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Dr. Barnes: 
Hello, my name is Geoffrey Barnes, I'm at the University of Michigan. We're going to talk about ongoing oral anticoagulation management strategies.

Let's start with a clinical case. Imagine if you will, a 64-year-old woman who's diagnosed with a low risk of acute pulmonary embolism. She’s started on apixaban 10 mg twice a day in the emergency department and then referred to your clinic for follow-up. And so, the question you may be asking yourself at this point is: What kinds of follow-up are needed for her anticoagulation regimen?

So, there's a couple things that we should consider when we have that first follow-up for any patient prescribed an anticoagulant. One of the questions I always ask is: Can the patient actually obtain the medication that was prescribed? Next, we want to make sure our patient is taking the medication as it was initially prescribed and to make sure that prescription is appropriate. And then of course, we want to make sure we're avoiding any of those medication-related side effects, specifically bleeding side effects.

Now, whenever we use an oral anticoagulant for the treatment of an acute venous thromboembolic event, we have to pay special attention to the dosing because that dosing and frequency will change during the course of treatment. If you're using an oral-only strategy, that's the strategy most commonly used for both apixaban and rivaroxaban, we know that there's a higher total daily dose for the initial management, that's the first 7 to 21 days of therapy. And then we go to our standard treatment for the primary treatment phase in those first 3 to 6 months. So, if you're prescribed apixaban, initially, that's going to be 10 mg twice a day for 7 days. It then will drop down to the primary treatment dose of apixaban 5 mg twice a day, and we'll continue that for 3 to 6 months. If on the other hand, you're using rivaroxaban, the initial treatment dose there is 15 mg twice a day for 21 days, and then it switches over to the standard dose of rivaroxaban 20 mg once a day for that full 3- to 6-month period. Now, some people might be using a parenteral lead-in with enoxaparin or unfractionated heparin and then switching to one of the other oral agents like dabigatran, edoxaban, or warfarin, and you need to make sure those transitions are happening appropriately as well. Of course, there may be a future dose change after 3 to 6 months in patients who are using either apixaban or rivaroxaban, and in those cases, some patients will drop to a half-dose therapy for long-term or secondary prevention.

Now, what should we do to try and prevent any drug-related complications? Well, one thing we want to think about is one of the most common complications and that's a nosebleed or epistaxis. It's really important to warn patients about this and encourage them to do preventative measures like saline sprays and even putting some Vaseline in the nose. We also know that GI bleeding can be a common and serious complication of being on anticoagulation therapy. So, if patients have to take multiple anti-thrombotics, think about prescribing them a proton pump inhibitor to reduce their risk of upper GI bleeding.

Now, if they experience a bleeding event while on an anticoagulant, it's important we help manage them through it. So, for instance, if they're having a nosebleed, talk to them about appropriate strategies for controlling that nosebleed event. And of course, warn them don't stop their anticoagulant medicine without contacting their clinician, because we certainly wouldn't want them to go unprotected against a future thrombotic event.

Now, we have to think about who needs short-term versus long-term anticoagulation therapy, and that's often going to rely on the assessment of their recurrence risk, as well as their assessment of bleeding risk. So, look for things like transient, maybe surgical or medication-related factors, or persistent long-term factors like cancer that may dictate whether people have shorter or longer courses of anticoagulation.

So, if we come back to our case, this was our 64-year-old woman, she had that acute low risk PE. Well, what kinds of appropriate follow-up is needed? First, we need to ensure she's got access to her medication, and because she's on apixaban, we're getting ready for that dose change at day 7. Second, we want to discuss any prevention or treatment strategies that she may need to know about in case there's an anticoagulant-related complication. And then of course, we're going to talk about our short-term versus long-term treatment plans.

Thank you for spending this time with me. I hope this was helpful.

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