In an interview with Pharmacy Times, Stephanie Dwyer Kaluzna, PharmD, BCCP, clinical assistant professor and cardiology clinical pharmacist at the University of Illinois Chicago Retzky College of Pharmacy, discussed optimizing anticoagulation management in patients with atrial fibrillation (AFib), including guideline-based risk stratification, individualized therapy selection, and the emerging class of factor XI/XIa inhibitors.
Dwyer Kaluzna emphasized that both risk stratification and therapy selection must be individualized, using tools such as the CHA₂DS₂-VASc score alongside the Anticoagulation and Risk Factors in Atrial Fibrillation score (ATRIA) and Global Anticoagulant Registry in the FIELD score (GARFIELD) to assess thromboembolic risk and the HAS-BLED score to identify patients requiring closer monitoring—not to withhold anticoagulation, but to guide it. She stressed that drug interactions, contraindications, and patient affordability are critical factors in therapy decisions.
On factor XI/XIa inhibitors, Dwyer Kaluzna described the class as promising for its potential to uncouple thrombosis and hemostasis, offering at least comparable efficacy to existing agents while potentially reducing bleeding risk. She noted these therapies may ultimately benefit patients who cannot tolerate current anticoagulants due to drug interactions or comorbidities. Regarding pharmacist-led care, she outlined a comprehensive role spanning drug selection, patient counseling, and ongoing monitoring—including renal function reassessment—as the foundation of individualized anticoagulation management.
Pharmacy Times: With updated guidelines and a growing list of anticoagulant options, how should pharmacists approach therapy selection and risk stratification for patients with AFib?
Key Takeaways
- Risk stratification in AFib should use CHA₂DS₂-VASc alongside tools like ATRIA and GARFIELD for thromboembolic risk, balanced with HAS-BLED to identify patients needing closer monitoring; not to exclude anticoagulation, but to personalize it.
- Factor XI/XIa inhibitors represent an exciting emerging class that may decouple thrombosis from hemostasis, potentially offering comparable efficacy to current anticoagulants with a reduced bleeding burden, particularly for patients intolerant of existing therapies.
- Pharmacist-led anticoagulation care encompasses the full continuum—from selecting the right agent and counseling patients on adherence to building and executing individualized monitoring plans based on each patient's clinical profile.
Stephanie Dwyer Kaluzna, PharmD, BCCP: Yeah, that's a wonderful question. Ultimately, I think both therapy selection and risk stratification have to be brought down to the individual patient level. When it comes to risk stratification, utilize our CHA₂DS₂-VASc scores and other scoring tools—such as ATRIA and GARFIELD—to assess thromboembolic risk, and then try to balance that with the bleeding risk that we can assess from the HAS-BLED score. Importantly, recognize that the HAS-BLED score shouldn't tell us not to anticoagulate, but just who might be at higher risk for bleeding events and need closer monitoring.
Therapy selection, as with any drug, always needs to be individualized. You need to think about things like drug interactions and contraindications that the patient may have, and then finally think about cost, accessibility, and affordability. A medication is only effective if a patient can afford to take it.
Pharmacy Times: Factor XI/XIa inhibitors are generating a lot of buzz. What do pharmacists need to know about how they work and where they might fit compared to current standard-of-care anticoagulants?
Dwyer Kaluzna: Yeah, it's a very exciting time in anticoagulation—hopefully promising. Our factor XIa and factor XI inhibitors seek to try to uncouple thrombosis and hemostasis. Ultimately, the hope is that they're going to be at least as effective as our current agents in preventing thrombotic events but potentially may be able to further reduce the bleeding events that we see with anticoagulant therapy. It's going to be very exciting over the next couple of years to see how the evidence with these therapies evolves in terms of where they might fit relative to the current standard of care.
I think that data is still ongoing and ultimately will be answered in the coming years. But again, the hope is that they may be an option for patients who are not tolerant of our current anticoagulant medications—perhaps those who have drug-drug interactions or drug-disease interactions that would prevent us from using the agents we currently have. So the hope is that they'll fit into that space.
Pharmacy Times: Anticoagulation in AFib is rarely one-size-fits-all. What does pharmacist-led shared decision-making actually look like when building an individualized plan for these patients?
Dwyer Kaluzna: Yes, that's a great question. In terms of making it pharmacist-led, I think we as pharmacists can take the initiative to, one, select the appropriate drug for the patient—taking into account all of the things we've discussed in terms of drug interactions, contraindications, dosing, accessibility, and affordability—and then making sure that the patient can get the drug and taking ownership of counseling and educating the patient as to why they need the medication so that they understand the importance of it.
And then I think what really brings it home from a pharmacist perspective is developing the monitoring plan for the patient while they're on this therapy. The pharmacist has the knowledge to be able to do that—we can say, "Okay, we need to repeat your renal function in 6 months or a year," depending on what the patient's baseline looks like. I think owning the entire process as a pharmacist—all the way from drug selection to drug monitoring—is a way that we as pharmacists can help ensure that the patient is getting the best therapy for them.
