1. INR for warfarin monitoring ©bpac nz, October 2006

2. Key Messages A systematic and methodological approach is needed for managing warfarin therapy Patient education is an important part of achieving good INR levels For most people once the INR is stable, the rate of testing can be extended 4 to 6 weekly

3. Introduction Good management of INR levels requires a systematic approach involving the whole practice team Warfarin is the most widely used anticoagulant in NZ Use of warfarin is associated with serious risks A systematic and methodological approach is needed for warfarin therapy

4. The role of INR

5. What is INR? INR = ( _________ ) ISI Some people are at particular risk from warfarin therapy The large number of variables in controlling INR levels There is no standard response to warfarin Elderly people often require lower doses of warfarin Poor literacy or numeracy skills are associated with poor INR control Patient PT Control PT

6. Low-dose initiation protocols Suitable for outpatients Safe Achieves therapeutic anticoagulation within 3 to 4 weeks Reduces the risk of over-anticoagulation

7. Transfer of care across the primary – secondary interface High risk due to: Poor communication on discharge Tablet strengths may be inappropriate for maintenance therapy. Other medications, e.g antibiotics, may interact with warfarin.

8. Transfer of care across the primary – secondary interface….. contd New Zealand hospitals must effectively transfer the following essential details of warfarin therapy: Condition for which warfarin has been prescribed Target INR range Planned duration of treatment Brand and strength of warfarin tablets given Last three doses Last three INRs Date next INR test due

9. Pre initiation tests Complete blood count including platelets INR/PR and APTT Liver function tests

10. Detailing the plan for warfarin therapy The patient notes should contain the following information: The patient is on warfarin Condition for which prescribed Target INR range Planned duration of treatment Brand of warfarin

11. Target INR range In most situations the target INR range is 2.0 – 3.0

12. Prescribing warfarin All clinicians should use the same brand of warfarin Warfarin use: Marevan ~ 95%, Coumarin® ~ 5% The brands are not interchangeable and come in different tablet strengths Use only 1 mg tablets during initiation to minimise confusion

13. Drug labelling can highlight the importance of INR monitoring Use labelling on warfarin to remind patients of the need for regular blood tests Labels such as “PRN” or “as required” may confuse A better option may be “Take the dose advised by your doctor or nurse. You need regular INR blood tests to make sure this dose is right for you”

14. Patient Education Patients who understand what they are doing, benefit more from treatment

15. Patient education must to cover: Need for patient to remind their health professional they are receiving warfarin Requirement for regular blood tests Adherence to dosage changes after blood tests Importance of avoiding other medications except with medical advise Significance of illness, such as diarrhoea, infection or fever Ability to recognise the signs of bleeding

16. Signs of possible bleeding Red or dark brown urine Severe headache Excessive menstrual bleeding Dizziness, trouble breathing or chest pain Dark, purplish or mottled fingers or toes Indications to call the doctor immediately: Red or dark brown stool Unusual weakness Prolonged bleeding from gums or nose Unusual pain, swelling or bruising Vomiting or coughing up blood

17. “The red book” Facilitates patient education Means of sharing information Patients should always show to any health professional Clinicians and pharmacists should asking to see the book The book should be kept up to date.

18. Monitoring INR A reasonable standard of warfarin therapy is an INR within the target range 60% of the time Regular testing of INR levels is essential Once the INR is stable the rate of INR testing can be extended to 4 to 6 weekly in most people

19. For patients initiated with low-dose protocol (warfarin initial dose 2 – 3mg daily): Initially: When INR < 4: Weekly When INR > 4: Every 2-3 days until stable for 2 consecutive tests Then: fortnightly until stable for 2 - 3 consecutive tests Maintenance: Most patients can be extended to 4 – 6 weekly testing however a minority may require more frequent testing.

20. For patients initiated with higher doses: Initially: daily for at least five days until stable for 2 consecutive tests Then: every 3 – 5 days until stable for 2 consecutive tests Then: weekly until stable for 2 - 3 consecutive tests Then: fortnightly until stable for 2 - 3 consecutive tests Maintenance: Most patients can be extended to 4 – 6 weekly testing however a minority may require more frequent testing.

21. Changes in INR levels Changes in the INR level in a usually stable patient may be due to a number of reasons: Non-adherence to dosage regimen Drug interactions (pharmaceutical or herbal) Major changes in diet or alcohol intake Systemic or concurrent disease Unknown causes

22. Managing alterations in the INR Changes in weekly doses are usually not required for minor fluctuations. For more significant fluctuations in the INR use a standard guide to assist dose modification.

23. Managing Overanticoagulation INR 5 – 8 without bleeding 1.Stop warfarin 2.Restart in reduced dose when INR < 5 3.Test INR daily until stable 4.Given Vitamin K 0.5 – 1 mg oral/sc if INR fails to fall, or reversal required within 24 – 48 hours

24. Managing Overanticoagulation…. contd INR > 8 with minor bleeding 1.Stop warfarin 2.Consider admission if clinical appropriate 3.Restart in reduced dos when INR < 5 4.Given Vitamin K 1 – 2 mg oral/sc

25. Managing Overanticoagulation…. contd High INR and major bleeding 1.Stop warfarin 2.Give Vitamin K 10 mg sc 3.Admit stat

26. Sample collection for INR Collect blood into a light blue top tube The tube must be filled completely View the patient handbook Ask questions specific to warfarin control, for example:  Adherence to the dosing regimen,  Any changes in diet  Any medications the patients may have stopped or started  Signs of bleeding

27. Ceasing warfarin therapy Warfarin therapy can be discontinued abruptly at the end of treatment period Prospective studies have not indicated a rebound prothrombotic state

28. Dental extractions and preoperative warfarin doses For minor surgical procedures aim for a target INR of approx 2.0 on the day of surgery Stop warfarin at least three days prior to major surgery When INR < 3.0 warfarin does not need to be stopped for dental extractions

29. Warfarin and pregnancy Pregnant women should never take warfarin, as it is teratogenic Women on warfarin should contact their doctor urgently if they think they are pregnant.

30. Managing warfarin in rest homes In rest homes there may be several health professionals involved in the prescribing, dose adjustment and administration of warfarin. Clear written instructions are necessary to guide rest home staff. Verbal instructions should be avoided whenever possible.

31. Near patient testing Near patient testing (NPT) of INR levels is effective for selected patients NPT is risky for patients who are unmotivated or do not understand the process NPT requires high standard of quality assurance procedures

32. Resources available from bpac nz for INR monitoring Evidence based guide “INR monitoring” Interactive online quiz Quiz feedback Clinical audit pack for general practice visit www.bpac.org.nz