OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England

Curtis, HJORCID logo; MacKenna, BORCID logo; Walker, AJORCID logo; Croker, RORCID logo; Mehrkar, AORCID logo; Morton, CEORCID logo; Bacon, S; Hickman, G; Inglesby, P; Bates, CORCID logo; +24 more...Evans, D; Ward, T; Cockburn, J; Davy, S; Bhaskaran, KORCID logo; Schultze, AORCID logo; Rentsch, CTORCID logo; Williamson, EORCID logo; Hulme, WORCID logo; McDonald, HIORCID logo; Tomlinson, LORCID logo; Mathur, RORCID logo; Drysdale, HORCID logo; Eggo, RMORCID logo; Wing, KORCID logo; Wong, AYORCID logo; Forbes, HORCID logo; Parry, JORCID logo; Hester, F; Harper, S; Evans, SJORCID logo; Douglas, IJORCID logo; Smeeth, LORCID logo; Goldacre, BORCID logo and (2020) OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England. MedRxiv. DOI: 10.1101/2020.12.03.20243535
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<jats:sec><jats:title>Background</jats:title><jats:p>Early in the COVID-19 pandemic the NHS recommended that appropriate patients anticoagulated with warfarin should be switched to direct acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately co-prescribed two anticoagulants following a medication change, and associated monitoring.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To describe which people were switched from warfarin to DOACs; identify potentially unsafe co-prescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Working on behalf of NHS England we conducted a population cohort based study using routine clinical data from &gt;17 million adults in England.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>20,000 of 164,000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in co-prescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. INR testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people co-prescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.</jats:p></jats:sec>


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