell et al; AC Forum Survey 2000


Anticoagulation clinics duration of service
Anticoagulation Clinics: Duration of Service

Ansell et al; AC Forum Survey 2000


Anticoagulation services
Anticoagulation Services

ATC

ACC

Warfarin Heparin Antiplatelet Tx LMWH

Others:

GPIIbIIIa

DTIs

Pentasaccharide

Risk Factor Management - CV Risk Reduction: weight loss, lipids, HTN, DM,

smoking cessation



Anticoagulation management services
Anticoagulation Management Services

  • Systematic, organized management of anticoagulation

  • Improved dose regulation

  • Continuous patient education

  • Early identification of potential risk factors for thrombotic or hemorrhagic complications

  • Timely, appropriate intervention to avoid or minimize complications


Disease states indications
Disease States - Indications

  • Atrial Fibrillation

  • Prosthetic Heart Valves

  • Valvular Heart Disease

  • VTE: DVT/PE

  • CVA/TIA

  • PAD/PVD

  • CAD/ACS

  • MI

  • Surgical: orthopedic, transplant, neurosurgery, general, trauma

  • Procedures: colonoscopy, dental, eye, etc.

  • Medical: CHF, cancer, lung disease


Anticoagulation clinics referral indications
Anticoagulation Clinics: Referral Indications

Ansell et al; AC Forum Survey 2000


Patient volume
Patient Volume

  • Small Volume Clinic

    • 150-200 active patients

    • 300 visits/month

  • Mid Volume Clinic

    • 400-500 active patients

    • 750 visits/month

  • High Volume Clinic

    • 500-1000 active patients

    • 1500 visits/month

  • Staffing:

    • 1 FTE/200-300 patients


Anticoagulation clinics size
Anticoagulation Clinics: Size

Ansell et al; AC Forum Survey 2000


Anticoagulation clinics staffing
Anticoagulation Clinics: Staffing

Ansell et al; AC Forum Survey 2000


Anticoagulation services functions roles
Anticoagulation Services: Functions-Roles

  • Patient education

  • Treatment initiation/change

  • LOT, Intensity

  • AC selection

  • Dose adjustment

  • Monitoring; order labs

  • Refills

  • Physical assessment

  • Minimum complications/maximum efficacy: QA

  • Health care provider education

  • Research

  • Formulary, protocols, pathways

  • Reversal of over-anticoagulation

  • Peri-procedure management

  • Patient triage: first line access to healthcare

  • Administrative


Ximelagatran potential initial indications
Ximelagatran: Potential Initial Indications

  • Orthopedic Surgery (THR/TKR)

    • METHRO

    • PLATINUM

    • EXPRESS

  • DVT/PE Treatment

    • THRIVE

  • Atrial Fibrillation

    • SPORTIF


Accp recommended dvt prophylaxis
ACCP Recommended DVT Prophylaxis

Geerts et al, Chest 2001.


Accp recommended treatment of vte
ACCP Recommended: Treatment of VTE

1992I.V. heparin/warfarin Grade A

1995 I.V. heparin/warfarin Grade A

(LMWH used in some centers) ---

  • I.V./S.C. heparin/warfarin Grade A1

    LMWH/warfarin Grade A1

    2001 LMWH/warfarin Grade A1 I.V./S.C. heparin/warfarin Grade A1

ACCP, American College of Chest Physicians: 2001


Current recommendations stroke prevention in atrial fibrillation
Current Recommendations Stroke Prevention in Atrial Fibrillation

RISK CATEGORYGOAL INR DURATIONCOMMENT

No risk factors None Chronic ASA 325mg qd

1 moderate risk factor 2.0 - 3.0 Chronic or ASA 325mg qd

> 1 moderate risk factor 2.0 - 3.0 Chronic

or any high risk factor

Moderate Risk Factors: Age 65-75 CAD Diabetes

High Risk Factors Age > 75 HTN Hx TIA/stroke/TE

 LV fxn MV dz valve replacement

ACCP Consensus Conference on Antithrombotic Therapy. Chest 2001; 119 (suppl 1):194-206.


Impact of po dtis
Impact of PO DTIs Fibrillation

Gradual Transition

Warfarin

Ximelagatran

THA/TKA

DVT/PE

Atrial Fibrillation

Other Indications ?

Valves, CVA, PVD, MI


Impact of po dtis on acc volume
Impact of PO DTIs On ACC Volume Fibrillation

Evaluate your patient mix/indications



Antithrombosis services risk reduction clinics
Antithrombosis Services FibrillationRisk Reduction Clinics

ATC

ACC

Warfarin

Antithrombotic Therapy

UFH

LMWH

Anti-Xa

Antiplatelet Agents

PO DTIs

Others


Will ximelagatran eliminate all follow up
Will Ximelagatran Eliminate ALL Follow-Up ? Fibrillation

  • Baseline Education Crucial

    • Disease state

    • Importance of compliance

  • Routine Follow-Up ?

    • Initially q few weeks (esp DVT/PE)

    • Long-term: Q 3-6 months

    • Treatment failures ?

    • Bleeding complications ?

    • Special patient circumstances


UIC Fibrillation


Antithrombosis services
Antithrombosis Services Fibrillation

  • Expertise in “all” antithrombotic agents

  • Risk stratification

  • Patient education

  • Compliance management

  • Special patient populations (high risk patients)

    • Monitoring

  • Disease management

    • Overall risk reduction (CV, stroke, etc.)

  • Guidelines, Pathways, Protocols


Will anticoagulation clinics survive
Will Anticoagulation Clinics Survive ? Fibrillation

YES!!!

Antithrombosis

Risk Reduction

Services

Warfarin/Coumadin

Clinics


Ac management the road ahead

Thromboembolic Fibrillation

Highway

AC Management: The Road Ahead

Disease Management

Warfarin Management


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