Practice Pearl #2 Lab Monitoring with DOACs

Experts discuss the recommendation in monitoring when using DOACs.

Jessica Kerr, PharmD, CDE: Going back to the lab-monitoring component, do you guys have any concerns with lack of monitoring? So many of my patients in the warfarin, or Coumadin, clinics were anxious to see what their INR was. Because if it was in a certain range, they felt confident that they’re ok. With the lack of monitoring, have you seen that clinicians are more skeptical of where the efficacy is really lying with that patient? Provide us some insight with that.

Paul Dobesh, PharmD, FCCP, BCPS: I’m sure Matt has perspective on this as well, but early on there was a lot of skepticism. It’s interesting: We bashed warfarin and hated the monitoring for 5 decades. Then we get something you don’t have to monitor, and we’re complaining there’s no monitoring. There was definitely some skepticism early on from both patients and practitioners. So you educate about how they provide a very consistent anticoagulant effect.

One of the things that seemed to help when I was doing these efforts was trying to get people to think about low molecular weight heparins, which came out 10, 15 years earlier. Low molecular weight heparins were things you didn’t have to monitor—consistent dosing. I’m describing the fact that it’s not much different from that. Even though it acts longer, it is a consistent effect. Today I don’t think a lot of clinicians—maybe in extreme of weight, maybe in renal insufficiency there’s some skepticism about excess levels or not enough. For a lot of clinicians, that’s gone away. For patients, especially when you’re transferring from warfarin, as you brought up, most of the time it’s been successful. I mean, I can describe it for them in just a couple of minutes. I don’t work in ambulatory care clinics, so I don’t have the exposure you do, Jessica. But usually they go, “OK, makes sense.” And they frankly embrace the lack of monitoring from that perspective. Matt, I’m sure you have a clinical perspective.

Matthew Johnson, MD: I agree. We need to just sit down and explain to them the first time about the beauty of these drugs, especially those patients who switched or transitioned from warfarin therapy. They tend to embrace that beauty and not having to monitor the lab draws. From a provider perspective, I do think, as Paul said, for maybe a few subsets you start to get some skepticism of the renal-insufficient patients, or those morbidly obese patients, and sometimes older patients get thrown in there too. But for the most part, that’s pretty well accepted from the provider’s standpoint.