Some patients switched to edoxaban without being properly informed, pharmacists say

Prescribers in England are switching patients to edoxaban without properly informing them, primary care pharmacists have told The Pharmaceutical Journal.

This includes one pharmacist working in a primary care network (PCN) in London, who said a patient was taking two anticoagulants at once because they thought that edoxaban was a new addition to their prescription, instead of a replacement.

In March 2022, NHS England announced three new incentives under the investment and impact fund (IIF) — which is used to support PCNs in delivering high quality care to their patients — for 2022/2023, including one that would reward GP practices with up to £14.8m for prescribing the direct oral anticoagulant (DOAC) edoxaban to more patients.

The incentive follows a deal struck between NHS England and edoxaban’s manufacturer, Daiichi Sankyo, which means that 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 that its national procurement deals on DOACs were aimed to make expanding access to the drugs more affordable and save money for both the NHS and the taxpayer from the reduction in strokes.

In July 2022, the Primary Care Cardiovascular Society, Primary Care Pharmacy Association and UK Clinical Pharmacy Association published guidance on implementing NHS England’s DOAC commissioning recommendations, including first-line use of edoxaban, warfarin to DOAC switching and DOAC to edoxaban switching.

The guidance says that to safely switch a patient from another DOAC to edoxaban, prescribers should “discuss options” with their patient or carers 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 Journal that, in some cases, this guidance is not being followed.

“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 high-risk medications — is proving 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 issue I’m hearing from my pharmacist colleagues is that patients are not being informed about the switch; one patient had even taken both anticoagulants together as they thought edoxaban was a new addition.”

Dadgar said that there may be a “myriad” of reasons as to why this is happening, including that some clinical commissioning groups are switching patients remotely and may assume another healthcare professional will do the appropriate monitoring and follow-up checks.  

“We also have to remember that many of these patients may be particularly vulnerable and elderly,” she added. “They may have been discharged from hospital on apixaban and may be confused and unclear about directions.

“Many patients will also be on dosette boxes and may not know what tablets they take. It’s our job to ensure we are doing everything we can to educate our patients with their medication.”

Dadgar said that safety measures needed to be put in place to ensure that patients were making an “informed” decision about their health.

“We also need up-to-date weight and renal function checks to ensure we are prescribing the correct dosage,” she said. 

“There should never be a blind switch on high-risk medicines with no patient involvement. And we should run clinical audits to ensure these standards are being met.”

Lynne Garforth, a pharmacist and director at Ashburton Prescribing, a prescribing support service, said she had also come across examples of patients being switched where they have not received a full explanation, and had also heard of incidents where patients had ended up taking two DOACs at the same time.

“My team have actually ‘caught’ a few of these examples of patients whilst signing off the daily repeat prescription requests and stopped the switch as they weren’t happy to sign the prescription request that had been submitted by the reviewing pharmacist,” she said.

“This may either be because it wasn’t clinically appropriate or the patient had not received a full explanation about the switch.

“My worry is that these prescription requests can easily slip through the net though as they end up mixed in between the large daily load of repeat prescriptions that need signing and other pharmacist prescribers or a GP may miss this,” she continued.

Garforth said that locally she had seen “a well-thought-through” protocol that insisted on gaining verbal consent from the patient or carer before any switch is made.

“The switch element of this work is part of a bigger project to review DOAC prescribing in general. It gives a detailed checklist and counselling list to use before a decision is made to switch and does state that the patient should be advised as to why this switch is happening — i.e. financial savings for the NHS — and also how to transition from one DOAC to another.”

A spokesperson for NHS England said: “NHS recommendations make clear that it is for the prescribing clinician to determine which DOACs are clinically appropriate for an individual patient, as well as help them with any concerns or questions about their conditions.”

This article was updated on 1 September 2022 to include a comment from NHS England.