Five tips for managing oral anticoagulation therapy in a community setting

As the scope of pharmacy practice expands across Canada, pharmacists in many provinces now have the ability to offer point-of-care (POC) testing, which has created opportunities to improve patient care.1 While there are several applications for POC testing, POC testing for International Normalized Ratio (INR) determination stands out as an impactful, evidence-based option. Studies have demonstrated benefits with POC INR testing for patients taking warfarin, including improvements in the time spent within the therapeutic range and higher patient satisfaction when compared to traditional venipuncture INR testing.2-5 The benefits of POC INR testing may create interest for community pharmacists to take on a more active role in managing their patients’ warfarin therapy. Here are some tips to ensure the success of a community pharmacy-based warfarin management service.1. Consider specialized professional developmentOne of the family physicians I work with once asked why I bothered developing a continuing education course for warfarin management. “There’s no rocket science to warfarin,” they said. “If the INR is low, increase the warfarin dose, and if it’s high, lower the dose.” Although it’s tempting to think this way, the assessment of a patient with an out-of-range INR value is far more complex. It includes finding out why the INR is out-of-range (e.g., missed or extra doses of warfarin, drug interactions, acute illness, lifestyle changes), estimating the patient’s risks of thromboembolism and bleeding, considering recent INR values, and applying knowledge related to the complex pharmacological properties of warfarin. Additionally, the management of warfarin can include advising how to manage warfarin therapy prior to and after surgical procedures, managing extreme INR values (e.g., INR > 6.0 and the possible need for vitamin K, or INR < 1.5 and the potential need for low molecular weight heparin). It can also involve assisting patients who plan to make changes to lifestyle, medication or dietary patterns that may affect warfarin dosing.Expanding your practice to provide warfarin therapy management services requires a solid foundation of specialized knowledge and skills. Consider investing in additional professional development, such as courses or certifications in warfarin therapy management. This will help you build the expertise needed to make informed clinical decisions and provide high-quality care. For example, an accredited Canadian course is available through the University of Waterloo: (https://watspeed.uwaterloo.ca/programs-and-courses/course-management-oral-anticoagulation-therapy.html).2. Determine your service delivery modelAn important decision is how you will provide warfarin therapy management in your pharmacy. Will it be appointment-based, allowing patients to schedule consultations for INR testing, or drop-in, where patients can seek assistance without prior arrangement? Will you offer it any day of the week, or only on certain days? Ideally, you should offer the service at least two or three times weekly to accommodate patients who have recently initiated therapy, as they require multiple INR tests per week for about the first month of therapy. One study estimated the time spent on a POC INR testing appointment and related follow-up activities in a community pharmacy is around 11 minutes, but some patient assessments can take significantly longer depending upon the complexity.6 Consider the needs and preferences of your patient population, and how this service will fit into your pharmacy workflow to choose the most suitable approach.3. Invest in anticoagulation clinic softwareAnticoagulation clinic software can streamline your practice and enhance patient care. At a minimum, look for software that allows you to build anticoagulation-specific profiles for your patients (e.g., indication for therapy, target INR and therapeutic range, thromboembolic and bleeding risks), and display historical data such as previous INR values and the associated clinic notes in a readily accessible manner. Some anticoagulation clinic software provides additional tools such as computerized warfarin dosing decision support and the ability to print off warfarin dosing schedules for patients. Two excellent Canadian products are INR Online Canada (https://www.inronline.ca) and Posologic (http://en.posologic.com).4. Collaborate with other primary care providersAs noted above, the scope of practice for pharmacists has expanded significantly. Although pharmacists can adapt prescriptions without prior authorization in most provinces, effective collaboration among primary care providers is essential for comprehensive patient care and maintaining healthy interprofessional relationships.7 Consider informing physicians in your area about your POC INR testing program and ask for their preference regarding how they would like to receive test results for their patients (e.g., after every test, quarterly). Regular communication and coordination with prescribers can ensure that everyone is on the same page regarding monitoring, warfarin dose adjustments, and any changes in concomitant therapy. A bonus is that you may get more referrals this way!5. Utilize valuable resourcesDon’t reinvent the wheel; make use of excellent resources available to support your practice. Thrombosis Canada (https://thrombosiscanada.ca) provides various clinical guides and tools for practitioners, and several resources developed specifically for patients. These materials offer evidence-based guidance that can enhance your practice. In addition to information about warfarin, the Thrombosis Canada website maintains up-to-date information about all anticoagulants you will encounter in community practice. For example, it has an excellent checklist that can be used for following up with patients prescribed a direct-acting oral anticoagulant (e.g., apixaban, rivaroxaban).SummaryProviding POC INR testing and warfarin management services is an excellent way for community pharmacists to contribute to improved patient care. A recent study of community pharmacists providing these services in Nova Scotia documented some of the highest warfarin-related quality of care ever reported in a primary care setting in Canada.8 Notably, the pharmacists involved had all completed specialized training in warfarin management, used anticoagulation clinic software with computerized decision support, had formal collaboration agreements with their patients’ primary care prescribers, and each developed unique service delivery models that worked for their circumstances. By considering the tips outlined in this article, community pharmacists can be confident in their ability to provide exemplary warfarin dosing services.Jeff Nagge (jnagge@uwaterloo.ca) is a Clinical Associate Professor, School of Pharmacy, University of Waterloo in Waterloo, ON, and an Assistant Clinical Professor, Michael G DeGroote School of Medicine, Department of Family Medicine, McMaster University in Hamilton, ON.References:Hutchings L, Shiamptanis A. Evaluation of point-of-care testing in pharmacy to inform policy writing by the New Brunswick College of Pharmacists. Pharmacy (Basel) 2022;10(6):159.Canadian Agency for Drugs and Technologies in Health. Guidance on the use of point-of-care testing of International Normalized Ratio for patients on oral anticoagulant therapy. Ottawa: The Agency; July 2014. (accessed December 13, 2023).Okuyama Y, Matsuo M, Matsuo H, et al. Introduction of point-of-care testing in Japanese outpatient clinics is associated with improvement in time in the therapeutic range in anticoagulant-treated patients. Circ J 2014;78:1342-8.Harrison J, Shaw JP, Harrison JE. Anticoagulation management by community pharmacists in New Zealand: an evaluation of a collaborative model in primary care. Int J Pharm Pract 2015;23(3):173-81.Kong MC, Lim TG, Ng HJ, et al. Feasibility, cost-effectiveness and patients’ acceptance of point-of-care INR testing in a hospital-based anticoagulation clinic. Ann Hematol 2008;87:905-10.Curtis L. Final evaluation of the Community Pharmacist-led Anticoagulation Management Service (CPAMS) Canada Project. Submitted to Pharmacy Association of Nova Scotia. 2019. (accessed December 13, 2023).Canadian Pharmacists Association. Scope of practice. Revised October 2, 2023. (accessed December 13, 2023).Morrison L, Nagge J. The quality of community warfarin management across two provinces in Canada: a cross sectional observational study. Can Pharm J 2024;157(2):77-83. (accessed February 23, 2024).

Five tips for managing oral anticoagulation therapy in a community setting

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