Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic

Xiaoye Li, Chengchun Zuo, Wenjing Lu, Ye Zou, Qing Xu, Xiaoyu Li, Qianzhou Lv, Xiaoye Li, Chengchun Zuo, Wenjing Lu, Ye Zou, Qing Xu, Xiaoyu Li, Qianzhou Lv

Abstract

Objective: This study was designed to evaluate the efficacy of remote medication management of rivaroxaban by pharmacists for geriatric patients with nonvalvular atrial fibrillation during the COVID-19 pandemic.

Methods: A single-site, prospective cohort study was conducted among patients with non-valvular atrial fibrillation who received rivaroxaban therapy from July 2019 to December 2019. Patients in the pharmacist-led education and follow-up service (PEFS) group were managed remotely by a pharmacist. In contrast, those in the usual care (UC) group were managed by other providers. Data of routine blood tests, coagulation function tests, which also included cardiac function parameters were collected. The number and type of provider encounters, interventions related to rivaroxaban therapy, the occurrence of thromboembolism or bleeding, and the time of the first outpatient visit after discharge were recorded.

Results: A total of 600 patients were recruited, and results of 381 patients were analyzed in the end, of which 179 patients were from the PEFS group and 202 were from the UC group. There was no significant difference between the two groups in terms of the occurrence ratio of systemic thrombosis, heart failure (LVEF < 40%), and left atrial dilation, which was defined as enlargement of left atrial diameter (LAD) > 40 mm. The cumulative incidences of bleeding complications, such as gastrointestinal tract and skin ecchymosis, were significantly higher in the UC group (12.4% vs. 6.1%, P=0.038; 4.5% vs. 0.6%, P=0.018). There was no significant difference after pharmacist intervention in terms of thrombosis occurrence ratio between the two groups (P = 0.338, HR: 0.722, 95% CI: 0.372-1.405). Remote instruction by a pharmacist reduced outpatient service frequency within the first 30 days after discharge (23.7% vs. 1.1%, P < 0.001). However, more patients in the PEFS group presented for the first outpatient revisit later than 40 days post-discharge (12.8% vs. 21.3%, P < 0.001).

Conclusion: Remote pharmacist-led medication instruction of rivaroxaban could reduce bleeding complications of the gastrointestinal tract and skin ecchymosis and postpone the first outpatient revisit after discharge.

Keywords: corona virus disease 2019; follow-up service; nonvalvular atrial fibrillation; pharmacist-led education; remote medication management; rivaroxaban.

Copyright © 2020 Li, Zuo, Lu, Zou, Xu, Li and Lv.

Figures

Figure 1
Figure 1
Flowchart recruitment procedure of the study.
Figure 2
Figure 2
Survival curve of bleeding ratio (A) and systemic thrombosis ratio (B) for 90-day follow-up between groups.
Figure 3
Figure 3
Anticoagulation interventions categorized by provider type.
Figure 4
Figure 4
Comparison for the first outpatient visit after discharge.

References

    1. Aidit S., Soh Y. C., Yap C. S., Khan T. M., Neoh C. F., Shaharuddin S., et al. (2017). Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care. Front. Pharmacol. 8, 637. 10.3389/fphar.2017.00637
    1. Ashjian E., Kurtz B., Renner E., Yeshe R., Barnes G. D. (2017). Evaluation of a pharmacist-led outpatient direct oral anticoagulant service. Am. J. Health Syst. Pharm. 74 (7), 483–489. 10.2146/ajhp151026
    1. Conti A., Renzi N., Catarzi S., Mazzucchelli M., Covelli A., Pampana A., et al. (2020). Bleeding events in patients aged 75 years and older under long-term anticoagulant therapy: a real-life study. Crit. Pathw. Cardiol. 19 (3), 131–138 10.1097/HPC.0000000000000205
    1. DiRenzo B. M., Beam D. M., Kline J. A., Deodhar K. S., Weber Z. A., Davis C. M., et al. (2018). Implementation and Preliminary Clinical Outcomes of a Pharmacist-managed Venous Thromboembolism Clinic for Patients Treated With Rivaroxaban Post Emergency Department Discharge. Acad. Emerg. Med. 25 (6), 634–640. 10.1111/acem.13311
    1. Fogg A., Staufenberg E. F., Small I., Bhattacharya D. (2012). An exploratory study of primary care pharmacist-led epilepsy consultations. Int. J. Pharm. Pract. 20 (5), 294–302. 10.1111/j.2042-7174.2012.00207.x
    1. Goto M., Miura S., Suematsu Y., Idemoto Y., Takata K., Imaizumi S., et al. (2016). Rivaroxaban, a factor Xa inhibitor, induces the secondary prevention of cardiovascular events after myocardial ischemia reperfusion injury in mice. Int. J. Cardiol. 220, 602–607. 10.1016/j.ijcard.2016.06.212
    1. Hawes E. M., Lambert E., Reid A., Tong G., Gwynne M. (2018). Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home. Am. J. Health Syst. Pharm. 75 (12), 901–910. 10.2146/ajhp170174
    1. January C. T., Wann L. S., Alpert J. S., Calkins H., Cigarroa J. E., Cleveland J. C., Jr., et al. (2014). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 130 (23), 2071–2104. 10.1161/CIR.0000000000000040
    1. Kim H. M., Choi E. K., Park C. S., Cha M. J., Lee S. Y., Kwon J. M., et al. (2019). Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in octogenarian patients with non-valvular atrial fibrillation. PLoS One 14 (3), e0211766. 10.1371/journal.pone.0211766
    1. Kirchhof P., Benussi S., Kotecha D., Ahlsson A., Atar D., Casadei B., et al. (2016). 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur. Heart J. 37 (38), 2893–2962. 10.1093/eurheartj/ehw210
    1. Kirchhof P., Haas S., Amarenco P., Hess S., Lambelet M., van Eickels M., et al. (2020). Impact of Modifiable Bleeding Risk Factors on Major Bleeding in Patients With Atrial Fibrillation Anticoagulated With Rivaroxaban. J. Am. Heart Assoc. 9 (5), e009530. 10.1161/JAHA.118.009530
    1. Li Q., Guan X., Wu P., Wang X., Zhou L., Tong Y., et al. (2020). Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N. Engl. J. Med. 382 (13), 1199–1207. 10.1056/NEJMoa2001316
    1. Liang J. B., Lao C. K., Tian L., Yang Y. Y., Wu H. M., Tong H. H., et al. (2020). Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial. Int. J. Pharm. Pract. 28 (1), 97–106. 10.1111/ijpp.12584
    1. Limone B. L., Hernandez A. V., Michalak D., Bookhart B. K., Coleman C. I. (2013). Timing of recurrent venous thromboembolism early after the index event: a meta-analysis of randomized controlled trials. Thromb. Res. 132 (4), 420–426. 10.1016/j.thromres.2013.08.003
    1. Linkins L. A., Dans A. L., Moores L. K., Bona R., Davidson B. L., Schulman S., et al. (2012). Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141 (2 Suppl), e495S–e530S. 10.1378/chest.11-2303
    1. Mielke N., Huscher D., Douros A., Ebert N., Gaedeke J., van der Giet M., et al. (2020). Self-reported medication in community-dwelling older adults in Germany: results from the Berlin Initiative Study. BMC Geriatr. 20 (1), 22. 10.1186/s12877-020-1430-6
    1. Mifsud E. M., Wirth F., Camilleri L., Azzopardi L. M., Serracino-Inglott A. (2019). Pharmacist-led medicine use review in community pharmacy for patients on warfarin. Int. J. Clin. Pharm. 41 (3), 741–750. 10.1007/s11096-019-00824-4
    1. Motulsky A., Weir D. L., Liang M., Lamy A., Moreault M. P., Schuster T., et al. (2020). Patient-initiated consultations in community pharmacies. Res. Soc. Adm. Pharm. S1551-7411 (19), 30933–30937 10.1016/j.sapharm.2020.03.001
    1. Muniz Lobato S., Tarrazo Tarrazo C., Gonzalez Fernandez E., Moran Alcala M. (2018). Clinical profile, adequacy of dosage and thromboembolic and bleeding outcomes in patients with nonvalvular atrial fibrillation treated with rivaroxaban in a regional hospital of Asturias, Spain. Future Cardiol. 14 (3s), 17–24. 10.2217/fca-2018-0022
    1. Nielsen P. B., Skjoth F., Sogaard M., Kjaeldgaard J. N., Lip G. Y., Larsen T. B. (2017). Effectiveness and safety of reduced dose non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ 356, j510. 10.1136/bmj.j510
    1. Niessen F., Schaffner F., Furlan-Freguia C., Pawlinski R., Bhattacharjee G., Chun J., et al. (2008). Dendritic cell PAR1-S1P3 signalling couples coagulation and inflammation. Nature 452 (7187), 654–658. 10.1038/nature06663
    1. Perlman A., Horwitz E., Hirsh-Raccah B., Aldouby-Bier G., Fisher Negev T., Hochberg-Klein S., et al. (2019). Clinical pharmacist led hospital-wide direct oral anticoagulant stewardship program. Isr. J. Health Policy Res. 8 (1), 19. 10.1186/s13584-019-0285-9
    1. Perzborn E., Roehrig S., Straub A., Kubitza D., Misselwitz F. (2011). The discovery and development of rivaroxaban, an oral, direct factor Xa inhibitor. Nat. Rev. Drug Discov. 10 (1), 61–75. 10.1038/nrd3185
    1. Pickett J. D. (2019). Direct Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation: Update and Periprocedural Management. Crit. Care Nurse 39 (2), 54–67. 10.4037/ccn2019292
    1. Qian X., Ren R., Wang Y., Guo Y., Fang J., Wu Z. D., et al. (2020). Fighting against the common enemy of COVID-19: a practice of building a community with a shared future for mankind. Infect. Dis. Poverty 9 (1), 34. 10.1186/s40249-020-00650-1
    1. Roseau C., Richard C., Renet S., Kowal C., Eliahou L., Rieutord A., et al. (2020). Evaluation of a program of pharmaceutical counseling for French patients on oral anticoagulant therapy. Int. J. Clin. Pharm. 42 (2), 685–694. 10.1007/s11096-020-00964-y
    1. Shore S., Carey E. P., Turakhia M. P., Jackevicius C. A., Cunningham F., Pilote L., et al. (2014). Adherence to dabigatran therapy and longitudinal patient outcomes: insights from the veterans health administration. Am. Heart J. 167 (6), 810–817. 10.1016/j.ahj.2014.03.023
    1. Silverio A., Di Maio M., Prota C., De Angelis E., Radano I., Citro R., et al. (2019). Safety and efficacy of non-vitamin K antagonist oral anticoagulants in geriatric patients with atrial fibrillation. Eur. Heart J. Cardiovasc. Pharmacother. pvz073. 10.1093/ehjcvp/pvz073
    1. Sinigoj P., Vene N., Kosmelj K., Mavri A. (2020). Risk of major bleeding in geriatric patients with atrial fibrillation on direct oral anticoagulants: real world experience. Int. J. Clin. Pharm. 42 (2), 445–452. 10.1007/s11096-020-01008-1
    1. Tsuyuki R. T., Al Hamarneh Y. N., Jones C. A., Hemmelgarn B. R. (2016). The Effectiveness of Pharmacist Interventions on Cardiovascular Risk: The Multicenter Randomized Controlled RxEACH Trial. J. Am. Coll. Cardiol. 67 (24), 2846–2854. 10.1016/j.jacc.2016.03.528
    1. Turner A., Hochschild A., Burnett J., Zulfiqar A., Dyer C. B. (2012). High prevalence of medication non-adherence in a sample of community-dwelling older adults with adult protective services-validated self-neglect. Drugs Aging 29 (9), 741–749. 10.1007/s40266-012-0007-2
    1. Turpie A. G. (2014). Rivaroxaban as an oral anticoagulant for stroke prevention in atrial fibrillation. Ther. Clin. Risk Manag. 10, 197–205. 10.2147/TCRM.S30159
    1. Valencia D. N. (2020). Brief Review on COVID-19: The 2020 Pandemic Caused by SARS-CoV-2. Cureus 12 (3), e7386. 10.7759/cureus.7386
    1. Virdee M. S., Stewart D. (2017). Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention. Int. J. Clin. Pharm. 39 (1), 173–180. 10.1007/s11096-016-0419-x

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa