Patients who suffer from AF and who are above the age of 65 years or have additional comorbidities such as diabetes, high blood pressure, heart failure and vascular disease have a much higher risk of suffering a stroke and it is for this reason they are prescribed anticoagulants. For several years, the only available oral anticoagulant which was proven to reduce strokes in such patients was warfarin. More recently however an alternative class of
anticoagulants have been developed which are as effective and even safer than warfarin. These agents are called the Non-Vitamin K oral antagonists (NOACS). The advantages of NOACS over warfarin are several and include the following:
- They are as effective as warfarin at preventing clot related strokes
- They are safer than warfarin because they are associated with a 50% less likelihood of causing intracranial bleeding
- They do not require frequent monitoring of blood tests like warfarin does
- They are effective almost immediately whereas with warfarin there can be a delay of several weeks to achieve optimal anticoagulation
3 reasons why GPs may not want to prescribe a NOAC
Despite these obvious advantages, many patients have a hard time convincing their GPs to prescribe them a NOAC or switch them from warfarin to a NOAC.
There are 3 reasons for this:
- The patient is genuinely not eligible for a NOAC
- The patient is eligible for a NOAC but the GP does not want to prescribe it because of the additional cost implications.The patient is eligible for a
- NOAC but the GP is not familiar with prescribing the NOAC and therefore prefers to prescribe the more familiar Warfarin.
When the patient is genuinely not eligible for a NOAC
NOACs are only licensed for use in Non-Valvular AF. Many doctors don’t know for sure what this means in practical terms. For the purposes of NOAC prescription, only the following two conditions should be considered as Valvular AF
- Patients who have rheumatic mitral stenosis and
- AFPatients who have metallic heart valves and AF
If the patient doesn’t have either of the above, then they have Non-Valvular AF and therefore would be eligible for a NOAC.
NOACs are not recommended in patients with severe kidney failure and in such patients Warfarin is definitely preferable.
NOACs are not recommended in pregnancy as there is not enough experience of their safety in pregnancy.
When the patient is eligible for a NOAC but the GP does not want to prescribe it because of the additional cost implications.
There is little doubt that the NOACs are more expensive than warfarin. However when the costs of regular blood tests, and patient transportation to have the blood test are factored in, the cost difference is not really as great. Nevertheless many GPs face a lot of pressure from the clinical commissioning groups (CCGs) to prescribe warfarin as 1st choice on account of the cost implications.
When the patient is eligible for a NOAC but the GP is not familiar with prescribing the NOAC and therefore prefers to prescribe the more familiar Warfarin.
Many GPs are not as familiar with prescribing NOACs. It is also true to say that many GPs erroneously believe that the main and only advantage of NOACs is simply that they are more convenient for the patient. Whilst this is undoubtedly an advantage, the biggest advantage is that NOACs are safer than Warfarin as they are associated with less risk of intracranial bleeding.
3 things to say to your GP when they are reluctant to prescribe a NOAC
- The recommendations from the National Institute of Clinical Excellence (NICE) whichwere published in 2014 clearly state that anticoagulation prescription should be based around patient preference and therefore the patient’s choice as to which anticoagulant they want to be prescribed has to be taken into account
- The European Society of Cardiology guidelines of AF published in 2016 state that a NOAC should be prescribed in preference to Warfarin in patients with AF who are eligible for a NOAC
- NOACs are inherently safer than warfarin in terms of intracranial bleeding risk and therefore obviously a more preferable choice.
The above 3 points will make it extremely difficult for your GP to deny you a NOAC.
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