Photo by Rhoda Baer
Pharmacists can greatly improve patients’ adherence to the anticoagulant dabigatran, according to a study published in JAMA.
When patients with atrial fibrillation had their dabigatran prescriptions filled by pharmacists who educated them about the drug and monitored them on a regular basis, these individuals were 80% more likely to adhere to medication guidelines than patients who didn’t receive this kind of support.
“Although pharmacist-led management of [dabigatran and other new oral anticoagulants] is uncommon in the US, the findings make the case that it is still important and can ultimately impact clinical outcomes,” said study author Mintu Turakhia, MD, of Stanford University School of Medicine in California.
Previous studies had suggested that some patients were not adhering well to treatment guidelines for dabigatran. So Dr Turakhia and his colleagues set out to determine if this lack of adherence could be explained by where patients were filling their prescriptions.
The team looked at Veterans Health Administration sites where 20 or more outpatients had dabigatran prescriptions filled between 2010 and 2012.
“Surprisingly, we found that treatment adherence varied not by individual, but by site,” Dr Turakhia said. “We didn’t expect to see that much variation by site.”
So the researchers conducted in-depth telephone interviews with the managers, usually pharmacists, at 41 of these sites.
“We rolled up our sleeves and looked at what each site was doing,” Dr Turakhia said.
At the sites with the highest patient adherence, there was usually a pharmacist actively educating patients on medication adherence, reviewing any possible drug interactions, and following up to make sure patients were taking the medication when they were supposed to and that prescriptions were being refilled on time.
The sites with patients who had the highest adherence levels had some key features in common, among them this type of “pharmacist-led patient management.”
“We determined there was a high level of scrutiny and review to make sure patients were getting the drugs,” Dr Turakhia said. “There was a lot of consideration of the dose, interaction with chronic kidney disease, and review to make sure that patients should be getting these drugs.”
These results suggest an unintended side effect of atrial fibrillation patients switching from warfarin to dabigatran or other new oral anticoagulants may be poorer adherence to medication guidelines because most patients no longer make routine visits to a lab for monitoring.
“This finding challenges the entire framework of healthcare delivery of these new agents,” Dr Turakhia said. “These medicines were pitched as easier for patients and for healthcare providers.”
Since patients on new oral anticoagulants are no longer required to visit labs regularly, in most cases, the physician and/or practice nurses are responsible for checking on adherence. And most doctors’ offices don’t have a system in place to verify how well patients take their medication or get patients their refills promptly before medications run out.
“We’re suggesting that greater structured management of these patients, beyond the doctor just prescribing medications for them, is a good idea,” Dr Turakhia said. “Extra support, like that provided in the VA anticoagulation clinics with supportive pharmacist care, greatly improves medication adherence.”
