A CPPE learning programme

New medicine serviceanticoagulantsand antiplateletsAugust 2016

CONTENTSThis programme contains the following sections:

How to use this learning programme

About New medicine service –anticoagulants & antiplatelets

The NMS

Your NMS consultations

Learning objectives

Reflection point

Questions about anticoagulants and antiplatelets

Anticoagulants and antiplatelets

Case studies

Next steps

Programme credits

Thank you for downloading this CPPE learning programme. We hope that you will find it a fun and informative way to help you learn about key points for conducting new medicine service (NMS) consultations with patients taking anticoagulants and antiplatelets.

The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learning opportunities for the pharmacy workforce. We are based in the University of Manchester’s School of Pharmacy and Pharmaceutical Sciences and are funded by the Department of Health to provide continuing education for practising pharmacists and pharmacy technicians providing NHS services in England. http://www.cppe.ac.uk

Learning with CPPE

This document uses interactive features that may not be supported if you are using it on a mobile device. For best results, please use on your PC or laptop, using an up-to-date version of Adobe Reader.

Welcome toNew medicine service – anticoagulantsand antiplatelets

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How to use thislearning programmeThis programme uses an interactive PDF format. You

can navigate your way through by using the arrows in

the bottom right corner of each page. Where directed,

you can also navigate to sections by clicking on text or

images. The programme uses case studies and web

links to help you explore this topic. You will need to be

connected to the internet to access the web links.

In the case studies, there will be space for you to type

answers to the questions. You can save your answers

by saving this document to your computer. You can

also view our suggested answers - these are hidden

behind the Reveal answer text.

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The programme contains four case studies that

highlight significant counselling points in patients who

are taking warfarin or clopidogrel as new medicines.

You will be able to type, save and reveal answers

to the case studies. We would recommend that you

keep notes as you go along as these could be ideal

to generate CPD records.

If you are using a printed version of this programme,

you will not be able to view our suggested answers.

To see these, either open this document on your

computer or download the separate answers

document from the CPPE website.

Please note that you will need your Royal

Pharmaceutical Society registration to access the

Pharmaceutical Journal links used in this programme.

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About New medicine service – anticoagulants and antiplatelets

NHS services are increasingly focused on delivering the

best possible outcomes for patients – the NMS was set up

with this in mind.

Adherence to medicines has been linked with better

patient outcomes.1,2 In delivering the NMS you will be

supporting patients in managing their newly prescribed

medicines. As well as helping them to optimise their

medicines use, the aim is to improve adherence by

engaging patients in shared decision making and providing

them with the knowledge needed to make informed

choices about treatment and self-management.

You will also be contributing to the NHS aim of providing

high-quality healthcare for everyone, a key cornerstone of

the NHS constitution.

1. DiMatteo MR et al. Patient adherence and medical outcomes: a meta-analysis. Medical Care 2002;40(9): 794-811.2. Haynes RB et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008;2: CD000011.

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This programme will provide and signpost you to

key learning to help you conduct effective NMS

consultations. It will provide a record of your learning

of the key points to consider and share with patients

taking anticoagulants and antiplatelets as new

medicines. We estimate that the whole programme

will take you three to four hours to complete.

The first few pages will provide you with learning

to ensure that you can provide an NMS. After

that, we will concentrate on anticoagulants and

antiplatelets, one of the four medicine groups for

which a first prescription qualifies a patient for an

NMS consultation. This programme is part of a series

of interactive PDF learning for the new medicine

service. Other topics include: asthma and COPD,

antihypertensives and type 2 diabetes.

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The NMSBefore you start, make sure that you have completed

enough learning to allow you to complete the

Pharmaceutical Services Negotiating Committee

(PSNC) and NHS Employers’ self-assessment form

to assure yourself, your employer (if appropriate)

and the NHS that you are ready to provide the NMS.

If you need to access the CPPE learning materials

for the NMS and complete the CPPE open learning

programme, you can do so by clicking on the images

of the learning programmes on the left.

The case studies on pages 37 to 54 of this learning

programme assume that you know what questions

are included in the intervention stage of the NMS.

If you’re not sure what these are, view them on the

PSNC website.

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Your NMS consultationsIf you have already worked through this exercise in

other programmes in this NMS series, then move on

to the next section.

Now that the NMS is up and running, what is stopping

you conducting more NMS consultations?

Type your answer in the box below.

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How are you going to overcome these barriers?

Complete the table below by adding the barriers you identified

in the left-hand column and typing in possible solutions in the

right-hand column. There is more space on the next page.

Barriers to the NMS Solutions Barriers to NMS Solutions

No consultation area

No medicines use review

(MUR) accreditation

Too few patients

Not enough experience

A bit scared to approach

patients

GPs are against the idea

Move to a pharmacy that has one. Get one built or installed. Improvise to createa private area.

Get MUR accreditation with CPPE or another HEI provider.

Try advertising or mobilising staff to recognise new medicines at prescription receipt. Contact your local hospital to discuss how they can refer patients to community pharmacy.

You’ve got to start somewhere! Do this learning.

Set up a system so that new medicines are recognised by you or a member of staff and automate it as far as possible. Then TALK to your patient.

Set up a meeting and convince them of the benefits. View the resources on PSNC and CPPE websites, such as the GP detailing card.

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Barriers to NMS Solutions Barriers to NMS Solutions

Another pharmacist nearby does them all

I’m a locum

I don’t know the patientsI see

I don’t have time

Complicated and confusing payment system

There is plenty of opportunity if you get a system set up to recognise new medicines

Then you have more time available to offer these services than employed pharmacists who are concerned with staff and management issues. Help them out and get invited back!

You can soon establish a relationship if you sell patients the benefits of the NMS, even if you don’t complete the three interviews.

Pharmacy staff can do more to free you up to do the services that matter to patients. Mobilise them to do this. Undertake CPPE’s Skill mix e-learning programme.

This has been simplified: you will now receive payment for every NMS conducted. The payment system is explained on the PSNC website.

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Now that we have looked at the NMS in general,

we are ready to move on to anticoagulants and

antiplatelets specifically.

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Learning objectives

The overall aim of this learning programme is

to provide and signpost you to key learning to

increase your confidence in providing effective

NMS consultations for patients newly prescribed an

anticoagulant or antiplatelet medicine.

By the end of this learning programme, you should

be able to:

discuss key issues and provide information regarding

side-effects, interactions and counselling points to

patients taking an anticoagulant or antiplatelet medicine

find key resources to help you plan and complete

NMS consultations for patients taking anticoagulants

and antiplatelets

provide advice for patients taking warfarin and

clopidogrel as a new medicine.

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Which medicines fall into the anticoagulants and

antiplatelets category? Which medicines are you

most likely to see as new medicines in community

pharmacy? Write your answers in the space below.

Reflection point

Anticoagulants and antiplatelets are listed in chapter 2

of the British National Formulary. Oral anticoagulants

include warfarin and phenindione. Four newer agents

are also given orally - apixaban, dabigatran, edoxaban

and rivaroxaban. Antiplatelets include aspirin,

clopidogrel, dipyridamole, prasugrel and ticagrelor.

Warfarin and clopidogrel are frequently prescribed to

members of these groups so we have concentrated on

these drugs in this learning.

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Questions about anticoagulants and antiplateletsLet’s see what you already know before you look at anticoagulants and antiplatelets in more depth. Do you know the answers to the questions below? Reveal our suggested answers to see if you are right.

What are the main uses of anticoagulants?

To prevent formation or growth of a thrombus in the venous circulation and also to prevent stroke secondary to atrial fibrillation.

What is the main use of antiplatelets?

To inhibit thrombus formation in the arterial circulation.

What is used for the management of venous thromboembolism in pregnancy?

Low-molecular weight heparins.

What does international normalised ratio (INR) measure?

It measures how long the patient’s blood takes to clot compared with a theoretical standard patient not on an anticoagulant who would have an INR value of 1.

What is the mode of action of coumarins and phenindione?

To antagonise the effects of vitamin K1.

What is the mode of action of dabigatran etexilate?

To inhibit thrombin directly.

What is the mode of action of apixaban, edoxaban and rivaroxaban?

To inhibit activated factor X (factor Xa) directly.

Give examples of glycoprotein IIb/IIIa inhibitors.

Abciximab, eptifibatide and tirofiban.

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What are the licensed indications of each of thecurrently available newer oral anticoagulants?

Dabigatran 1. Prevention of VTE in adult patients undergoing surgery

2. Treatment of VTE and prevention or recurrent VTE

3. For prevention of stroke and systemic embolism in

patients with non-valvular AF with certain risk factors

Apixaban 1. Prevention of VTE in adult patients undergoing surgery

2. Treatment of VTE and prevention of VTE

3. For prevention of stroke and systemic embolism in

patients with non-valvular AF with certain risk factors

Edoxaban 1. Treatment of VTE and prevention of recurrent VTE

2. For prevention of stroke and systemic embolism in

patient with non-valvular AF with certain risk factors

Rivaroxaban 1. Prevention of VTE in adult patients undergoing surgery

2. Treatment of VTE and prevention or recurrent VTE

3. For prevention of stroke and systemic embolism in

patients with non-valvular AF with certain risk factors

4. Prophylaxis of atherothrombotic events in acute

coronary syndrome.

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Well, how well did you do? You can find more

learning resources with detailed information

on these areas by clicking on the topics on the

following page.

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Anticoagulants and antiplatelets

starting pointproperties

indications monitoring

factors

patient counselling

antiplatelets

consultation tips

patient support

Click on the titles below to reveal more information on that topic. We suggest you begin with ‘starting point’. You will be able to return to this menu by clicking the link at the bottom of the page at the end of each section.

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A good starting pointBefore you get to grips with the key learning and case studies in this e-learning programme you may feel that you need to refresh your knowledge on the medicines, their uses, appropriate doses, side-effects and interactions.

The British National Formulary (BNF) is a good starting point. Here you will find key information, including a quick summary of guidance issued by the National Institute for Health and Care Excellence (NICE) relating to this group of medicines – for example, some of the newer medicines such as apixaban, dabigatran etexilate, edoxaban and rivaroxaban. These newer medicines are often referred to as the DOACs - direct oral anticoagulant agents. If you have not already done so, you will need to register with the BNF website to access the information within.

Click on the BNF logo to access the BNF website, then log on and read through the sections on anticoagulants and antiplatelets.

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Anticoagulants as a group are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital. Because of this, they are the main focus of this programme. The National Patient Safety Agency, which is now part of the NHS Commissioning Board Special Health Authority, developed guidance on actions which can make anticoagulant therapy safer.

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The Pharmaceutical Journal has published a useful overview article looking at uses of oral anticoagulants and oral antiplatelets, choices and monitoring.

There have been several articles published in The

Pharmaceutical Journal and Clinical Pharmacist about

anticoagulation and how the pharmacy team can

support patients taking oral anticoagulants:

Akinwunmi F. Common concerns of warfarin patients.

Pharm J 2011;287: 255-256.

Akinwunmi F. What you need to know about warfarin.

Pharm J 2011;287: 251-254.

Bhandal S, Pattinson J. How to support patients taking

new oral anticoagulant medicines. Clinical Pharmacist

2013;5: 268.

Return to anticoagulants and antiplatelets menu

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Properties ofanticoagulantsYou have already considered some of the properties of anticoagulants by reading through section 2.8 of the BNF.

Now click on the image of the CPPE focal point on anticoagulation to read more about anticoagulant properties. Complete Practice point 1 – you will find our suggested answers at the end of the extract.

* Please note the focal point was written in March 2013 and since then the DOACs have been licenced for more indications. Additionally in July 2015 edoxaban (a factor Xa inhibitor) was launched onto the UK market and NICE issued technology appraisals later that year.

An antidote to dabigatran is now available, and an antidote to the factor Xa inhibitors is expected in 2017.

Return to anticoagulants and antiplatelets menu

BOOK 1

A F o c A l p o i n t l e A r n i n g p r o g r A m m e

ANTICOAGULATION

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The effectiveness and safety of warfarin is critically dependent upon maintaining the INR within a target range, typically within 0.5 of the target INR value. There are different targets indicated for different conditions and it is useful to be aware of these when discussing anticoagulant medicines with patients and noting targets in their record book (for example the ‘yellow book’).

In addition to the information in the BNF, you can read more about the indications for therapy and INR targets by clicking on the image of the CPPE focal point.

You will see in terms of stroke prevention, the NICE Clinical guideline 180: Atrial fibrillation (AF), released in in June 2014, no longer lists aspirin monotherapy solely for stroke prevention to patients with atrial fibrillation. Please bear this guidance in mind when reading this programme.

* Please note that some of the information from the anticoagulation focal point programme on these pages is now partially out of date since the publication of the NICE guidance for AF, clinical guideline 180.

Also note that in addition to apixaban, dabigatran and rivaroxaban, edoxaban is also used for prevention of stroke in patients with non-valvular atrial fibrillation.

Some of the information regarding bleeding risks has been updated - please see the next page for the current information.

Indications for anticoagulant therapy and INR targets

BOOK 1

A F o c A l p o i n t l e A r n i n g p r o g r A m m e

ANTICOAGULATION

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Information on bleeding risks of the direct oral anticoagulants compared to warfarin

Major bleeding risk: no difference between dabigatran 150mg BD and warfarin and rivaroxaban and warfarin. Less common with dabigatran 110mg BD and warfarin, apixaban and warfarin and edoxaban and warfarin.

Gastrointestinal bleeding risk: more common with dabigatran 150mg BD than warfarin, also rivaroxaban and edoxaban and warfarin. No difference between dabigatran 110mg BD and warfarin and apixaban and warfarin.

Intracranial bleeding risk: Less common with both doses of dabigatran than with warfarin, with rivaroxaban than with warfarin, with apixaban than with warfarin and edoxaban then with warfarin.

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Another good resource is the Clinical knowledge summaries (CKS) website. This has lots of information on clinical topics, including a web page on indications and the target INR.

It can sometimes be difficult to establish the intended length of therapy of an antiplatelet but it is useful to know, as patients may raise this as a question during the consultation. This is patient-dependent but you can find guidance on this on the CKS website.

Return to anticoagulants and antiplatelets menu

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When you are conducting the NMS consultation with a patient, they may ask you how often they need to have their INR monitored. The timescales will vary from patient to patient, as will the actual dose of warfarin required to maintain the patient with a therapeutic INR. Read more by clicking on the image of the CPPE focal point.

As a pharmacist you have a responsibility to ensure that the patient’s INR is monitored regularly and that the INR is at a safe level for the repeat prescription to be dispensed. You can find this information in the patient’s record / yellow book. The NMS consultation is a good time to remind the patient to bring in this book each time they collect their anticoagulant medicine.

Monitoring ofanticoagulants

BOOK 1

A F o c A l p o i n t l e A r n i n g p r o g r A m m e

ANTICOAGULATION

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On the CKS website, you can read information on how warfarin should be monitored. There is also information to help you when dealing with patients who like to be fully involved in their own anticoagulant care and are keen to self-test or self-manage.

NICE guidance on self-testing and self-monitoring for patients with atrial fibrillation and heart valve disease was published in September 2014.

Monitoring of the DOACsPrior to starting a DOAC it is recommend to take the following blood tests: clotting screen, urea and electrolytes (U & Es), liver function tests (LFTs), full blood counts (FBC), blood pressure and creatinine clearance. Ongoing monitoring includes U & Es, LFTs, FBC at least once a year. As the DOACs need dose adjusting, or avoidance in reduced renal function it is recommended to repeat U & Es every 6 months if CrCl is 30-60 mL/min or every 3 months if CrCl is 15-30mL/min.

Return to anticoagulants and antiplatelets menu

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There are many factors which can affect a patient’sresponse to warfarin. As patients who take warfarinoften have so many long-term conditions, it cansometimes seem almost impossible to use amedicine which does not interact with it. In addition,there are risks associated with taking herbal oralternative medicines, and it is important to be awareof how lifestyle influences warfarin therapy along withother disease states.

To find out more about this, click on the image of theCPPE focal point.

In addition to this you can find more informationrelating to drug interactions in appendix 1 of the BNF(you will need to be logged into the BNF website firstto read this online) and on the CKS website.

Factors affectinganticoagulant therapy

Dietary supplements and herbal remedies may also affect warfarin therapy. The following article published in The Pharmaceutical Journal provides more information:

Stockley IH and Lee R. Can I take herbal products or dietary supplements with my warfarin? Pharm J 2009;282:424.

BOOK 1

A F o c A l p o i n t l e A r n i n g p r o g r A m m e

ANTICOAGULATION

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TASK

Return to anticoagulants and antiplatelets menu

Is the effect of warfarin possibly enhanced or inhibited by the following medicines and herbal remedies?

Amiodarone

Carbamazepine

Cimetidine

Miconazole

St John’s wort

NSAIDs

Enhances anticoagulant effect

Reduces anticoagulant effect

Enhances anticoagulant effect

Enhances anticoagulant effect

Reduces anticoagulant effect

Enhance anticoagulant effect

(possible with topical preparations)

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Most patients usually have some form of counselling during the discussion about starting warfarin therapy; however, as there is so much information to take in, it is to be expected that some of this will be forgotten. An NMS consultation for an anticoagulant is the ideal opportunity to reiterate or introduce a patient to the key messages associated with warfarin therapy.

Before you continue, write down all the key counselling points you would include in your consultation for a patient newly prescribed warfarin.

Patient counsellingfor anticoagulants

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Click on the screen below to watch a brief video on patient education on warfarin. Please note that the advice in the video regarding telling patients to avoid drinking cranberry juice is no longer current. Instead, patients who drink cranberry juice should be advised to have consistent intake. Also, we should be avoiding the terminology of warfarin being a ‘blood thinner’ with patients, and explaining that warfarin and anticoagulants increase the time it takes for blood to clot instead.

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The patient booklet Oral AnticoagulantTherapy – Important information for patientsprovides a reminder of the key points toremember so it would be useful to point these out during the consultation. It is useful to be familiar with the contents of this booklet and encourage patients to refer to it for guidance.

Confusingly, like the patient record book, thisbooklet is yellow (a golden, rather than alemon colour). The patient record book is used for recording the patient’s INR results, warfarin doses and appointments.

Not all clinics use the yellow record bookalthough the majority do. However pharmacists must still comply with the NPSA guidance for safe dispensing of anticoagulants. Page 13 of the oral anticoagulant therapy information forpatients book recommends avoiding cranberry juice altogether. Please see the note regarding cranberry juice on the page 29 of the PDF.

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Patients may also ask for advice when having dental treatment. You can find more information on this by clicking on the image of the CPPE focal point.

Return to anticoagulants and antiplatelets menu

BOOK 1

A F o c A l p o i n t l e A r n i n g p r o g r A m m e

ANTICOAGULATION

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We have already covered anticoagulants in some detail but it is important not to forget some of the key points when counselling patients taking antiplatelets for the first time.

You have already refreshed your knowledge by looking at the information in the BNF. Here is some further learning and considerations when conducting a consultation for the NMS.

The Pharmaceutical Journal has published two helpful articles to support pharmacists delivering the NMS. Click on the titles below to read the articles:

Antiplatelets – the key points

Let’s recap on antiplatelet agents

What’s this fuss about aspirin?

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Some patients will be more at risk of gastrointestinalside-effects when taking antiplatelet medicines.

The CKS website provides comprehensiveinformation on which types of patient are more at riskand the management of these patients. Considerationswhen seeing patients prescribed an antiplatelet for thefirst time would be concurrent medicines which mayincrease the risk of gastrointestinal side-effects. Thereare several scenarios included.

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The use of two antiplatelet medicines in combination willincrease the risk of bleeding in a patient, but there arespecific indications which warrant combination therapy.

You can find out more at the NICE website about thecombination of aspirin and clopidogrel in unstable anginaand non-ST segment elevation myocardial infarction, aswell as the combination of clopidogrel and modifiedrelease dipyridamole for the prevention of occlusive vascular events.

Finally, NICE has published technical appraisals on theuse of ticagrelor (TA236, October 2011) and prasugrel(TA182, October 2009) for the treatment of acutecoronary syndromes.

Return to anticoagulants and antiplatelets menu

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Tips for your consultationsThere are many different resources available to support you in your NMS consultation, some of which may have a MUR focus but will still be helpful in giving you some pointers for your NMS consultations.

Chemist+Druggist has a learning toolkit that includes counselling tips for the NMS. You can also access MUR tips for warfarin and for patients taking medicines for secondary prevention of ischaemic stroke and TIAs.

The Royal Pharmaceutical Society also has a page to support pharmacists in delivering the NMS. A resource for antiplatelet and anticoagulant medicines was in development when this programme was written.

MURtraining.co.uk is a website with resources for pharmacists conducting MURs. Some of the counselling tips are also useful for patients taking antiplatelets and anticoagulants as new medicines. Please note that advice given on this website regarding eating more green vegetables and warfarin intake has changed. Current advice would be to advise the patient that the increase in green vegetables is the likely cause of the change in INR but to get the patient to contact his clinic so they can adjust the dose of the warfarin. The patient should be advised to maintain a consistent intake of green vegetables to prevent the fluctuating INR.

Return to anticoagulants and antiplatelets menu

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Support for patientsSignposting patients to appropriate information is an important part of any medicines consultation. The following resources may be useful for patients.

NHS Choices

Patient.co.uk

British Heart Foundation website

Anticoagulation Europe (ACE)

Return to anticoagulants and antiplatelets menu

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This programme contains four case studies.

In these, there will be space for you to type answers to the questions. You can save your answers by saving this document to your computer and view our suggested answers - these are hidden behind the Reveal answer text.

Case studies – introduction

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Case studiesThe case studies look at four areas. Click on a title below to go straight to that case. You will be able to return to this menu by clicking the link at the bottom of the page at the end of each case study.

warfarin

clopidogrel anticoagulant

adverse effects herbal medicines

and warfarin

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Warfarin counselling – Wendy Wendy Craske is 64 years old and is a regular customer who picks up her husband’s insulin and other diabetic medication. You have not seen her for a while and have heard that she has been in hospital following a blood clot.

She comes into your pharmacy. “I’m relieved to be home,” she tells you, “but I’m likely to be seeing you more often over the next few months, as they’ve put me on warfarin.” She hands you an NMS referral from the local hospital pharmacy.

This is the first time they have referred someone to you. Wendy tells you that the hospital discharge pharmacist covered everything with her, but you make an appointment with Wendy for five days’ time. She shows you her yellow anticoagulant therapy record book and you notice that she is still being monitored daily as she has only just stopped the enoxaparin subcutaneous injections started in hospital.

41In addition to the normal questions on the interview schedule, what counselling points should you make sure that you cover with Wendy at the intervention interview?

As well as the interview questions for the intervention stage, you should cover the following key counselling points for patients on warfarin, represented by the mnemonic ‘WARFARINISED’:

W - When to take. Best at teatime so INR checks can inform a dose change next day.

A - Alcohol. Anticoagulant effect varies with intake.R - Risk of bleeding as blood clotting takes longer. Refer to accident and

emergency if bleeding from nose (for longer than 10 minutes), gums (severe), or in stools.

F - Follow up. Must get INR checked as directed.A - Aspirin. Avoid, unless prescribed.R - Reason for taking – slows rate of clotting. Find out the reason for the warfarin

therapy.I - Interactions with drugs (including over-the-counter preparations) and vitamin

K-rich foods (eg, leafy greens).N - Notify dentist, nurse and pharmacist, as this will alter other treatment options.I - INR – what is your target?S - Skipped dose – do not miss a dose. If you do, note it, but do not double up.E - End of course – how long will you be on warfarin?D - Dose. Varies depending on INR result.

Additional counselling points to consider include keeping the alert card with you at all times, ensuring a time frame so a delayed dose can be taken if remembered, how to obtain supplies and what the different colours of tablets mean.

Finally - it is important throughout the consultation to check for understanding and if the patient has any questions or concerns about taking the medication.

Even if Wendy thinks the hospital pharmacist has covered everything, the pharmacist may have missed out something important or Wendy may have forgotten – it is a lot of information to take in at once. Also remind Wendy to carry something which would alert others that she is taking warfarin in the case of an emergency and also to provide at other appointments such as the dentist.

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At the intervention interview, Wendy tells you that she has returned to her part-time job as a carer for social services as her clients have missed her and the service is short-staffed.

As she is always out and about at teatime, she has started taking her warfarin at different times of the day to suit her schedule. She thinks it’s always best to divide the dose as she is aware from her work with older people that a divided dose schedule keeps blood levels more stable.

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What would you say to Wendy?Type your answer into the speech bubble below.

You’ve raised some very interesting points there, Wendy. However, it is very important to take all your warfarin dose together at the same time every day (about teatime), partly to help you remember to take your medicine but also because you have your INR measured during the working day and the teatime dose gives you the best chance of getting a stable, reliable reading the next day.

Return to case study menu

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Wendy takes the point about needing to take her entire dose at once and, importantly, at the same time every day, but stresses that she is out and about until about 7:00pm every weekday.

Conscious that you must listen to Wendy’s needs and allow her to share the decision making, you agree with her that she will take her warfarin as soon as she gets home and you phone the INR clinic to ask them to add that to her notes.

Wendy attends your pharmacy three weeks later for her follow-up interview. Her INR has settled to between 2.4 and 2.7 and she tells you her clients are happy to have her back. You complete the interview schedule with no further issues and Wendy thanks you for your help.

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Sandeep Singh is 54 years old and has been taking aspirin for a number of years following a heart attack in his early 40s. Now, following a mild stroke, he has been switched to clopidogrel monotherapy. He presents to you with his first prescription for clopidogrel. You book him in for an NMS consultation and, while preparing for it, you notice from the patient medication record that he was taking omeprazole until three months ago.

Clopidogrel counselling – Sandeep

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What questions, in addition to those on the interview schedule, should you ask Sandeep at the intervention interview?

As well as the interview questions for the intervention stage, you should consider asking about the omeprazole prescription. Was it because he was having stomach discomfort due to the aspirin he takes? Has he experienced any since? What about since starting the clopidogrel? If he does experience stomach discomfort (and many patients taking clopidogrel do), his doctor may give him another medicine for his discomfort, but it is unlikely that this will be omeprazole as this may have an interaction with clopidogrel, reducing its antiplatelet effect.

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Sandeep tells you that he has taken his first few doses of clopidogrel without feeling any discomfort but has lots of questions to ask you about it. “I took omeprazole for a couple of years as I having was stomach discomfort,” he tells you. “But I’ve not had any problems since I managed to lose two stones on a diet.”

He is worried about all the side-effects listed on the patient information leaflet and is sure that he will get some of them. He asks you whether it is worth continuing with the clopidogrel.

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What would you say to Sandeep?Type your answer into the speech bubble below.

It’s only natural to worry about a new medicine, Sandeep, particularly when you read the patient information leaflet. However, clopidogrel has been used very safely and effectively for a number of years now and does a good job in preventing further heart attacks and strokes. It’s well worth persevering with it, particularly as you are not having any problems with it. Why don’t you carry on and see how you get on, then come back in three weeks and let me know? In the meantime, if you feel as though you are starting to have problems again with your stomach or any of the other side-effects that you read about, then please come straight back to see me.

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Sandeep returns for his follow-up appointment and admits that he had been scared of this new medicine and was about to stop taking it for fear of side-effects, but is now getting on well with it. He thanks you for persuading him that it was worth taking.

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Dealing with anticoagulantadverse effects – Edward

Edward Mason is a regular customer of yours. You conducted a NMS consultation with him a month ago when he was initiated on warfarin therapy for atrial fibrillation.

Today, he comes into the pharmacy in a slight panic as he has a bleeding nose and is holding several handkerchiefs spotted with blood. “My nose started bleeding about 15 minutes ago. I can’t stop it,” he tells you. He hands you his yellow book and you notice that his last INR reading was taken two weeks ago and was 2.9.

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What actions would you take to help Edward with his bleeding nose?

Edward should follow the advice in his Oral Anticoagulant Therapy – Important information for patients booklet. A nosebleed lasting more than ten minutes that does not stop requires medical assistance. You should refer Edward immediately to his GP practice, if someone there is able to attend to him quickly, or to the nearest accident and emergency department.

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Edward returns two weeks later to tell you that his nosebleed was attended to quickly at the GP practice but that his INR value, when checked, was 3.8. The INR clinic staff have changed Edward’s warfarin dose. He asks you why there was such a fluctuation in his INR value.

You look at his patient medical record, which reads as follows:

Amiodarone 200 mg daily – initiated 14 days ago

Amoxicillin 500 mg three times a day – initiated four days ago

Aspirin 75 mg daily – reintroduced 14 days ago

Digoxin 125 micrograms daily – initiated 28 days ago

Ramipril 5 mg daily – initiated 28 days ago

Warfarin 1 mg as directed – initiated 28 days ago

Warfarin 3 mg – initiated 28 days ago

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Which of these medicines could increase Edward’s bleeding risk and what could you do about it?

Edward has several medicines-related factors that would increase his bleeding risk: he is taking warfarin and there are several potential drug interactions in his list of medicines, including the addition of an antibiotic.

It would be prudent to confirm that the co-prescribing of aspirin is intended. Aspirin makes the patient more likely to bleed without an elevated INR, particularly as Edward has probably had a loading dose of amiodarone previous to the maintenance dose. There are a couple of drug interactions to note with amiodarone and the antibiotic. Any introduction or change in dose of these medicines can affect the INR value and the patient’s risk of bleeding.

There are also other factors to consider such as changes in diet, increase in alcohol consumption and, importantly, how he takes his medication. Alternative therapies may also affect the INR and it would be worthwhile asking if he is taking any over-the-counter medicines.

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Herbal medicinesand warfarin – George

George Byrne is a 72-year-old man who is a regular customer in your pharmacy. He has been referred by the hospital for an NMS consultation for his new prescription for warfarin. During the consultation you ask George whether or not he is taking any other medicines not listed on his patient medical record.

He mentions that he has been taking garlic capsules as part of his mission to maintain a healthy heart as he gets older. He has been taking them for 12 months now and has great faith in them. “I even throw a bit of garlic in when I’m cooking, just to give the capsules a boost,” he says.

55What points could you raise with George during your discussion to help him make a decision as to whether to continue the garlic capsules?

Garlic taken in amounts used in cooking does not interact with warfarin. However, at higher doses (as found in garlic capsules and tablets) it may have an antiplatelet effect. In general, this should not result in the patient’s INR increasing, though it may occasionally increase the risk of bleeding.

You could cover the following points:

Garlic does not seem to have an important interactionwith warfarin.Alternative, complementary and herbal medicineshave not been studied to the same extent asprescription medicines and therefore there is notmuch information available about safety andinteractions.George could continue taking the garlic but needs to watch for signs of bleeding.If he decides to stop taking garlic capsules then he needs to tell someone at the anticoagulant clinic as this could alter his next INR reading.

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Next stepsNow that you have completed the case studies, what’s next?

You might like to:

email CPPE with any feedback you may have

on your learning experience.

return to the learning if you have identified gaps

in your knowledge

return to the start of the case studies

revisit the learning objectives. Are you confident

that you have achieved these?

tackle the reflective essay that you can download

from your CPPE record

complete a CPD record

We hope that you have enjoyed your learning.Come back for more learning when we publish more programmes in this NMS series later this year.

CreditsCPPE programme manager Geraldine Flavell, regional manager

Lesley Grimes, senior pharmacist learning development

External reviewerFrances Akinwunmi, anticoagulation consultant pharmacist,

Imperial College Healthcare NHS Trust

CPPE reviewersTiffany Barrett, regional manager

Jan Douglas, regional manager

Alison Levine, learning and development pharmacist

Karen Wragg, regional manager

Piloted byPaul Jenks, divisional trainer, Boots

Samantha White, community pharmacist, Boots

DisclaimerWe have developed this learning programme to support your

practice in this topic area. We recommend that you use it in

combination with other established reference sources. If you are

using it significantly after the date of initial publication, then you

should refer to current published evidence. CPPE does not accept

responsibility for any errors or omissions.

Acknowledgements CPPE acknowledges the support of Chemist+Druggist for allowing

us to signpost to learning in their publication.

ProductionGemini West Ltd, 25 Hockeys Lane, Fishponds, Bristol, BS16 3HH

T:0117 965 5252. http://www.gemini-west.co.uk

Originally published in October 2012. This version was updated in August2016 by the Centre for Pharmacy Postgraduate Education, ManchesterPharmacy School, University of Manchester, Oxford Road, Manchester M13 9PT.www.cppe.ac.uk

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