Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
2.8.2 Oral anticoagulants

Stopping anticoagulation
• In people with a diagnosis of atrial fibrillation, do not stop anticoagulation solely because atrial fibrillation is no longer detectable. [2021]
• Base decisions to stop anticoagulation on a reassessment of stroke and bleeding risk using CHA2DS2-VASc and ORBIT and a discussion of the person's preferences. [2021]

Assess the risk of bleeding when:
• considering starting anticoagulation in people with atrial fibrillation and Atrial fibrillation
• reviewing people already taking anticoagulation.
• Use the ORBIT bleeding risk score because evidence shows that it has a higher accuracy in predicting absolute bleeding risk than other bleeding risk tools. Accurate knowledge of bleeding risk supports shared decision making and has practical benefits, for example, increasing patient confidence and willingness to accept treatment when risk is low and prompting discussion of risk reduction when risk is high. Although ORBIT is the best tool for this purpose, other bleeding risk tools may need to be used until it is embedded in clinical pathways and electronic systems. [2021]

• Offer anticoagulation with a direct-acting oral anticoagulant to people with atrial fibrillation and a CHA2DS2-VASc score of 2 or above, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance (see anticoagulation treatment in the NICE Pathway on preventing stroke in people with atrial fibrillation. [2021]
• Consider anticoagulation with a direct-acting oral anticoagulant for men with atrial fibrillation and a CHA2DS2-VASc score of 1, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance (see anticoagulation treatment in the NICE Pathway on preventing stroke in people with atrial fibrillation). [2021]
• If direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with atrial fibrillation, offer a vitamin K antagonist. See the section on self-monitoring and self-management of vitamin K antagonists. [2021].
• For adults with atrial fibrillation who are already taking a vitamin K antagonist and are stable, continue with their current medication and discuss the option of switching treatment at their next routine appointment, taking into account the person's time in therapeutic range. [2021]
• Do not offer stroke prevention therapy with anticoagulation to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA2DS2-VASc score of 0 for men or 1 for women). [2021]
• Do not withhold anticoagulation solely because of a person's age or their risk of falls. [2021]
Related guidance
2021 Updated European Heart Rhythm Association Practical Guide on the use of non-Vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation
CoumarinsManagement of patients on warfarin should be in line with the National Enhanced Service specification.
Warfarin500mcg tablets: £1.46
1mg tablets: £0.85
3mg tablets: £0.94
5mg tablets: £0.97
Warfarin is included in the formulary for the following indications (with target INRs):
• Atrial fibrillation: target INR = 2.5
• Treatment of DVT or PE: target INR = 2.5
• Recurrent DVT or PE: target INR = 3.5
• Mechanical prosthetic heart valves: target INR dependent on type and location of valve. Generally a target INR of 3 is recommended for mechanical aortic valves and a target INR of 3.5 for mechanical mitral valves
Direct Oral Anticoagulants
(DOACs formerly NOACs)
For primary care prescribing see NICE guidance on:
Dabigatran - Dabigatran for the prevention of stroke and systemic embolism in atrial fibrillation– TA249
Dabigatran - HOSPITAL ONLY Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults (TA157)
Dabigatran - Dabigatran for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism – TA327
Rivaroxaban – Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation (TA256)
Rivaroxaban – HOSPITAL ONLY Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults (TA170)
Rivaroxaban – Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism (TA261)
Rivaroxaban – Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism (TA287)
Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome (TA335)
Rivaroxaban for preventing atherothrombotic events in people with coronary or peripheral artery disease (TA607)
Apixaban – Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation (TA275)
Apixaban - HOSPITAL ONLY Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults (TA245)
Apixaban - Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (TA341)
Edoxaban - Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (TA355)
Edoxaban - Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (TA354)

Primary prevention of venous thromboembolic events in adult patients after elective total hip replacement surgery or total knee replacement surgery is hospital prescribing only: (see NICE TA157 Dabigatran, NICE TA170 Rivaroxaban, and NICE TA245 Apixaban. The full course should be supplied when the procedure is carried out & there should be no requirement to prescribe for either 10mg rivaroxaban or 75mg dabigatran in primary care. (RED Indication in TLG)
Direct thrombin InhibitorDabigatran75mg capsules: £51.00 (60)
75mg only for after
elective knee & hip surgery in some patients* – RED DRUG

110mg capsules:£51.00 (60)
150mg capsules:£51.00 (60)
Dabigatran is included for
• Prevention of stroke & systemic embolism for people with non-valvular atrial fibrillation where patients fit the criteria in NICE TA249. See Implementation priorities.
• Treatment of DVT and PE, and prevention of recurrent DVT and PE in adults. See TA327
See note above for use post elective hip & knee replacement (NICE TA157).
* Link to SPC
Avoid with dronedarone, HIV protease inhibitors,itraconazole, ketoconazole, voriconazole. St John's Wort and rifampicin reduce DOAC plasma levels
Specific reversal agent for dabigatrinIdarucizumab (Praxbind®)2.5g/50ml solution for injection
Price to be confirmed
For secondary care use only: RED DRUG

Praxbind is a specific reversal agent for dabigatran and is indicated in adult patients treated with Pradaxa (dabigatran etexilate) when rapid reversal of its anticoagulant effects is required:
• For emergency surgery/urgent procedures
• In life-threatening or uncontrolled bleeding.
Direct inhibitor of activated Factor XEdoxaban15mg tablets: £18.50 (10)
Only to be used when switching from 30mg to VKA
30mg tablets: £49.00 (28)
60mg tablets: £49.00 (28)
N.B. Edoxaban is first-line DOAC for AF, where its use is appropriate

Edoxaban is included for prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (NVAF), with one or more risk factors, such as congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA). See NICE TA355 (Sept 15)

Edoxaban is NICE approved for treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrent DVT and PE in adults. NICE TA354 However Apixaban or Rivaroxaban are considered first line for these indications
Rivaroxaban10mg tablets: £54.00 (30)
10mg only for after
elective knee & hip
surgery – RED DRUG

15mg tablets: £50.40 (28)
20mg tablets: £50.40 (28)
• For the prevention of stroke & systemic embolism for people with non-valvular atrial fibrillation in accordance with NICE TA256. See below for implementation priorities
and;
• For treating and preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) for adults in accordance with NICE TA261
and;
• An option for treating pulmonary embolism and preventing recurrent deep vein thrombosis and pulmonary embolism in adults in accordance with NICE TA287
and;
• plus aspirin for preventing atherothrombotic events in people with coronary or peripheral artery disease (TA607)
and;
• As an option to treat signs and symptoms of DVT
and;
• 15mg and 20mg strengths for prevention of cardiovascular disease in patients with atrial fibrillation undergoing cardioversion

See note above for use post elective hip & knee replacement (NICE TA170)

Recent update to license -When extended prevention of recurrent DVT and PE is indicated (following completion of at least 6 months therapy for DVT or PE), the recommended dose is 10 mg once daily . In patients in whom the risk of recurrent DVT or PE is considered high, such as those with complicated comorbidities, or who have developed recurrent DVT or PE on extended prevention with rivaroxaban 10 mg once daily, a dose of rivaroxaban 20 mg once daily should be considered.
Avoid with dronedarone, HIV protease inhibitors, azole antifungals. Effect of rivaroxaban is reduced by St Johns's Wort and rifampicin
Apixaban2.5mg tablets: £57.00 (60)

5mg tablets: £53.20 (56)
Apixaban is included for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation, with one or more risk factors, such as prior stroke or transient ischaemic attack (TIA); age ≥ 75 years;

See note above for use post elective hip & knee replacement (NICE TA245).

For the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism NICE TA341 (June 2015)

The recommended dose of apixaban for the prevention of recurrent DVT and PE is 2.5 mg taken orally twice daily. When prevention of recurrent DVT and PE is indicated, the 2.5 mg twice daily dose should be initiated following completion of 6 months of treatment with apixaban 5 mg twice daily

Use in reduced kidney function- from European Heart Journal, see link above