title: Evaluation of prescribing and patient use of target-specific oral anticoagulants in the outpatient setting.
abstract: OBJECTIVE
  Pharmacist-managed anticoagulation programmes have been shown to improve appropriate use of warfarin, but few programmes have included the new target-specific oral anticoagulants (TSOACs) in their protocols. A greater understanding of TSOAC prescribing, monitoring and administration is needed to identify common errors in the current outpatient practice. The objective of this study is to assess the rate of errors related to prescribing, baseline monitoring and patient administration of TSOACs.
  
  
  METHODS
  A retrospective chart review was conducted to identify patients on TSOAC therapy in each of four outpatient practice sites. Data were abstracted to include TSOAC indication, dosage and frequency prescribed, pertinent past medical history, and laboratory monitoring obtained at the time of TSOAC initiation. In addition, patients were contacted by telephone to assess TSOAC adherence, storage, administration and incidence of adverse events.
  
  
  CONCLUSIONS
  A total of 395 patients were included in the evaluation. Prescribers did not obtain baseline laboratory values within 1 week before or after the time of TSOAC initiation for a majority of study patients. At the time of TSOAC initiation, two patients had abnormally elevated alanine aminotransferase, six had elevated total bilirubin, and 43 had low haemoglobin. A majority (61%) of study patients were prescribed an appropriate TSOAC dose based upon their indication and renal function; however, dosing accuracy could not be determined for all patients as baseline serum creatinine was not obtained by prescribers for 148 patients (37%) at the time of prescribing. TSOACs were dosed inappropriately according to baseline serum creatinine in six patients, and two patients receiving treatment for venous thromboembolism were maintained on a high dose of rivaroxaban for an inappropriate duration. A total of 157 (40%) patients were available by phone and agreed to answer questions regarding their current TSOAC use. Twenty-four patients (23%) reported taking rivaroxaban inappropriately without food, and six patients (14%) endorsed inappropriate storage of dabigatran. Ten patients (6%) reported missing at least one TSOAC dose per week, and 25 (16%) described minor bleeding with their TSOAC.
  
  
  CONCLUSIONS
  Inappropriate prescribing, monitoring and administration of TSOACs occurred frequently in patients not formally enrolled in an anticoagulation monitoring programme. These results indicate a need for more thorough patient education at the time of TSOAC initiation, as well as improved prescriber education regarding recommended TSOAC dosing and monitoring.
authors.affiliation: Department of Pharmacy Practice, University of Charleston School of Pharmacy, Charleston, WV, USA.
authors.forename: J
authors.initials: J
authors.lastname: Simon
authors.affiliation: Department of Pharmacy, UNC Medical Center, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA.|Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC, USA.
authors.forename: E
authors.initials: E
authors.lastname: Hawes
authors.affiliation: Department of Pharmacy, UNC Medical Center, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA.
authors.forename: Z
authors.initials: Z
authors.lastname: Deyo
authors.affiliation: UNC General Internal Medicine, UNC School of Medicine, UNC Eshelman School of Pharmacy, Advanced Practice Provider Center, UNC Health Care, Chapel Hill, NC, USA.
authors.forename: B
authors.initials: B
authors.lastname: Bryant Shilliday
keywords: ambulatory care; anticoagulants; apixaban; dabigatran; factor Xa; rivaroxaban