Anticoagulation therapy is the utilization of medication to prevent the formation of blood clots in the body. Because these medications are common among the senior population, they require careful consideration from medical directors when making decisions about medications for PACE participants. Anticoagulation therapy is commonly utilized in PACE participants who:
- have had a blood clot previously
- have atrial fibrillation
- have a synthetic heart valve
- have had knee or hip replacement therapy
- have mitral stenosis
- have endocarditis
Under normal circumstances, blood clotting is essential to one’s well-being to prevent excessive bleeding when we are cut or injured. Blood clots that form outside of this situation can be very detrimental as they can become dislodged and travel to the brain, heart, or lungs, resulting in stroke, heart attack, or pulmonary embolism.
Medications for PACE Participants: Understanding the Role of Anticoagulants
Individuals who are at a higher risk for blood clots include those who have atherosclerosis, diabetes, heart failure, irregular heart rates, immobility, obesity, and malignancy. Each year 900,000 Americans are affected by either a deep vein thrombosis or pulmonary embolism, resulting in 100,000 deaths annually. Half of blood clots occur during or soon after surgery or a hospital stay. Approximately 25 percent of individuals with pulmonary embolism die without warning. Anticoagulation therapy following an initial incident is important considering 30 percent of people who have a blood clot will have another clotting incident within ten years. While it is known that medications are one of the leading causes of emergency room visits and rehospitalizations, anticoagulation therapy leads the pack of medications that can be attributed to these incidents. [Tweet “PACE participants & anticoagulation therapy: What you should know. #PACEpharmacy”]
How Anticoagulants Work for PACE Participants
Anticoagulation therapy can be used to either dissolve a clot that has already formed in the body or as prophylaxis to either prevent additional clots from forming or to prevent an initial clotting incident in at-risk participants. While anticoagulant medications are commonly referred to as blood thinners, they do not make the blood thinner.
Anticoagulants function to reduce the ability of the blood to form a clot either by inhibiting vitamin K in the body or by directly inhibiting the formation of clotting factors. By affecting the body’s ability to form a clot, anticoagulants can effectively prevent unwanted clots, but unfortunately, can also place a participant at risk for prolonged bleeding, which is the primary unwanted effect of anticoagulation therapy.
Anticoagulant medications are available as either injectable or oral products. Injectable products are generally utilized more at the start of therapy, especially for the treatment of an active clot. Oral medications are generally utilized for ongoing prophylaxis in the outpatient setting for easier administration.
Over the past several years, there have been several new oral anticoagulation therapies approved by the FDA—Eliquis® (apixaban), Pradaxa® (dabigatran), Savaysa® (endoxaban), and Xarelto® (rivaroxaban). These therapies function by inhibiting thrombin (Pradaxa) or factor Xa (Eliquis, Savaysa, and Xarelto), thereby altering clot formation.
While one benefit of the new oral therapies is they do not require routine blood monitoring, there are several other considerations that need to be kept in mind with these medications for PACE participants.
All four of these therapies are short-acting compared to warfarin (Coumadin), therefore, if therapy is missed, interrupted, or not consistent, there is a risk for breakthrough strokes. If adherence is a concern, these medications may not be the best option for the participant, and warfarin therapy may need to be considered.
As mentioned previously, while prolonging the time to form a clot is the primary intent of anticoagulation therapy, the less-than-desirable side effect to this is an increased risk for bleeding, which may be possible with all anticoagulant therapies.
Warfarin has a reversal agent (vitamin K), which can be administered if the blood becomes too thin. Pradaxa has a reversal agent (praxbind) that was recently approved by the FDA; however, its availability is primarily limited to the hospital setting at this time. The other three oral medications—Elquis, Savaysa, and Xarelto—do not currently have a reversal agent on the market. There is an interest in developing reversal agents for these medications, but there are none that are commercially available at this time.
When switching to warfarin from Eliquis, Pradaxa, Savysa, or Xarelto, the participant will need to continue his or her current anticoagulant therapy in addition to the warfarin until his or her INR reaches a therapeutic level. It will normally take about five days for warfarin to reach appropriate levels in the body. With Pradaxa, it is recommended to stop therapy after one to two days on warfarin for participants with normal renal function. If the participant has impaired renal function, wait until day 3 to stop Pradaxa therapy.