title: Evaluation of dabigatran for appropriateness of use and bleeding events in a community hospital setting.
abstract: BACKGROUND
  Warfarin has been the predominant anticoagulant for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). Its disadvantages are well-known and include a narrow therapeutic index, drug interactions, and the need for frequent monitoring. Dabigatran etexilate, a direct thrombin inhibitor, presents less complexity in prescribing and has emerged as an alternate therapy to warfarin. Although dabigatran does not require routine monitoring, concerns associated with its use include the lack of a reversal agent, complex dose adjustments, and limited guidance to the management of drug interactions.
  
  
  OBJECTIVE
  The goals of this study are to describe and to evaluate the use of dabigatran at a community hospital to identify areas for improvement in its prescribing.
  
  
  METHODS
  This retrospective chart review of patients at a community hospital in St Louis, MO, included patients who received at least 1 dose of dabigatran between December 2010 and June 2012. The appropriateness of dabigatran was evaluated based on recommendations approved by the US Food and Drug Administration for stroke prophylaxis in the setting of NVAF. The composite end point of bleeding included hospital readmission within 1 year of receiving at least 1 dose of dabigatran at the study institution secondary to bleeding, bleeding associated with a decrease in hemoglobin level by ≥2 g/dL or transfusion of ≥2 units of blood, or a notation of bleeding in the patient's medical record.
  
  
  RESULTS
  Of the 458 patients included in the evaluation, 76 (16.6%) patients receiving dabigatran were using an inappropriate regimen of this drug, based on dose and frequency on the first day of therapy of dabigatran or the presence of valvular disease. Many patients (42.3%) received at least 1 dose of a concomitant parenteral anticoagulant. The composite end point for bleeding was reported in 66 (14.4%) patients, including 23 (5%) with confirmed gastrointestinal bleeding.
  
  
  CONCLUSIONS
  High-risk medications such as dabigatran require monitoring of prescribing habits to improve patient safety and outcomes. Various initiatives, such as pharmacist interventions, therapeutic interchanges, and obtaining appropriate patient parameters, can be implemented in the practice setting to ensure the appropriate use of oral anticoagulants and improved patient outcomes.
authors.affiliation: Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, St Louis College of Pharmacy, MO.
authors.forename: Anastasia L
authors.initials: AL
authors.lastname: Armbruster
authors.affiliation: Assistant Professor of Pharmacy Practice, St Louis College of Pharmacy, MO.
authors.forename: Katie S
authors.initials: KS
authors.lastname: Buehler
authors.affiliation: Staff Pharmacist, Walgreens Co, Longview, TX.
authors.forename: Sun H
authors.initials: SH
authors.lastname: Min
authors.affiliation: PGY-1 Pharmacy Resident, Indiana University Health, Indianapolis.
authors.forename: Margaret
authors.initials: M
authors.lastname: Riley
authors.affiliation: Clinical Pharmacy Manager, St Louis University Hospital, MO.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Daly