Personalised anti-coagulation: an example of how technology drives efficacy and efficiency.

Simon JonesDr Harsh Sheth

Content• Personalised medicine

• Alignment of the right treatment with the right patient to achieve the greatest clinical outcomes and cost effectiveness

• Using technology to test sensitivity prior to treatment• The more we understand before embarking on course of treatment the more

effective it should be

• Optimised medication regimes• Once on treatment regime – let’s optimise it

Personalised anti-coagulation pathway • Two main treatments – Warfarin, NOAC

• Both NICE approved• Both appropriate treatment options

• Huge cost differential• Given health gain from each drug it’s important to understand cost v health gain

• Inconsistent prescribing patterns• Local variations on which treatment to use• Some based on cost others on more clinically based protocols

The Warfarin PatientA patient nowMary, 58 with AF. GP prescribes warfarin, misses appointments, collapses, severe internal bleeding, lucky to survive…

In the future….. Mary is one of the 4-5% who metabolise warfarin slowly…. .Mary’s GP does a quick pharmacogenetics test using special equipment in the surgery…… starts on lower, safer dose of warfarin… suited to personal genetic makeup.

OR… test shows Mary is sensitive to Warfarin so GP prescribes NOAC.

Pirmohamed M et al, New England Journal of Medicine 2013

In a multi centre trial involving Newcastle, genotype guided dosing resulted in participants reaching the therapeutic window earlier and

with fewer episodes of over dosing

A simple test of three variants responsible fortwo thirds of the interpersonal variation

Routing of patients to warfarin/ NOAC based on genotype

Reduced bleeding with endoxaban in sensitive and highly sensitive responders compared to warfarin (low dose P=0.0036; high dose P=0.0066)

Mega et al. Lancet 2015

6mg, 24%

5mg, 7%

4mg, 31%

4mg, 4%

4mg, 1%

3mg, 0.5%

4mg, 8%

3mg, 6%

3mg, 1%

3mg, 13%

2mg, 3%

2mg, 0.1%1mg, 0.2%1mg, 0.1%

2mg, 1%1mg, 0.3%

2mg, 0.2%

2mg, 2%

Patient self-tests INR at home on agreed

date

Using either an automated phone call or on-line submission, the

patient provides their INR reading, current warfarin dose, and

questions around bleeding and medication

Patient follows new dosing regime and

notes date of next test

The service can integrate directly with 4S-DAWN or INRstar. This means that clinic staff can dose from within

their existing system, or from the Inhealthcare portal if the clinic uses a

different decision support system

The service then informs the patient of their warfarin dose and the date of next INR test

Patient INR Self-Testing• There are 1.2 million people in the UK that are on

warfarin, creating 17 million out-patient appointments per year to have their blood tested (INR tests)

• This service allows patients on warfarin to self-test their INR at home instead of attending out-patient clinic, and then for them to receive their new warfarin dose at home

• When assessed, the self-testing patients had a higher level of compliance than clinic-based patients, meaning that the timethat their INR was in a safe range increased from 59% to 72%.

Evaluation data from 200 clinical patient pilot at NHS County Durham and Darlington NHS Foundation Trust

North East ProjectStage 1• Request genotyping on all “problem cases” and new cases of AF• Consider switching “high risk” cases to NOAC• Increase numbers of self testing – to secure increased TTR

Stage 2Redesign anti-coagulation pathway so we can:• Genotype all new referrals• Accelerate induction of “wild type”• Align appropriately those patients who would achieve better outcomes through self testing

Summary• Introduction of 3 innovations to the clinical pathway- rapid genotyping,

self testing INR and cloud based warfarin dose adjustment

• Objective stratification of patients to warfarin or NOAC treatment

• Improved INR control, improved drug adherence, reduced risk of bleeding events and reduced clinic visits

• Overall cost saving of ~£3 million in Newcastle area alone

• Please come and see us on stand 73

• Any questions?

• Follow Inhealthcare on Twitter @InHealthcareUK