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OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic.
Curtis, Helen J; MacKenna, Brian; Walker, Alex J; Croker, Richard; Mehrkar, Amir; Morton, Caroline; Bacon, Seb; Hickman, George; Inglesby, Peter; Bates, Chris; Evans, David; Ward, Tom; Cockburn, Jonathan; Davy, Simon; Bhaskaran, Krishnan; Schultze, Anna; Rentsch, Christopher T; Williamson, Elizabeth; Hulme, William; Tomlinson, Laurie; Mathur, Rohini; Drysdale, Henry; Eggo, Rosalind M; Wong, Angel Yun; Forbes, Harriet; Parry, John; Hester, Frank; Harper, Sam; Douglas, Ian; Smeeth, Liam; Goldacre, Ben.
  • Curtis HJ; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • MacKenna B; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Walker AJ; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Croker R; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Mehrkar A; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Morton C; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Bacon S; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Hickman G; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Inglesby P; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Bates C; TPP, Leeds, UK.
  • Evans D; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Ward T; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Cockburn J; TPP, Leeds, UK.
  • Davy S; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Bhaskaran K; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Schultze A; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Rentsch CT; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Williamson E; Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK.
  • Hulme W; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Tomlinson L; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Mathur R; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Drysdale H; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
  • Eggo RM; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Wong AY; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Forbes H; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
  • Parry J; TPP, Leeds, UK.
  • Hester F; TPP, Leeds, UK.
  • Harper S; TPP, Leeds, UK.
  • Douglas I; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Smeeth L; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
  • Goldacre B; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK ben.goldacre@phc.ox.ac.uk.
Open Heart ; 8(2)2021 11.
Article in English | MEDLINE | ID: covidwho-1523054
ABSTRACT

BACKGROUND:

Early in the COVID-19 pandemic, the National Health Service (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 coprescribed two anticoagulants following a medication change and associated monitoring.

OBJECTIVE:

To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.

METHODS:

With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England.

RESULTS:

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 coprescribing 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. International normalised ratio (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).

CONCLUSIONS:

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 coprescribed 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.
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Full text: Available Collection: International databases Database: MEDLINE Main subject: State Medicine / Warfarin / Blood Coagulation / Practice Patterns, Physicians' / Practice Guidelines as Topic / Drug Substitution / Factor Xa Inhibitors / COVID-19 / Anticoagulants Type of study: Controlled clinical trial / Etiology study / Clinical Practice Guide / Observational study / Prognostic study / Risk factors Limits: Aged / Female / Humans / Male / Middle aged Country/Region as subject: Europa Language: English Year: 2021 Document Type: Article Affiliation country: Openhrt-2021-001784

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Full text: Available Collection: International databases Database: MEDLINE Main subject: State Medicine / Warfarin / Blood Coagulation / Practice Patterns, Physicians' / Practice Guidelines as Topic / Drug Substitution / Factor Xa Inhibitors / COVID-19 / Anticoagulants Type of study: Controlled clinical trial / Etiology study / Clinical Practice Guide / Observational study / Prognostic study / Risk factors Limits: Aged / Female / Humans / Male / Middle aged Country/Region as subject: Europa Language: English Year: 2021 Document Type: Article Affiliation country: Openhrt-2021-001784