Prescribers in England switch patients to edoxaban without properly informing them, first-line pharmacists have been told The pharmaceutical magazine.
This includes a pharmacist working in a primary care network (PCN) in London who said a patient was taking two anticoagulants at once because they thought edoxaban was a new addition to their prescription, rather than a replacement.
In March 2022, NHS England announced three new incentives under the Investment and Impact Fund (IIF) – used to support PCNs in delivering high-quality care to their patients – for 2022/2023, including one that would support GP practices reward up to £14.8 million for prescribing the direct oral anticoagulant (DOAC) edoxaban to more patients.
The stimulus follows a deal struck between NHS England and edoxaban manufacturer Daiichi Sankyo, meaning it has the lowest net acquisition cost by a significant margin compared to other DOACs.
In a statement published in November 2021, NHS England said its national purchasing agreements for DOACs aimed to make access to the medicines more affordable and save money for both the NHS and taxpayers by reducing strokes.
In July 2022, the Primary Care Cardiovascular Society, Primary Care Pharmacy Association and UK Clinical Pharmacy Association published guidelines for implementing NHS England’s DOAC recommendations, including first-line use of edoxaban, warfarin to DOAC switching and DOAC to edoxaban switching.
The guideline says that in order to safely transfer a patient from another DOAC to edoxaban, prescribers should “discuss options” with their patient or caregivers and, “with consent,” prescribe edoxaban at the appropriate dose. Prescribers should then remove the current DOAC from the repeat prescription after adding edoxaban.
However, pharmacists have told: The pharmaceutical magazine that this guideline is not followed in some cases.
“Cost savings are important in all parts of the NHS and we can all do more to help. However, switching patients who are stable on their anticoagulants – which are risky drugs – appears to be more of a patient safety concern,” said Melissa Dadgar, a clinical pharmacist at a central London PCN.
“There may be clinically justifiable reasons for the switch, such as improving adherence with the once-daily dosing of edoxaban. But the main problem I hear from my pharmacy colleagues is that patients are not being informed about the switch; one patient had even taken both anticoagulants together because they thought edoxaban was a new addition.”
Dadgar said there could be “a myriad” of reasons why this is happening, including the fact that some groups of clinical principals switch patients remotely and assume that another health care professional will perform appropriate monitoring and follow-up checks.
“We also need to remember that many of these patients may be particularly frail and old,” she added. “They may have been discharged from the hospital on apixaban and may be confused and unclear about the direction.
“Many patients will also be on dosette boxes and may not know which tablets they are taking. Our job is to make sure we do everything we can to educate our patients about their medication.”
Dadgar said safety measures needed to be put in place to ensure patients made an “informed” decision about their health.
“We also need current weight and kidney function checks to make sure we’re prescribing the right dosage,” she said.
“There should never be a blind switch to high-risk drugs without patient involvement. And we need to conduct clinical audits to ensure these standards are met.”
Lynne Garforth, a pharmacist and director at Ashburton Prescription, a prescribing support service, said she had also come across examples of patients being switched where they hadn’t been given a full explanation, and had also heard of incidents where patients ended up taking two DOACs at the same time.
“My team ‘caught’ a few of these patient samples as they signed off the daily repeat prescription requests and then stopped switching because they weren’t happy to sign the prescription request submitted by the reviewing pharmacist,” she said.
“This could be because it was not clinically appropriate or because the patient had not been given a full explanation of the switch.
“My concern is that these prescription requests can easily slip through the net because they get mixed up between the large daily amount of repeat prescriptions that have to be signed and other pharmacists prescribing or a GP might miss this,” she continued.
Garforth said she saw “a well-thought-out” protocol at the scene that insisted on getting verbal consent from the patient or caregiver before switching.
“The linking element of this work is part of a larger project to review DOAC prescribing in general. It provides a detailed checklist and advice list to use before making a decision to switch and states that the patient should be informed as to why this switch is taking place – ie financial savings for the NHS – as well as how to switch from one DOAC to another.”
A spokesperson for NHS England said: “NHS recommendations make it clear that it is up to the prescribing physician to determine which DOACs are clinically appropriate for an individual patient, and help them with any concerns or questions about their conditions.”
This article was updated on 1 September 2022 with a comment from NHS England.