Home' Australian Pharmacist : Australian Pharmacist October 2014 Contents Australian Pharmacist October 2014 I ©Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
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1. What is the estimated prevalence of
atrial fibrillation in Australia?
2. Which ONE of the following is a
direct thrombin inhibitor?
3. In the case study, based on the
information available, what is the
patient’s CHADS2 score?
4. Which ONE of the following treatment
regimens was associated with a
statistically significant reduced risk
of ischaemic stroke compared to
warfarin in its Phase III trial?
a) Apixaban 5 mg twice daily.
b) Rivaroxaban 20 mg daily.
c) Dabigatran 150 mg twice daily.
d) Edoxaban 30 mg daily.
5. Which ONE of the following agents
is preferred in a patient with AF and
valvular heart disease?
the future to reduce the risk of bleeding,
as new data suggests that if the plasma
levels of the drug were measured and
the dose was adjusted accordingly
major bleeds could be reduced by
30–40% compared with well-controlled
of bleeding complications is more
problematic than with warfarin due to the
lack of reversal agents.
Anticoagulant treatment in AF should
be individualised and based on shared
decision-making after review of stroke
and bleeding risk and consideration of the
patient preferences. The CHA2DS
and HAS-BLED scores are being
increasingly used to guide treatment
following their inclusion in international
guidelines. It is important to recognise
that the risk of stroke in patients with AF
without anticoagulant treatment exceeds
the risk of bleeding with anticoagulant
treatment in the majority of patients;
when the HAS-BLED score is high, the
risk of stroke or other embolic events
is usually even higher.
The risk of
bleeding may also be modifiable (e.g.
through better management of blood
pressure, better INR control, or removal
of medicines that increase bleeding risk).
Therefore anticoagulation should be
considered the rule, except in patients at
very low risk of stroke in whom no stroke
prevention therapy is warranted including
aspirin. In contemporary guidelines, sole
antithrombotic therapy with aspirin is
no longer recommended in AF, except in
patients who cannot tolerate or refuse an
anticoagulant. It is important to note that
warfarin remains the preferred option
in patients with AF and valvular heart
disease, and in patients with severe renal
impairment.33 For other patients with AF,
there are now several options.
In the patient described in the case,
there is a clear case to replace aspirin
with an anticoagulant given the risk of
stroke. There is no clear guidance on
which NOAC is best, as no head-to-head
data is available. If warfarin therapy
can be well-controlled, it also remains
a reasonable choice. If considering a
NOAC then comorbidities, renal function,
drug interactions and anticipated
adherence with therapy should be taken
References located on page 73.
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