220.127.116.11 Atrial fibrillation
For advice on warfarin monitoring during the Covid-19 pandemic, refer to MHRA guidance
Prophylaxis of Stroke and Systemic Embolism in Non-valvular* Atrial Fibrilliation (AF)
|1st choices||Direct Acting Oral anticoagulant (DOAC) /||Dose:|
|Non-vitamin K Antagonist Oral Anticoagulant (NOAC):|
|Apixaban||See table below|
|Dabigatran||See table below|
|Edoxaban▼||See table below|
|Rivaroxaban▼||See table below|
|Warfarin tablets 1mg, 3mg||As per international normalised ratio (INR)|
*Patients with mechanical valves or significant mitral valve stenosis are excluded from this treatment protocol
|Doses of DOACs in renal impairment|
|(reduce dose in renal impairment based on Cockcroft Gault calculation of CrCl. Do not use estimated GFR)|
|≥ 50 ml/min||30-49 ml/min||15-29 ml/min||<15ml/min|
|Apixaban||5 mg twice daily|
Reduce to 2.5 mg twice daily in patients with two or more of the following characteristics:
- Age ≥80 years
- Body weight ≤60kg
- Serum creatinine ≥1.5mg/dL (133 micromoles/L)
|Reduce dose to 2.5mg twice daily||Do not use|
|Dabigatran||Usual dose is 150mg twice daily|
Consider reducing to 110mg twice daily in patients aged 75-80years, or with moderate renal impairment, gastritis/ GORD or at increased risk of bleeding
Always reduce to 110mg twice daily in patients >80 years or if taking verapamil
|Do not use||Do not use|
|Edoxaban||60mg once daily|
Reduce to 30mg edoxaban once daily in patients with one or more of the following clinical factors:
- Low body weight <60kg
- Concomitant use of ciclosporin, dronedarone, erythromycin or ketoconazole
|30mg once daily||Do not use|
|Rivaroxaban||20 mg once daily with food||Reduce dose to 15mg daily with food||Do not use|
- Refer to COMPASS Therapeutic Notes on the management of Atrial Fibrillation 2018
- Refer to NICE CG 180 on the management of AF and NICE TA355 Edoxaban for preventing stroke and systemic embolism in people with non-valvular AF.
- NICE have developed a patient decision aid that can be used in consultations to help patients make informed decisions regarding which anticoagulant option to take.
- Warfarin is mandatory for patients with mechanical prosthetic valves or significant mitral stenosis.
- Warfarin should remain first line in the following circumstances:
- patients with severe renal dysfunction (CrCl<15mL/min)
- patients for whom the ability to reverse the effects or to monitor the extent of anticoagulation is paramount (e.g. for adherence or safety reasons)
- Patients at extremes of body weight (i.e. <50kg or >120kg) have been under-represented in the DOAC clinic trials and warfarin may be considered preferable. Refer to EHRA guidance.
- Calculating creatinine clearance (CrCl) for DOACs:
- CrCl calculators embedded within GP IT systems do not give a reliable estimate of CrCl for the adjustment of DOAC doses and are not recommended
- The use of a web based application such as MDCalc is suggested where actual bodyweight is used to calculate the CG CrCl. If in addition the patient’s height is added the different weight method calculations (modified for body weight) can be seen giving a range of possible values for CrCl. Refer to DOAC dosing in renal impairment SPS guide for further details
- People in whom adherence to medicines is known to be an issue may not be suitable for DOACs. The anticoagulant effect of DOACs fades rapidly 12-24 hours after the last intake. Therefore strict compliance by the patient is crucial for adequate protection. In contrast, the anticoagulant effect of warfarin persists for several days after the last warfarin dose.
- Sub-optimal compliance with warfarin alone is not an indication for changing therapy to a DOAC as many of the causes of non-compliance with warfarin may also result in non-compliance with the newer agents (e.g. alcoholism, chaotic lifestyle, wilful non-compliance).
- Vitamin K (phytomenadione) can be given to reverse the effects of warfarin but takes 6-12 hours to become effective. If rapid reversal of warfarin is required specialist haematological advice on the agreed regional policy should be sought. Also refer to the BNF.
- Specialist haematological advice should be sought regarding strategies for the reversal of the anticoagulant effects of DOACs. An antidote for dabigatran (idarucizumab▼ – hospital only) is now available. An antidote for the factor Xa inhibitors apixaban and rivaroxaban▼ (andexanet alfa) is undergoing NICE assessment. For information on the management of bleeding complications see ‘EHRA Practical Guide to NOAC use in AF’.
- Renal function should be monitored at initiation and at least annually for patients taking DOACs. Ensure any necessary dose reductions are made. Refer to DOAC dosing in renal impairment SPS guide for further details.
- Refer to EHRA guidance (section 4) for information on switching between anticoagulant regimens.
- Clinical Knowledge Summaries provide a comprehensive overview in relation to oral anticoagulation and includes information that patients should be given prior to treatment and monitoring that should be carried out.
- Anticoagulation should not be withheld solely because the person is at risk of having a fall.
- Only warfarin 1mg and 3mg tablets should be prescribed.
- Indication and duration of treatment should be clearly recorded at initiation of treatment, the patient-held anticoagulant treatment booklet should be used. See BNF for details.
- Patients should be warned of the hazards of treatment with anticoagulants. In particular, they should be aware of the need to report symptoms such as bruising. Anticoagulant treatment cards must be carried by patients and can be ordered by e-mailing the HSC Business Services Organisation at firstname.lastname@example.org.
- Dabigatran capsules cannot be crushed or opened and cannot be used in standard compliance aids due to the instability of the drug.
- Guidance on the management of dental patients taking anticoagulants or antiplatelet drugs by the Scottish Dental Clinical Effectiveness Programme (SDECP) has been adopted for use in Northern Ireland and is available at http://www.sdcep.org.uk.
- For advice on warfarin monitoring during the Covid-19 pandemic, refer to MHRA guidance
- A lower initial loading dose of warfarin is recommended in patients aged over 70 years.
- There are many clinically important interactions with warfarin, clinicians are strongly advised to consult BNF before prescribing.
- The MHRA Drug Safety Update June 2020 detailed the risk of serious haemorrhage with dabigatran, rivaroxaban▼ and apixaban,▼ clarified contraindications and reminded healthcare professionals of the need to monitor renal function.
- DOACs are contraindicated in the setting of mechanical (metallic) valves. They may be used in bioprosthetic valves after 3 months post operatively. This is in line with EHRA guidance (see Table 1); recommendations in SPC may differ.
- DOACs are contraindicated in the setting moderate to severe mitral stenosis but may be used with other native valvular disease. (See EHRA guidance 2018, table 1).
- Refer to BNF for full details of cautions, contraindications and interactions with DOACs .