Navigating Treatment Options for Venous Thromboembolism (VTE) Disease

A patient was presented at the ER with an unprovoked deep vein thrombosis (DVT). It  was eventually assessed to require indefinite oral anticoagulation therapy. He was started on rivaroxaban, a NOAC (novel oral anticoagulant).  Rivaroxaban as well as other NOACs  are recommended in the latest Chest guidelines as first line treatment options for venous thromboembolism disease. But the provincial drug plan does not recognize this update yet and is set up such that warfarin is the preferred agent for long term anticoagulation therapy. NOACs would only be reimbursed for the initial 6 months if treating conditions such as DVT.

I can talk about my view on warfarin vs NOAC but that’s for another post. Many physicians are now prescribing more NOACs as we gain more clinical experience.  But the challenge continues to exist for patients without any drug coverage.  And when the clinical guidelines and coverage criteria do not align, what should your patient do?

For patients who do not any any means to pay for long term use of NOACs for recurrent DVT, they should never be started on a NOAC in the first place.  It would be difficult to go from taking Rivaroxaban 20mg once daily to taking warfarin which requires routine monitoring as well as considerations for many factors that may affect it adversely.  These patients who cannot afford the medication may simply stop taking the NOAC and put themselves at risk for developing another potentially fatal thrombotic event.

But I think a more effective solution is to engage all stakeholders more effectively.  After all, we are all connected in different ways to deliver patient care. When a set of new clinical guidelines has been released that can significantly change prescribing practices, provincial drug payers as well as suppliers should proactively review if their internal processes or systems require any adjustment.  For example:

  • Should the provincial payers be more proactive to update their coverage criteria for NOACs after the release of the CHEST guidelines? That may be naive on my part. After all, provincial payers do not need to be accountable to the committee who developed these guidelines.
  • Should suppliers be more proactive to adjust their production of NOACs which are more widely recommended? They probably have already given the brand name manufacturers have market access departments to monitor closely any prescribing trends.. But if the guidelines have recommended warfarin more widely which is now a generic medication, we may face potential drug shortages.

I doubt that there is any effective communication at all.  That is why we have a broken health care system that isn’t patient-centred.

Do you have any comments or possible solutions?  Thank you for reading my post.




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My name is Cynthia Leung and I am a practicing pharmacist in Kingston Ontario, Canada. This blog is for me to share my ideas, opinions and perspectives on how medications are used in our health care system. Note that these posts are my own opinions and do not represent the opinions of my current or former employers and / or organizations that I may belong to. Any possible case scenarios described in my posts would be modified to maintain patient confidentiality. This blog is not a platform for professional advise for patients or health care providers and the content is not meant to support any clinical decisions or replace professional opinions. Also the images are either taken or created by the author, or adapted with permission. I hope you will enjoy reading my posts!

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