Taking a Look at Anticoagulant Use in the PACE Environment

Anticoagulants are common medications in the PACE environment and are used to prevent blood clots from forming in the body. Popularly known as “blood thinners,” these medications require serious scrutiny from medical personnel when making decisions about care and other medications for PACE participants. Normally, blood clotting is an essential function of the body to protect itself against excessive bleeding in the event of an injury. In other circumstances, though, blood clots can become a dangerous threat to health and well-being if they travel through the blood vessels to the heart, lungs, or brain. Therefore, anticoagulants are typically used in the PACE environment for participants who suffer from:

  • Atrial fibrillation
  • Endocarditis
  • Mitral stenosis
  • Previous blood clots

Also, participants in the PACE environment who have had a synthetic heart valve implanted or received knee or hip replacement are generally on some form of anticoagulant. Let’s take a look at how and why anticoagulants are used within the PACE environment—and examine the risks and benefits.

The Role of Anticoagulants in the PACE Environment

Every year in the United States, approximately 900,000 people suffer a pulmonary embolism or deep vein thrombosis, resulting in 100,000 deaths. At least 25 percent of individuals who suffer a pulmonary embolism die suddenly without any warning symptoms. Men and women who are at a higher risk for blood clots include those who have atherosclerosis, diabetes, heart failure, irregular heart rates, immobility, obesity, and malignancy. Prescribing anticoagulants following an initial blood clot is vital, considering 30 percent of those who have a blood clot will have another clotting incident within ten years. Half of blood clots occur during or soon after surgery or a hospital stay. Many within the PACE environment display one or more risk factors for forming blood clots. [Tweet “#Anticoagulant use is common in the #PACE environment, but it requires some careful considerations.”]

Anticoagulants in the PACE Environment

Although anticoagulants are commonly called “blood thinners,” they do not make the blood thinner. They serve a dual purpose of:

  • Preventing new or additional blood clots from forming
  • Dissolving existing blood clots in the body

Anticoagulants defeat blood clots by reducing the blood’s ability to clot, either by inhibiting vitamin K or by stopping other clotting factors from operating.

While this is good news for eliminating clots or reducing their risk, it raises the risk of prolonged bleeding should a person suffer a cut or nick. This is the primary risk and unwanted side effect of anticoagulants.

Anticoagulants are available as either oral or injectable products. Oral medications are generally used for ongoing prophylaxis in the outpatient setting for easier administration.

A benefit of the new oral therapies in the PACE environment is they do not require routine blood monitoring. Injectable products are typically used more at the beginning of therapy, especially when treating an existing clot.

In recent years, several new oral anticoagulation therapies were approved by the FDA—Eliquis® (apixaban), Pradaxa® (dabigatran), Savaysa® (edoxaban), and Xarelto® (rivaroxaban). These anticoagulants defeat blood clots by inhibiting thrombin (Pradaxa) or factor Xa (Eliquis, Savaysa, and Xarelto).

The above medications are short-acting compared to warfarin (Coumadin®). So, if therapy is missed, interrupted, or irregular, there is a risk for breakthrough strokes.

If regular therapy is a concern, these medications may not be the best option within the PACE environment, and warfarin may be the likely anticoagulant of choice.

As mentioned above, while the desired results of anticoagulants are admirable and desired, the most undesirable effect is an increased risk for prolonged bleeding. While administering vitamin K has a reversing effect for the anticoagulant warfarin, others do not have reversing agents.

An interest certainly exists for developing reversal agents for the other mentioned products, but none are available at this time.

When switching to warfarin from Eliquis, Pradaxa, Savysa, or Xarelto, those in the PACE environment will need to continue current anticoagulant therapy in addition to the warfarin until their INR reaches effective levels. This should take about five days.

With Pradaxa, medical professionals recommend stopping therapy after one to two days on warfarin, so long as renal function is normal. If renal function is impaired, wait until day three to stop administering Pradaxa.

PACE participants have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.

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