DOAC Pre-Authorisation Form

Pre-Authorisation: DOAC Formulary & Medicines Optimisation

GP approval to pre-authorise changes to DOAC choice and strength in accordance with clinical parameters and following a patient tele-consultation. *

Rows	Authorisation (Y/N)
Optimise DOAC strength in line with clinical parameters (e.g. CrCl and Weight)
Where deemed appropriate; change Rivaroxaban to appropriate strength of Edoxaban
Where deemed appropriate; change Apixaban to appropriate strength of Edoxaban
Where deemed appropriate; change Dabigatran to appropriate strength of Edoxaban

Pre-Authorisation: DOAC Initiation

GP to approve initiation of DOAC therapy following a pharmacist led patient tele-consultation and notes based review to ensure the initiation meets the clinical criteria e.g. Chadsvasc ≥2, and appropriate blood monitoring and weight, in line with DOAC initiation guidelines and NHSE DOAC commissioning recommendations (Note: list of patients consenting is shared to provide opportunity for GP feedback prior to DOAC initiation) *

Rows	Authorisation (Y/N)
Pharmacist to conduct telephone consultation to discuss and gain patient consent for DOAC initiation and request appropriate monitoring parameters
Where deemed appropriate; initiate a suitable strength of Edoxaban

Service authorised by*

First NameLast Name
On behalf of (Practice name)*
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This service has been financially supported by Daiichi Sankyo UK Ltd

DON/22/0006 Feb 2022
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Pre-Authorisation: DOAC Formulary & Medicines Optimisation