LAUSR

Dear editor We read with great interest a recent contribution published by Poli et al. (2020), highlighting the impacts of the COVID-19 pandemic on therapeutic choices in managing oral anticoagulation therapy (OAC). We would like to add some comments and reflections on the specific impact that the restriction measures adopted for flattening the epidemic curve of the COVID-19 pandemic have on strategies for managing outpatients in OAC. We strongly agree with the authors’ suggestions of favoring anticoagulation with direct oral anticoagulants (DOACs) in patients without contraindications, and to promote the use of point-of-care (POC) devices in those on vitamin K antagonists (VKAs) [1]. To add evidence to these suggestions and support their implementation, we report some data from the interim analysis we have conducted on a National Italian study aimed to describe independent risk factors of non-adherence among patients on OAC during the COVID-19 pandemic. So far, we enrolled 258 patients during the epidemic tail-end of the first Italian epidemic wave (June–August 2020). At the beginning of the lockdown due to the COVID-19 outbreak in Italy (March–May 2020), the Italian Federation of Anticoagulation Clinics (FCSA) published statements to offer advice for preventing person-to-person diffusion [1]. Based on the statements of the FCSA, Poli et al. (2020) provided practical guidance for improving patient care during both lockdown and reopening phases (June–August 2020). In particular, some actions have been identified for the reopening phase (tail-end of the first Italian epidemic wave), such as maintening all recommended precaution for ensuring safety for staff and patients, rapid and active clinical and laboratory follow-ups, and switch from AVK to DOAC when feasible [1]. In our interim analysis, among the subgroup of patients that could be theoretically switched from VKAs to DOACs (n = 207), only 23 were switched. Patients under VKAs were 222, and only 81 practised a self-management model of OAC. Among the patients who reported to adopt a self-management model, the majority (74.3%) did not receive either any educational training in self-management or any proposal to attend educational initiatives. However, our survey suggests that patients are generally willing to be involved in educational initiatives for best managing OAC: 72.4% of patients treated with VKAs and traditional OAC model (105 out of 145 patients) are willing to self-manage their treatment during the restriction measures derived from the COVID-19 pandemic. Anyhow, a relevant barrier to self-management is the high cost of POC, which is defined as “unsustainable” from 43.5% of patients. Finally, considering patients under DOACs (n = 36), 33% of them (n = 12) did not receive adequate information on the management and clinical features of DOACs. These results reflect a system-related difficulty in receiving the recommendations for best practice in managing OAC [1], more than reflecting the clinician-level decision-making in adhering to those recommendations. In other words, from a public health perspective, there is an emerging mismatch between the pivotal strategies to manage OAC during this pandemic situation (e.g., safe therapeutic switch and implementation of self-management models when a switch from VKAs to DOACs is not feasible) and the availability of public healthcare services. The main public healthcare services * Arianna Magon [email protected]