OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID-19 pandemic in England
The OpenSAFELY Collaborative None., Curtis H., MacKenna B., Walker A., Croker R., Mehrkar A., Morton C., Bacon S., Hickman G., Inglesby P., Bates C., Evans D., Ward T., Cockburn J., Davy S., Bhaskaran K., Schultze A., Rentsch C., Williamson E., Hulme W., McDonald H., Tomlinson L., Mathur R., Drysdale H., Eggo R., Wing K., Wong AYS., Forbes H., Parry J., Hester F., Harper S., Evans SJW., Douglas I., Smeeth L., Goldacre B.
Background Early in the COVID-19 pandemic the NHS recommended that appropriate patients anticoagulated with warfarin should be switched to direct acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately co-prescribed two anticoagulants following a medication change, and associated monitoring. Objective To describe which people were switched from warfarin to DOACs; identify potentially unsafe co-prescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic. Methods Working on behalf of NHS England we conducted a population cohort based study using routine clinical data from >17 million adults in England. Results 20,000 of 164,000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in co-prescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. INR testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420). Conclusions Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people co-prescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.