2.8.2. Oral anticoagulants
Prescribing Notes:
Apixaban is the preferred DOAC
- for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurring DVT and PE in adults.
- for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (NVAF) with one or more risk factors, such as congestive heart failure, hypertension, age 75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA).
Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website
VTE prophylaxis in orthopaedic surgery
The use for the primary prevention of venous thromboembolic events (VTE) in adults undergoing elective hip or knee replacement surgery is non-formulary.
Restrictions:
Restricted to use in accordance with the prescribing notes below
Prescribing Notes:
Prevention of stroke in atrial fibrillation
Use for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation and with one or more risk factors is restricted to:
- newly diagnosed patients
- those currently receiving warfarin who have poor INR control despite evidence that they are complying
- patients with allergy or intolerable side effects from coumarin anticoagulants
- patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate
Risk factors include:
- previous stroke, transient ischaemic attack, or systemic embolism
- left ventricular ejection fraction <40%
- symptomatic heart failure, ≥ New York Heart Association (NYHA) Class 2
- age ≥75 years
- age ≥65 years associated with one of the following: diabetes mellitus, coronary artery disease or hypertension
Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website
Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrent DVT and PE
Use is restricted to patients who fail to tolerate other therapeutic options or where other agents are not appropriate, where the intended duration of treatment is 3-6 months. Where indefinite duration is indicated, the treatment of choice should be or apixaban or low molecular weight heparin followed by warfarin.
VTE prophylaxis in orthopaedic surgery
- The use for the primary prevention of venous thromboembolic events (VTE) in adults undergoing elective hip or knee replacement surgery is non-formulary.
Prescribing Notes:
Second line DOAC for
- the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (NVAF) with one or more risk factors, such as congestive heart failure, hypertension, age 75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA).
- the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurrent DVT and PE.
Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website
Restrictions:
Prevention of stroke in atrial fibrillation
Use for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation and with one or more risk factors is restricted to:
- those currently receiving warfarin who have poor INR control despite evidence that they are complying
- patients with allergy or intolerable side effects from coumarin anticoagulants
- patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate
Risk factors may include: congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischaemic attack.
Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website
Treatment of VTE
- Rivaroxaban for the treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) and prevention of further DVT and PE is restricted to use in patients requiring anticoagulation where the intended duration of treatment is 3 to 6 months and in whom apixaban is deemed unsuitable.
VTE prophylaxis in orthopaedic surgery
- The use in VTE prophylaxis in orthopaedic surgery is restricted to specialist use only in accordance with local protocol.
Use in combination with aspirin in Coronary Artery Disease
- Rivaroxaban co-administered with aspirin for the prevention of artherothrombotic events in adults is restricted to initiation by, or on the advice of a consultant only in patients with stable coronary artery disease that do not require dual antiplatelet therapy.
It should be noted that use of rivaroxaban in combination with aspirin for the prevention of atherothrombotic events in patients with peripheral artery disease (PAD) alone was not considered by SMC and the use in this setting is non-Formulary.
Prescribing Notes:
The following indications are not recommended for use by the SMC and are non-Formulary:
- Acute Coronary Syndrome: The use of rivaroxaban for the prevention of atherothrombotic events in adult patients after an acute coronary syndrome (ACS) with elevated cardiac biomarkers is not recommended for use within NHS Scotland and is therefore non-Formulary.
- Prevention of atherothrombotic events: use of rivaroxaban in combination with aspirin for the in patients with peripheral artery disease (PAD) alone was not considered by SMC and the use in this setting is non-Formulary.
- Atrial fibrillation: rivaroxaban is not included in the Formulary for use in newly diagnosed patients.