Economic evaluation of prescribing conventional and newer oral anticoagulants in older adults.

INTRODUCTION: Anticoagulants refer to a variety of agents that inhibit one or more steps in the coagulation cascade. Generally, clinical conditions that require the prescribing of an oral anticoagulant increase in frequency with age. However, a major challenge of anticoagulation use among older patients is that this group of patients also experience the highest bleeding risk. To date, economic evaluation of prescribing of anticoagulants that includes the novel or newer oral anticoagulants (NOACs) in older adults has not been conducted and is warranted. Areas covered: A review of articles that evaluated the cost of prescribing conventional (e.g. vitamin K antagonists) and NOACs (e.g. direct thrombin inhibitors and direct factor Xa inhibitors) in older adults. Expert commentary: While the use of NOACs significantly increases the cost of the initial treatment for thromboembolic disorders, they are still considered cost-effective relative to warfarin since they offer reduced risk of intracranial haemorrhagic events. The optimum anticoagulation with warfarin can be achieved by providing specialised care; clinics managed by pharmacists have been shown to be cost-effective relative to usual care. There are suggestions that genotyping the CYP2C9 and VKORC1 genes is useful for determining a more appropriate initial dose and thereby increasing the effectiveness and safety of warfarin

Anticoagulation control of pharmacist-managed collaborative care versus usual care in Thailand

Objective There has been a lack of evidence of the effects of pharmacist-managed warfarin therapy (PMWT) in developing countries (e.g. Southeast Asian countries) where the patients' characteristics, genetic make-up, clinical practice and healthcare system are different from the Western world. This study aimed to compare the anticoagulation control and clinical outcomes associated with warfarin therapy provided by PMWT to usual care (UC) in the Thai population. Setting A 1,000-bed tertiary-care hospital in Nakornratchasima province of Thailand. Method A quasi-experimental study comparing PMWT and UC in patients receiving long-term warfarin therapy. For PMWT group, clinical pharmacists optimised the warfarin therapy and suggested recommendations (e.g. dose adjustment, safer alternative drugs, and follow-up time) to physicians. The UC group received the standard care. Main outcome measure Time in therapeutic range (TTR), both actual- and expanded-TTR, bleeding and thromboembolic complications, and physician' acceptance of pharmacist suggestions. Results Of 433 patients enrolled, 220 and 213 were in the PMWT and UC groups respectively. At baseline, patient's characteristics of both groups were comparable. At the end of follow-up period, patients in the PMWT group had significantly higher actual-TTR (48.3% vs. 40.1%; P < 0.001) and expanded-TTR (62.7% vs. 53.9%; P < 0.001) compared to those in the UC group. Rates of major bleeding were 4.4 vs 4.5 events per 100 person-years for the PMWT and UC groups, respectively. Pharmacists performed 284 interventions with an acceptance rate of 80.3% from physicians. Conclusion Pharmacist-managed warfarin therapy resulted in a significantly better anticoagulation control. This study showed that a collaborative approach in anticoagulation management can be successfully implemented in a developing country. Implementation of such care model in other developing countries should be considered