Community pharmacist prescribing may help reduce stroke risk in AF

A significant percentage of people with atrial fibrillation (AF) are unnecessarily at risk for stroke and its consequences due to major gaps in the delivery of appropriate oral anticoagulation. In an attempt to address this gap, Alberta researchers conducted a study to determine whether community pharmacist prescribing of oral anticoagulants can improve stroke risk reduction therapy in individuals with AF.1The prospective, open-label, patient-level randomized clinical trial of early vs delayed pharmacist intervention was conducted in 27 community pharmacies in Alberta. After comprehensive training, community pharmacists with independent prescribing authority and electronic health record access identified patients ≥ 65 years of age with one additional stroke risk factor and known, untreated AF (i.e., no prescription, inappropriate medication [e.g., an antiplatelet agent] or suboptimal dosing of an oral anticoagulant). Alternatively, they performed screening using a 30-second single-lead electrocardiogram to detect previously unrecognized AF. Patients with undertreated or newly diagnosed AF eligible for oral anticoagulant therapy were considered to have “actionable AF.”1 For the early intervention group, pharmacists provided AF education, blood pressure assessment, and prescribed oral anticoagulant therapy using guideline-based algorithms, with follow-up visits at one and three months. For the delayed intervention group (which served as the usual care control), the primary care physician was notified about actionable AF along with the patient’s medication list After three months, if oral anticoagulant treatment had not been optimized by the primary care physician, control group patients then received delayed pharmacist intervention.1The primary outcome was the difference in the rate of guideline-recommended oral anticoagulant OAC use in the two groups at three-month follow-up, as determined by a research pharmacist blinded to treatment allocation.1Results showed the following:Eighty patients were enrolled with actionable AF (11.3% newly diagnosed in 235 individuals screened; mean age 79.7 years; 56.3% female).Guideline-concordant oral anticoagulant use at three months occurred in 36 of 39 patients (92.3%) in the early intervention group vs 23 of 41 (56.1%) in the control group (p < 0.001), with an absolute increase of 34% and number needed to treat of 3. Of the 23 patients who received appropriate oral anticoagulant prescription in the control group, the primary care physician called the pharmacist for prescribing advice in six patientsAt the 12-month mark, oral anticoagulant adherence was at least 90% in both groupsA patient survey revealed high satisfaction with pharmacists’ services.1The authors conclude that pharmacist oral anticoagulant prescribing is a potentially high-yield opportunity to effectively close gaps in the delivery of stroke risk reduction therapy in AF. However, they acknowledge that the scalability and sustainability of pharmacist oral anticoagulant prescribing will require larger trials demonstrating effectiveness and safety.1An accompanying commentary points out that a significant proportion of patients with AF at high risk for stroke do not receive any preventive therapy, increasing the likelihood of ischemic strokes, permanent disability and death. Therefore, novel approaches are required to address the underuse of oral anticoagulants in high-risk patients with AF.2Despite the excitement and success from this study, appropriate caution is warranted as well.First, most data defining rates of OAC nonuse in populations with AF are based on high-level claimsReferences:Sandhu RK, Fradette M, Lin M, et al. Stroke risk reduction in atrial fibrillation through pharmacist prescribing. A randomized clinical trial. JAMA Network Open 2024;7(7):e2421993. (accessed July 24, 2024).Allen AL, Barnes GD. Addressing undertreatment of atrial fibrillation with community pharmacists (invited commentary). JAMA Netw Open 2024;7(7):e2421955. (accessed July 24, 2024).

Community pharmacist prescribing may help reduce stroke risk in AF

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