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Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Anticoagulation Debbie L. Cardell, MD Asst. Clinical Prof of Medicine Medical Director UHC-D Anticoagulation.

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Presentation on theme: "Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Anticoagulation Debbie L. Cardell, MD Asst. Clinical Prof of Medicine Medical Director UHC-D Anticoagulation."— Presentation transcript:

1 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Anticoagulation Debbie L. Cardell, MD Asst. Clinical Prof of Medicine Medical Director UHC-D Anticoagulation Clinic

2 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Today’s Topics Diagnoses for which anticoagulation is necessary Diagnoses for which anticoagulation is necessary Duration of therapy Duration of therapy INR goal INR goal Starting warfarin Starting warfarin Sources of evidenced based medicine Sources of evidenced based medicine Drug/Drug interactions Drug/Drug interactions System wide protocol System wide protocol Work up of PE/DVT Work up of PE/DVT

3 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Diagnoses requiring warfarin Atrial fibrillation - sometimes Atrial fibrillation - sometimes Valvular Heart Disease Valvular Heart Disease Prosthetic heart valves Prosthetic heart valves DVT DVT PE PE Hypercoagulable States - sometimes Hypercoagulable States - sometimes THR, TKA, hip fracture repair THR, TKA, hip fracture repair Pulmonary Hypertension Pulmonary Hypertension

4 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Copyright ©2001 American Heart Association Fuster, V. et al. Circulation 2001;104:2118-2150 Antithrombotic therapy for prevention of stroke (ischemic and hemorrhagic) in patients with nonvalvular AF: adjusted-dose warfarin compared with placebo

5 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Case 1 46 y.o. male continuity patient with allergic rhinitis, found on exam to have irregular pulse. No other medical problems. 46 y.o. male continuity patient with allergic rhinitis, found on exam to have irregular pulse. No other medical problems. Pulse irreg. 76 bpm, BP 132/76 Pulse irreg. 76 bpm, BP 132/76 EKG shows a-fib EKG shows a-fib

6 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 1 Does the patient need anticoagulation? Does the patient need anticoagulation?

7 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Answer No No Provide proof for your answer Provide proof for your answer

8 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Atrial Fibrillation CHADS2 score is an easy to use clinical tool for determining who needs warfarin CHADS2 score is an easy to use clinical tool for determining who needs warfarin C – CHF- 1 point C – CHF- 1 point H – treated HTN - 1 point H – treated HTN - 1 point A – age >75 – 1 point A – age >75 – 1 point D – diabetes – 1 point D – diabetes – 1 point S – prior history of stroke or TIA-2 points S – prior history of stroke or TIA-2 points

9 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 CHADS2 score and risk of stroke Score Risk of Stroke per 100 patient years 01.9 12.8 24.0 35.9 48.5 52.5 618.2

10 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Interpreting the CHADS2 score ScoreRisk Anticoagula tion Therapy Considerati ons 0LowAspirin 325 mg likely to offer most benefit 1-2Moderate Aspirin or Warfarin INR goal 2- 3 3HighWarfarin

11 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Exception to CHADS2 Although a patient with a prior stroke and no other risk factors would only have a score of 2 and calculates out as a moderate risk, they are truly high risk and should be treated with warfarin in the absence of contraindications. Although a patient with a prior stroke and no other risk factors would only have a score of 2 and calculates out as a moderate risk, they are truly high risk and should be treated with warfarin in the absence of contraindications.

12 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Case 2 54 y.o. man with HTN well controlled on HCTZ and metoprolol, found to have irregular pulse 54 y.o. man with HTN well controlled on HCTZ and metoprolol, found to have irregular pulse EKG shows a-fib EKG shows a-fib Echo one year ago EF 60% Echo one year ago EF 60%

13 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 2 Does this patient need warfarin? Does this patient need warfarin?

14 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Interpreting the CHADS2 score ScoreRisk Anticoag- ulation Therapy Considera- tions 0LowAspirin 325 mg likely to offer most benefit 1-2Moderate Aspirin or Warfarin INR goal 2-3 2-3 3HighWarfarin INR goal 2-3

15 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Valid contraindications to warfarin Patient refusal Patient refusal Non-compliance with INR monitoring Non-compliance with INR monitoring Alcohol consumption Alcohol consumption Bleeding diathesis Bleeding diathesis History of major bleeding History of major bleeding

16 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 3 56 y.o. woman with MVP admitted 4 mos ago for TIA 56 y.o. woman with MVP admitted 4 mos ago for TIA Does she need warfarin? Does she need warfarin?

17 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Answer Only if she is an ASA failure Only if she is an ASA failure MVP with h/o stroke or TIA –ASA dose of 50-160mg daily MVP with h/o stroke or TIA –ASA dose of 50-160mg daily If fails ASA – then warfarin If fails ASA – then warfarin

18 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Valvular Disease MVP with h/o stroke or embolization – ASA 50- 160 mg MVP with h/o stroke or embolization – ASA 50- 160 mg MVP with ASA failure – warfarin – long-term range 2-3 MVP with ASA failure – warfarin – long-term range 2-3 Rheumatic heart disease – mitral valve – with a- fib and/or prior history of stroke – lifetime use of warfarin with a goal of 2-3 Rheumatic heart disease – mitral valve – with a- fib and/or prior history of stroke – lifetime use of warfarin with a goal of 2-3 Rheumatic Mitral Valve disease and NSR with Left Atrial size >5.5 cm – lifetime warfarin goal 2-3 Rheumatic Mitral Valve disease and NSR with Left Atrial size >5.5 cm – lifetime warfarin goal 2-3

19 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 4 60 y.o. man with prosthetic aortic valve, echo shows nl EF. He has never had a stroke or TIA. He has a bi-leaflet valve. 60 y.o. man with prosthetic aortic valve, echo shows nl EF. He has never had a stroke or TIA. He has a bi-leaflet valve. What is his INR goal? What is his INR goal?

20 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Prosthetic Heart Valves Goals Goals –Aortic position – NSR, NL LA size, bi-leaflet or tilting disc prosthesis - INR 2.0-3.0 –Aortic position – other risk factors* INR 2.5-3.5 –Mitral position – 2.5-3.5 Duration – lifetime if mechanical, 12 weeks post surgery if bio-prosthetic (porcine) Duration – lifetime if mechanical, 12 weeks post surgery if bio-prosthetic (porcine)

21 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 AVR + Other Risk Factors = INR 2.5-3.5 Atrial Fibrillation Atrial Fibrillation Myocardial infarction Myocardial infarction Left atrial enlargement > 5.5cm Left atrial enlargement > 5.5cm Endocardial damage Endocardial damage Low ejection fraction Low ejection fraction Caged ball or caged disc valve Caged ball or caged disc valve

22 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 5 Patient with AVR tells you his brother just had an MI at 49y.o. He picked up a new habit, smoking, since you last saw him. Patient with AVR tells you his brother just had an MI at 49y.o. He picked up a new habit, smoking, since you last saw him. Would you start ASA for primary prevention of CV disease? Would you start ASA for primary prevention of CV disease?

23 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Answer Yes Yes

24 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Aspirin Plus Warfarin? When? When? Only proven benefit is in patients with Prosthetic Valves and increased CV risk or previous MI Only proven benefit is in patients with Prosthetic Valves and increased CV risk or previous MI –WARIS II –ASPECT 2 Dose should be 81mg Dose should be 81mg

25 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Next Case 28 y.o. woman presents to the ER on one of your call days with a unilateral swollen leg 28 y.o. woman presents to the ER on one of your call days with a unilateral swollen leg Doppler reveal a DVT Doppler reveal a DVT History reveals she just had breast reduction surgery 2 weeks ago History reveals she just had breast reduction surgery 2 weeks ago

26 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 6 What is her INR goal? What is her INR goal? How long would you treat her? How long would you treat her?

27 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Deep Vein Thrombosis INR goal is 2.0-3.0 INR goal is 2.0-3.0 Duration depends on clinical scenario Duration depends on clinical scenario

28 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Classifying Patients First-episode DVT secondary to a transient risk factor First-episode DVT secondary to a transient risk factor First-episode DVT and concurrent cancer First-episode DVT and concurrent cancer First-episode idiopathic DVT First-episode idiopathic DVT First-episode DVT associated with a prothrombotic genotype First-episode DVT associated with a prothrombotic genotype Recurrent DVT Recurrent DVT CHEST 2003

29 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 1 st DVT, Transient Risk Factor Treat to INR 2-3 for 3 months Treat to INR 2-3 for 3 months Transient Risk factors include Transient Risk factors include –Surgery –Pregnancy –Hospitalization –Trauma –Fracture

30 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Next Case 67 y.o. male continuity patient seeing you after hospital discharge, comes to clinic for follow up. He was admitted for a UE DVT. During admission he was found to have widely metastatic liver cancer. 67 y.o. male continuity patient seeing you after hospital discharge, comes to clinic for follow up. He was admitted for a UE DVT. During admission he was found to have widely metastatic liver cancer. What is your anticoagulant of choice? What is your anticoagulant of choice? How long do you treat him? How long do you treat him?

31 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 DVT in the setting of Cancer LMWH is recommended the in CHEST guidelines for the first 3-6 months of long term therapy LMWH is recommended the in CHEST guidelines for the first 3-6 months of long term therapy LMWH is recommended for advanced and metastatic cancers LMWH is recommended for advanced and metastatic cancers LMWH is recommended during chemotherapy LMWH is recommended during chemotherapy In select patients with localized disease, warfarin can be considered In select patients with localized disease, warfarin can be considered

32 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Next Case 37 y.o. man in your clinic comes in acutely complaining of leg pain and swelling. 37 y.o. man in your clinic comes in acutely complaining of leg pain and swelling. He denies, travel, recent surgery, hospitalization, prolonged immobilization. He denies, travel, recent surgery, hospitalization, prolonged immobilization. You are able to obtain dopplers. You are able to obtain dopplers. He has a DVT He has a DVT

33 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 7 What is his INR goal? What is his INR goal? How long do you treat him? How long do you treat him?

34 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 First Idiopathic VTE At least 6 months (6-12 months) At least 6 months (6-12 months) –PREVENT trial – after 3 months of anticoagulation, 508 patients randomized to continuation of warfarin (INR 1.5-2.0) vs. placebo. Trial stopped after 4.3 years when there was a significantly lower rate of recurrent VTE in the warfarin group (2.6 versus 7.2 per 100 patient-years, hazard ratio [HR] 0.36, 95% CI 0.19-0.67) –ELATE – after 3 months of INR 2.0-3.0, 738 patients randomized low dose warfarin INR 1.5-1.9 vs. 2.0- 3.0. f/u 2.4 yrs. Recurrent VTE was significantly lower in the higher dose warfarin group (1.9 versus 0.7 per 100 patient-years, HR 2.8, 95% CI 1.1-7.0).

35 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 After six months Risks and benefits need to be reviewed with the patient Risks and benefits need to be reviewed with the patient –Risk of minor bleeding with continued anticoagulation 12.8 per 100 pt years, major bleeding is 2.7 per 100 patient-years, with a case fatality rate of 9.1 percent (95% CI 2.5-22) Ann Intern Med 2003 Dec 2;139(11):893-900. –Risk of recurrent VTE on no warfarin 7.2-8.4 per 100 pt years in PREVENT and THRIVE III trials, low dose warfarin 1.9-2.6 per 100 pt years (ELATE and PREVENT), and.7 episodes per 100 pt years on full dose warfarin (ELATE)

36 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Case Continued His 6 months of warfarin therapy are over His 6 months of warfarin therapy are over You discuss the risks and benefits of treating him for a year vs. stopping now You discuss the risks and benefits of treating him for a year vs. stopping now He opts to stop the warfarin He opts to stop the warfarin Should you test him for acquired and hereditary thrombophilias? Should you test him for acquired and hereditary thrombophilias? Are there any other tests to determine his individual risk? Are there any other tests to determine his individual risk?

37 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 The risk-benefit of indefinite treatment with a VKA for a second episode of VTE has been evaluated in a randomized trial in which Schulman et al58 compared 6 months of treatment with indefinite treatment (average, 4 years) in 227 patients with a second episode of VTE. Conventional-intensity anticoagulant treatment (INR, 2.0 to 3.0) was used in both groups. After 4 years of follow-up, the cumulative incidence of recurrent VTE was 20.7% in patients who received 6 months of therapy, compared to 2.6% in patients who continued anticoagulant treatment (p < 0.001; absolute risk reduction, 18.1%; RRR, 87%). This benefit was offset partially by major bleeding. The cumulative incidence of major bleeding was 8.6% for the indefinite treatment group, compared with 2.7% in the 6-months group (p = 0.084; absolute risk increase, 5.9%). Thus, during extended treatment for an average of 4 years, the number needed to treat (NNT) to prevent one episode of recurrent VTE was 6, and the number needed to harm (NNH) for major bleeding was 17. The risk-benefit of indefinite treatment with a VKA for a second episode of VTE has been evaluated in a randomized trial in which Schulman et al58 compared 6 months of treatment with indefinite treatment (average, 4 years) in 227 patients with a second episode of VTE. Conventional-intensity anticoagulant treatment (INR, 2.0 to 3.0) was used in both groups. After 4 years of follow-up, the cumulative incidence of recurrent VTE was 20.7% in patients who received 6 months of therapy, compared to 2.6% in patients who continued anticoagulant treatment (p < 0.001; absolute risk reduction, 18.1%; RRR, 87%). This benefit was offset partially by major bleeding. The cumulative incidence of major bleeding was 8.6% for the indefinite treatment group, compared with 2.7% in the 6-months group (p = 0.084; absolute risk increase, 5.9%). Thus, during extended treatment for an average of 4 years, the number needed to treat (NNT) to prevent one episode of recurrent VTE was 6, and the number needed to harm (NNH) for major bleeding was 17.58 CHEST CHEST

38 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Screening for Thrombophilias Controversial – there is no consensus Controversial – there is no consensus Arguments against screening – Arguments against screening – –excessive, not cost effective, does not impact treatment Arguments for screening – Arguments for screening – –some patients (1-2%) have very high risk profiles, knowledge could help manage risky situations such as surgery and pregnancy –Helps in screening of family members

39 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Inherited Thrombophilias Require life long anticoagulation only in the following cases: Require life long anticoagulation only in the following cases: –Two or more spontaneous thromboses or one spontaneous thrombosis in the case of antithrombin deficiency or the antiphospholipid syndrome antithrombin –One spontaneous life-threatening thrombosis (e.g., near-fatal pulmonary embolism; cerebral, mesenteric, or portal vein thrombosis) –One spontaneous thrombosis at an unusual site (e.g., mesenteric or cerebral vein) –One spontaneous thrombosis in the presence of more than a single genetic defect predisposing to a thromboembolic event UpToDate

40 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Consider screening In Strongly Thrombophilic patients – In Strongly Thrombophilic patients – –First idiopathic VTE prior to 50 y.o. –History of recurrent thrombotic episodes –First-degree relative with thrombotic episode prior to the age of 50

41 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 When not to screen Recent major surgery, trauma, or immobilization Recent major surgery, trauma, or immobilization Active malignancy Active malignancy Systemic lupus erythematosus Systemic lupus erythematosus Inflammatory bowel disease Inflammatory bowel disease Myeloproliferative disorders Myeloproliferative disorders Heparin-induced thrombocytopenia with thrombosis Heparin-induced thrombocytopenia with thrombosis Preeclampsia at term Preeclampsia at term Retinal vein thrombosis Retinal vein thrombosis

42 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Individual Risk Assessment D-dimer testing – 4 studies have shown an increased risk of recurrent VTE in patients with elevated D-dimers after 3 months of anticoagulation HR 2-2.5 D-dimer testing – 4 studies have shown an increased risk of recurrent VTE in patients with elevated D-dimers after 3 months of anticoagulation HR 2-2.5 –One of the studies showed only 5 patients out of 186 with a normal D-dimer with a recurrent VTE, this give a negative predictive value of >96%. Thromb Haemost 2002 Jan;87(1):7-12.

43 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Recurrent VTE Trials are ongoing to determine the optimal duration of treatment, but for now recommendations say “indefinite” unless there is a reversible cause Trials are ongoing to determine the optimal duration of treatment, but for now recommendations say “indefinite” unless there is a reversible cause If reversible cause – then treat until the risk factor is no longer an issue If reversible cause – then treat until the risk factor is no longer an issue

44 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Upper Extremity Thrombosis General consensus is that this represents a more thrombogenic patient General consensus is that this represents a more thrombogenic patient No randomized controlled trials to determine the most appropriate length of therapy No randomized controlled trials to determine the most appropriate length of therapy If a reversible cause – can treat for 3-6 months If a reversible cause – can treat for 3-6 months If not – long term anticoagulation If not – long term anticoagulation

45 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Next Case You are called to the ER to see one of your clinic patients. She is 42 y.o. c/o SOB for 1 day, she is breathing rapidly and is tachycardic, her O2 sats are 88%. CXR is negative. WBCs are normal. She is not hypotensive. You are called to the ER to see one of your clinic patients. She is 42 y.o. c/o SOB for 1 day, she is breathing rapidly and is tachycardic, her O2 sats are 88%. CXR is negative. WBCs are normal. She is not hypotensive. You order a PE protocol CT. It is positive. You order a PE protocol CT. It is positive. How long will this patient need to be treated for her PE? How long will this patient need to be treated for her PE?

46 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Treatment for PE Treatment goals are the same as DVT Treatment goals are the same as DVT Duration the same as DVT Duration the same as DVT Exception is “massive PE” which is defined as “shock” or requiring pressors – this would constitute a reason for lifelong anticoagulation Exception is “massive PE” which is defined as “shock” or requiring pressors – this would constitute a reason for lifelong anticoagulation

47 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Other Considerations Compression Stockings should be prescribed at 30-40mm Hg at the ankle in all patients with DVT within a month after Dx and continued for 1-2 years. This has been proven to reduce the incidence of post-thrombotic syndrome by 50% Lancet 1997;349,759-762 Compression Stockings should be prescribed at 30-40mm Hg at the ankle in all patients with DVT within a month after Dx and continued for 1-2 years. This has been proven to reduce the incidence of post-thrombotic syndrome by 50% Lancet 1997;349,759-762 Patients should be on “ambulation as tolerated” Patients should be on “ambulation as tolerated” NSAIDs are not recommended during the acute treatment of DVT NSAIDs are not recommended during the acute treatment of DVT

48 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Total Hip Replacement Low Molecular Weight Heparin (LMWH) Low Molecular Weight Heparin (LMWH) or or Warfarin with a target INR of 2.0-3.0 Warfarin with a target INR of 2.0-3.0 or or Fondaparinux 2.5 mg daily Fondaparinux 2.5 mg daily Duration: 28-35 days Duration: 28-35 days

49 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Hip Fracture Surgery Same recommendations as Total Hip Replacement Same recommendations as Total Hip Replacement

50 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Total Knee Arthroplasty (TKA) LMWH at high risk doses LMWH at high risk doses or or Warfarin with INR goal 2.0-3.0 Warfarin with INR goal 2.0-3.0 or or Fondaparinux Fondaparinux Duration: 10 days Duration: 10 days

51 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Next Case 62 y.o. female with Pulmonary Hypertension secondary to COPD 62 y.o. female with Pulmonary Hypertension secondary to COPD She is in NSR She is in NSR Her last echo showed an EF of 50% Her last echo showed an EF of 50%

52 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 8 Does she need warfarin? Does she need warfarin? Does your recommendation change if her EF was 20%? Does your recommendation change if her EF was 20%?

53 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Pulmonary Hypertension INR goal of 2.0 for INR goal of 2.0 for –Pulmonary Hypertension secondary to chronic thromboembolic disease –PulmHTN with afib –Idiopathic Pulmonary Hypertension –Familial Pulmonary Hypertension –Pulmonary Hypertension with severe left heart failure

54 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Starting Dose Start with 5mg of warfarin (CHEST) Start with 5mg of warfarin (CHEST) Consider a lower dose in very elderly Consider a lower dose in very elderly Get a baseline INR Get a baseline INR Follow a nomogram Follow a nomogram

55 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Nomogram One can be found in the Annals One can be found in the Annals –Annals of Internal Medicine 2003;138:714 2003;138:714

56 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Kovacs, M. J. et. al. Ann Intern Med 2003;138:714-719 5-mg Warfarin Initiation Nomogram

57 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Initiation Case Your previous DVT patient is started on 5mg warfarin (following CHEST guidelines) Your previous DVT patient is started on 5mg warfarin (following CHEST guidelines) His baseline INR is 1.1 His baseline INR is 1.1 You start him on 1mg/kg of enoxaparin BID You start him on 1mg/kg of enoxaparin BID He comes back on day three with an INR of 1.4 He comes back on day three with an INR of 1.4

58 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Question 9 What dose do you tell him to take? What dose do you tell him to take? When do you tell him to come back? When do you tell him to come back?

59 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Follow up Arrange for appointments as per the nomogram Arrange for appointments as per the nomogram INR check on days 3,4,5,6, INR check on days 3,4,5,6, Then twice weekly for two weeks Then twice weekly for two weeks Weekly for two more weeks Weekly for two more weeks If stable, then every 4 weeks If stable, then every 4 weeks

60 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Initiation of anticoagulation How many days of enoxaparin should you write for? How many days of enoxaparin should you write for? What are the instructions for stopping the enoxaparin? What are the instructions for stopping the enoxaparin?

61 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Answer Write for a minimum of five days of enoxaparin Write for a minimum of five days of enoxaparin INR should be therapeutic for two days in a row before stopping enoxaparin INR should be therapeutic for two days in a row before stopping enoxaparin

62 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Monitoring After the initial 2 weeks, INRs usually become more stable After the initial 2 weeks, INRs usually become more stable Maintenance nomograms may be utilized to help in decision making Maintenance nomograms may be utilized to help in decision making An experienced clinician is equivalent to a nomogram An experienced clinician is equivalent to a nomogram

63 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Maintenance Case 65 y.o. woman with A-fib, DM and hyperlipidemia had to switch her statin from atorvastatin to simvastatin for insurance coverage purposes. 65 y.o. woman with A-fib, DM and hyperlipidemia had to switch her statin from atorvastatin to simvastatin for insurance coverage purposes. Her repeat INR after med change shows the INR is 3.6 Her repeat INR after med change shows the INR is 3.6 What adjustment do you make? What adjustment do you make? When should she follow up? When should she follow up?

64 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 INR changes while on maintenance Worsening CHF Worsening CHF New medication New medication Stopped a medication Stopped a medication Stopped or started smoking Stopped or started smoking Increased or decreased physical activity Increased or decreased physical activity Infection Infection This is why an experienced clinician performs as well as a nomogram or calculator

65 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Anticoagulation Clinic vs. PCP Anticoagulation Clinic saves money Anticoagulation Clinic saves money Decreases hospitalizations (related to anticoagulation) Decreases hospitalizations (related to anticoagulation) Decreases INRs outside of range Decreases INRs outside of range Decreases anticoagulation related complications Decreases anticoagulation related complications Am J Hosp Pharm 985:42,304-308, Pharmacotherapy 10=995:15,732-739, Drug Intell Clin Pharm 1985;19,575-580, Arch Intern Med 1998:158,1641-1647, Chest 2005:127,1515-1522. Am J Hosp Pharm 985:42,304-308, Pharmacotherapy 10=995:15,732-739, Drug Intell Clin Pharm 1985;19,575-580, Arch Intern Med 1998:158,1641-1647, Chest 2005:127,1515-1522.

66 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Point of Care vs. Lab Point of care testing (POC) – utilizes the finger stick to obtain an INR Point of care testing (POC) – utilizes the finger stick to obtain an INR –Convenient –Quick –Less blood needed –Reliable There are restrictions There are restrictions

67 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 When not to use POC While on enoxaparin While on enoxaparin Hct below 30 Hct below 30 Patients with antiphospholipid antibodies Patients with antiphospholipid antibodies

68 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Drug Interactions Safest to assume all drugs interact with warfarin Safest to assume all drugs interact with warfarin Check all new medications in epocrates or a similar program Check all new medications in epocrates or a similar program Don’t forget about herbals and over the counter meds Don’t forget about herbals and over the counter meds

69 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Common Bad Actors Acetataminophen Acetataminophen Trimethoprim/sulfamethoxazole Trimethoprim/sulfamethoxazole Fluoroquinolones Fluoroquinolones Antibiotics in general Antibiotics in general Gemfibrozil Gemfibrozil Aspirin Aspirin Clopidogrel Clopidogrel Prednisone Prednisone

70 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 When Forced If you must use one of these medications, recheck the INR in 3 days If you must use one of these medications, recheck the INR in 3 days OR look on MicroMedex and see how strong the interaction is OR look on MicroMedex and see how strong the interaction is For Bactrim, decrease weekly warfarin dose by 30% and recheck in 3 days For Bactrim, decrease weekly warfarin dose by 30% and recheck in 3 days

71 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 System Based Protocol Goals Uniformity of treatment Uniformity of treatment Encourage the use of evidence based guidelines Encourage the use of evidence based guidelines Create a patient registry Create a patient registry Uniformity of dose adjustment and follow up Uniformity of dose adjustment and follow up Provide seamless care Provide seamless care

72 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Resources CHADS2 score CHADS2 score Wells score for DVT and PE Wells score for DVT and PE Warfarin initiation nomogram Warfarin initiation nomogram Warfarin maintenance calculator Warfarin maintenance calculator CHEST guidelines CHEST guidelines Patient information in English and Spanish Patient information in English and Spanish

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82 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08

83 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08

84 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08

85 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08

86 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Referring Patients From inpatient setting – use Consult upon discharge option From inpatient setting – use Consult upon discharge option Anticoagulation referral Anticoagulation referral Tell patient to go to ExpressMed at the hospital in 2-3 days (follow protocol) Tell patient to go to ExpressMed at the hospital in 2-3 days (follow protocol) Order INR in Sunrise Order INR in Sunrise –Stat patient waiting –Give paper to patient

87 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Referring Patients From Outpatient setting From Outpatient setting –Use Outpatient Consult or Anticoagulation Consult –In pull down menu, select anticoagulation –Tell patient to go to ExpressMed clinic in 2-3 days (follow protocol) –Order INR from within Sunrise Stat patient waiting Stat patient waiting Hand the paper to the patient Hand the paper to the patient

88 Debbie L. Cardell, MD Div Gen Med UTHSCSA2/29/08 Questions


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