Clinical Tools

Clinical Tools for Providers

These clinical tools have been put together to help guide decision making.

  1. Determine stroke and bleeding risk: It is important to first determine the risk of stroke and bleeding in your patient with atrial fibrillation to determine if therapy with anticoagulation is appropriate.

Tools for assessing risk

  1. Specific considerations for your patient: When determining which anticoagulant is best for your patient it is important to keep the following in mind:

Chronic Kidney Disease:  Calculate the patients Creatinine Clearance (CrCl)

CrCl < 25 to 30ml/min: generally recommend warfarin therapy
CrCl 30-49 ml/min: Consider Rivaroxaban 15mg daily or apixaban 5mg twice daily (use the 2.5mg lower dose if two of the following are present: age >80 years, body weight <
60kg, creatinine > 1.5mg/dl
CrCl > 50ml/min: All choices are appropriate

Patients with recurrent gastrointestinal (GI) bleed: As seen in the figure on the clinical trials overview page, dabigatran and rivaroxaban had higher rates of GI bleeding when compared to warfarin. For apixaban, there was no difference in GI bleeding compared to Warfarin. So in patients who have difficulty with recurrent GI bleeding, it would be reasonable to consider apixaban until more data are available with the other agents

Elderly Patients: Given lower rates of intracranial hemorrhage in the clinical trials, these drugs may be attractive options for this population. Patients over the age of 75 years were well represented in the trials. Treatment benefits were consistent for all the drugs with the one exception being with 150mg of dabigatran. With this dose there was relatively more bleeding than with warfarin. For apixaban, the benefits of the drug was consistent in a population >80 years. Thus novel agents, with the exception of dabigatran at the 150mg dose, are a good option in patients over 75.

Patients on aspirin and antiplatelet therapy (triple therapy): Review indication for aspirin and/or other antiplatelet agent. If possible avoid triple therapy. If both aspirin and P2Y12 inhibitor are both indicated, use triple therapy for the shortest time possible. Double check aspirin is low dose aspirin. Recommend use of proton pump inhibitor during time of triple therapy.

Recommend using clopidogrel rather than prasugrel or ticagrelor.

Cost of medication/Patient barriers: Always consider cost and other barriers that may interfere with therapy e.g. transportation to INR clinics for warfarin INR monitoring or cost of the newer anticoagulants.

  1. How to manage patients on anticoagulation: These two tools are meant to inform providers who are managing patients taking anticoagulation around the time of procedures or if they present with bleeding.

Procedure Advisor: Recommendations at Duke for invasive and non-invasive procedures

Bleeding Advisor: How to manage a patient who presents with bleeding while taking one of these medications

Clinical Guide for Use of Oral Anticoagulants