Patient decision aid for Direct Oral Anticoagulants (DOACs) and Warfarin

  • Reference Number: HEY-795/2016
  • Departments: Stroke Services

Introduction

Your doctor has decided that you would need a strong blood thinning medication to reduce your risk of stroke from atrial fibrillation (a heart rhythm problem) or to treat a clot in your legs or lungs. There are a few different medications available.  The decision tool below is designed to clarify for you the relative advantages and disadvantages of the different groups of medications, which in turn should help you to choose between the two groups.

What is the name of the proposed treatment?

The first option is Warfarin. The second option is a group of medications that are collectively known as direct oral anticoagulants (DOACs).  There are four different DOACs:  Dabigatran, Apixaban, Edoxaba and Rivoroxaban.  The first two come as a twice a day dose, and the last two as a once a day dose.

Why do I need this treatment?

Your doctor has decided that you need strong blood thinning medication to reduce your risk of stroke from atrial fibrillation (a heart rhythm problem) or to treat a clot in your legs or lungs.

Can there be any complications or risks?

The table below may help you choose between the options available and details the risks and benefits of Warfarin and DOACs.

Warfarin

DOACs

Benefits in terms of reducing the risk of stroke Warfarin reduces the risk of stroke from 40:1000 people to 14:1000 people. These medications are as effective as warfarin in reducing the risk of stroke.
Risk of bleeding The commonest side effect is the risk of bleeding, either in the brain or from the gut. The risk of this happening in the brain is about 5-7:1000 people taking the medication for a year.  Bleeding in the gut occurs in about 10-20:1000 people every year The trials have shown that bleeding in the brain is much less common with these agents: 1-5:1000 per year. Bleeding in the gut occurs in 8-30:1000 per year. There are small differences between the four agents and your doctor will take these into consideration when considering the best one for you.
Methods of administration Once a day orally Once or twice a day orally depending on the specific DOAC chosen.

Apixaban, Edoxaba and Rivoroxaban can be crushed for tube feeding and can go into a NOMAD system if needed. Dabigatran cannot.

Need for blood tests. You will need blood tests to monitor your levels of blood thinning. These will be more frequently in the beginning and less frequently once your blood levels are in range. No blood tests are necessary for this treatment. However, this means you have to remember to take your medications at the specified time as we have no readily available ways of checking your blood levels.  You will need 6 monthly or yearly blood tests for your kidney and liver functions.
Time taken to achieve therapeutic levels of drugs It may take at least 4-7 days to achieve adequate levels of warfarin in your system. Your doctor may decide to give you additional Warfarin by injection to ensure you are receiving the adequate dose during this time. Therapeutic levels of these drugs are usually reached within 3-4 hours. You therefore do not need any other medications in addition.
Interactions with food, alcohol and other medications Warfarin interacts with a number of food substances, alcohol and a variety of commonly used medications. You will be given a list of food substances that you should avoid. These medications are not known to interact with food substances or alcohol and interact with very few medications.
Can the effects of this medication be reversed? If you have a complication you can be given blood products and a medication (vitamin K) to stop further bleeding. Antidote for Dabigatran has been approved and has been available since January 2016. The antidote for the others will be available early 2016.
How much is known about this medication? Warfarin has been around for several years and we know about the long term effects of this drug. These medications have been around only for a short while and long term safety data is awaited.

What happens now?

Please read this information leaflet. Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you.

Once you have chosen the drug you wish to take, the doctor who has given you this leaflet will either give you a prescription for DOACs or refer you to the nearest anticoagulation service for blood tests.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Stroke Department on tel no: (01482) 608721/608746

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.