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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.

slide3

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

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

Evaluate your patient mix/indications

antithrombosis services risk reduction clinics
Antithrombosis ServicesRisk 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 ?
  • 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
antithrombosis services
Antithrombosis Services
  • 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 ?

YES!!!

Antithrombosis

Risk Reduction

Services

Warfarin/Coumadin

Clinics

ac management the road ahead

Thromboembolic

Highway

AC Management: The Road Ahead

Disease Management

Warfarin Management

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