Dronedarone Rifampin Verapamil Carbamazepine Combined P-gp inhibitor Diltiazem P-gp inducers Phenytoin and moderate CYP3A4 Eyrthromycin Phenobarbital inhibitor Cyclosporine St. John’s wort Tamoxifen Rifampin Combined P-gp inducer Carbamazepine and strong CYP3A4 Phenytoin Phenobarbital inducer St. John’s wort DOAC MONITORING Atrius Health Anticoagulation Management Services do not monitor patients taking DOACs. Expert consensus recommends routine monitoring of adherence, risk for bleeding, renal function, drug interactions and select physical findings (e.g., blood pressure, fall risk) for all patients on chronic DOACs. Atrius clinicians prescribing should use the DOAC Monitoring Checklist created by Thrombosis Canada to regularly monitor patients. Standard work for clinicians, nurses, and/or population managers: use the SmartPhrase in a progress note at the time of initiation of DOAC and the “.DOACstart” SmartPhrase for follow-up contacts with patient, ideally every 6 months but at least once yearly. Monitoring should occur more “.DOACmonitoring” frequently in patients who are elderly, have renal impairment, or who are considered to be at higher bleeding risk. Weblink: SWITCHING DOACs FROM/TO WARFARIN AND OTHER ANTICOAGULANTS66-69 above, - edoxaban apixaban rivaroxaban dabigatran Discontinue warfarin and start Discontinue warfarin and start Discontinue warfarin and start Discontinue warfarin and start when Switching FROM warfarin when INR when INR <2.0 when INR <3.0 INR <2.0 ≤2.5
P-gp inducers Rifampin Carbamazepine Phenytoin Phenobarbital St. John’s wort Combined P-gp inhibitor and moderate CYP3A4 inhibitor Dronedarone Verapamil Diltiazem Eyrthromycin Cyclosporine Tamoxifen Combined P-gp inducer and strong CYP3A4 inducer Rifampin Carbamazepine Phenytoin Phenobarbital St. John’s wort DOAC MONITORING Atrius Health Anticoagulation Management Services do not monitor patients taking DOACs. Expert consensus recommends routine monitoring of adherence, risk for bleeding, renal function, drug interactions and select physical findings (e.g., blood pressure, fall risk) for all patients on chronic DOACs. Atrius clinicians prescribing should use the DOAC Monitoring Checklist created by Thrombosis Canada to regularly monitor patients. Standard work for clinicians, nurses, and/or population managers: use the SmartPhrase “.DOACstart” in a progress note at the time of initiation of DOAC and the SmartPhrase “.DOACmonitoring” for follow-up contacts with patient, ideally every 6 months but at least once yearly. Monitoring should occur more frequently in patients who are elderly, have renal impairment, or who are considered to be at higher bleeding risk. Weblink: SWITCHING DOACs FROM/TO WARFARIN AND OTHER ANTICOAGULANTS66-69 above, - edoxaban apixaban rivaroxaban dabigatran Switching FROM warfarin Discontinue warfarin and start when INR ≤2.5 Discontinue warfarin and start when INR <2.0 Discontinue warfarin and start when INR <3.0 Discontinue warfarin and start when INR <2.0
Anticoagulation%20Management%20Service%20Guideline.100118.docx