Guidelines for Anticoagulation Initiation and Management Y2014 UHS CLINICAL CARE COLLABORATION: Outpatient & Inpatient Topic Page Number MEDICATION FLOW AND PATIENT FLOW... 2 AND 3 PARENTERAL ANTICOAGULANTS... 2 CLINIC FOLLOW UP AND CONSULTS....3 ANTICOAGULATION DECISION SUPPORT... 4 DRUG INTERACTIONS WITH WARFARIN 4 AND 6 BRIDGING WITH A PARENTERAL ANTICOAGULANTS IN PERI-PROCEDURAL PERIOD... 4, 8 AND 9 WARFARIN INITIATION NOMOGRAMS... 5 WARFARIN MAINTENANCE DOSE ADJUSTMENTS... 5 PE PROGNOSIS... 6 WARFARIN REVERSAL(MANAGEMENT OF ELEVATED INR)... 6 ATRIAL FIBRILLATION... 7 COLLABORATORS AND REFERENCES... 10 1
Hypercoagulation Atrial Fibrillation DVT PE Mechanical valve Others MEDICATION FLOW PATIENT FLOW 2 Anticoagulation Parenteral 5mg Warfarin Start Day #1 1 UHS Inpatient 6 Drug interaction Restart treatment Follow-up Day #3,4,5,6 Follow-up 2x/wk x 2 wks 1x/wk x 2 wks 3 4 UHS Emergency Dept. Anticoagulation Clinic EMC (Back-up) CMA Clinics Specialty Clinics Cardiology Primary Care Providers Accessibility Availability Capability Convenience 5 Table 1: Parenteral Anticoagulation Follow-up Q 1 month [INR check can be stretched to Q 1-2 months if some stability is reached] 2
These guidelines are not meant to preclude clinical judgment Medication Flow (See page 2) o Anticoagulation therapy will be initiated with parenteral anticoagulation and Warfarin 5mg or 2.5mg, started on day #1 o Parenteral anticoagulation should be overlapped with Warfarin for at least 5 days AND until 2 consecutive INRs are in therapeutic range, 24 hours apart Note: Check Anticoagulation Clinic Consult for details about anticoagulation therapy, i.e. diagnosis, start date, therapy duration, etc Note: Point-of-care INR cannot be used for patients with Hct < 30, patients currently on parenteral anticoagulation, patients with lupus anticoagulant or anti-phospholipid antibodies venous blood draw is required o Patient INRs will be followed on days #3, #4, #5 and #6. Warfarin will be adjusted according to the 5mg or 2.5mg Warfarin Initiation Nomograms (see page 5). Thereafter, doses will be adjusted using the Maintenance Dose Adjustment Algorithms (see page 5) Note: Check either Visit History or IDX to confirm Anticoagulation Clinic appointment o Patient can then be followed 2x per week x 2 weeks then 1x per week x 2 weeks Patients with stable chronic anticoagulation therapy can be followed Q1-2months if INR stability is achieved Note: A baseline INR should be measured before the patient received the first dose of Warfarin Note: If Warfarin is initiated inpatient, see Inpatient Warfarin INR Monitoring Policy posted to the Clinical Intranet Patient Flow (See page 2) o Anticoagulation therapy can be initiated from any locations, i.e. Emergency Center, Inpatient Care, Express Med Clinic or other clinics. o Medication Flow will be our guide to initiate, monitor and adjust the therapy Clinic Follow-up o Patients started on anticoagulation therapy can be followed on regular basis by Anticoagulation Clinic or other permanent medical homes (i.e. PCP, CMA clinics, specialty clinics, etc) o Express Med Clinic can serve as back-up for Anticoagulation Clinic o Contact numbers during regular work days, Monday Friday 8AM-5PM Anticoagulation Clinic = (210) 358-6518 or Navigator for Ambulatory Connection Clinic = (210) 358-9521 Consults can be made to Anticoagulation Clinic using Sunrise consult note Consult (Outpatient)(Anticoag Clinic) Anticoagulation Protocol o See page 4 Anticoagulation Decision Support for recommended target INR and duration of therapy and page 5 for dosing decision support o Isolated calf vein or distal DVT start anticoagulation therapy x 3 months o Unprovoked 1st VTE start anticoagulation therapy x 3 months, then reassess bleeding risk o Asymptomatic lower extremity DVT anticoagulation therapy similar to symptomatic lower extremity DVT o Spontaneous superficial vein thrombosis prophylactic parenteral anticoagulation for at least 45 days o Symptomatic proximal DVT- use elastic compression stocking x 2yrs ankle pressure gradient 30-40mmHg if feasible o Hypercoagulable diseases, i.e. anti-phospholipid syndrome, anti-lupus, etc Recommendation: if the patient has an ischemic event, initiate anticoagulation therapy with warfarin, unless contraindicated o Pulmonary Embolism: See page 6 PE Prognosis for estimating prognostic risk for patients with Pulmonary Embolism Recommendation: Class I and II can be treated as outpatient 3
o See page 6 Management of Significantly Elevated INR With or Without Bleeding o Atrial Fibrillation: See page 7 CHA2DS2-VASc Score and HAS-BLED for estimating risks of stroke and bleeds Drug Interactions (See table 7) If the prescribed antibiotics / medications have known interactions with Warfarin, the patients should be followed in 3 days, then Q4-5 days until after the antibiotic / medication course is completed and INR level is therapeutic and stable If the prescribed antibiotics / medications have minimal or no known interaction with Warfarin, the patients should be counseled to monitor for signs and symptoms of increased bleeding and follow-up as needed. Or the patients can be followed as above Bridging with parenteral anticoagulant in the Perioperative Setting o See pages 8 to evaluate patients risk of bleeding and underlying thromboembolic risk, then see page 9 for recommendations on warfarin interruption and bridging suggestions. Mechanical valve - restart parenteral anticoagulation along with Warfarin DVT & chronic A Fib - restart parenteral anticoagulation along with Warfarin if first 3 months after DVT & CHADS 2 & INR < 1.5 Hypercoagulable state - restart parenteral anticoagulation along with Warfarin if the patient is a high risk patient Table 2: ANTICOAGULATION DECISION SUPPORT 1 Indication Target INR Therapy Duration SORT DVT or PE First episode, provoked 2.0 3.0 3 months B [Oral contraceptive, pregnancy, surgery or hospitalization in past 3 months, trauma, central venous lines, prolonged travel] First episode, unprovoked 2.0 3.0 At least 3 months but extended therapy is preferred if no B contraindications or excessive bleeding risk First episode, patient with cancer 2.0 3.0 Therapeutic LMWH for 6 mos then warfarin or continue LMWH Treat until cancer is resolved B Recurrent DVT 2.0 3.0 Indefinitely B Atrial Fibrillations 2.0 3.0 Indefinitely Anticoagulation after cardioversion 2.0 3.0 At least 4 wks after cardioversion, then for subsequent therapy refer to CHA2DS2-VASc Score on page 7 B Valvular Disease Bio-prosthetic valve: Aortic ASA or Warfarin 2.0 3.0 3 months Bio-prosthetic valve: Mitral Warfarin 2.0 3.0 3 months Mechanical valve 2.0 3.0 Indefinitely Mechanical valve plus one the below high risk features 2.5 3.5 Indefinitely Mitral valve position Low EF (<50%) Caged ball valve History of TIA/stroke Atrial fibrillation 4
Table 3: Table 4: October 2014 Table 5: Maintenance Dose Adjustment Algorithms (Based on Total Weekly Dose) For Target INR = 2.0-3.0, no bleeding* INR < 1.5 1.5-1.9 2.0-3.0 3.1-3.9 4.0-4.9 >5.0 Increase dose 10-20%, Hold 0-1 day Adjustment Increase dose 5-10% No change Decrease dose 5-10% See next page consider extra dose Decrease dose 10% No. of consecutive in-range Next INR 14 days 7-14 days 7-14 days 4-8 days See next page INR x 1wk (max 4 wks) For Target INR = 2.5-3.5, no bleeding INR < 1.5 1.5-2.4 2.5-3.5 3.6-4.5 4.5-6.0 >6.0 Increase dose 10-20%, Hold 0-1 day Adjustment Increase dose 5-10% No change Decrease dose 5-10% See next page consider extra dose Decrease dose 10% Next INR 14 days 7-14 days *-See -If INR is 1.7-1.9 or 3.1-3.3, consider no change with repeat INR in 7-14 days -For example, if a patient has had 4 consecutive in-range INR values, re check in 4wks -If INR is 2.3-2.4 or 3.6-3.7, consider no change with repeat INR in 14 days No. of consecutive in-range INR x 1wk (max 4 wks) 7-14 days 4-8 days See next page 5
Table 6 : PE Prognosis Table 7 : Warfarin Interactions: Drug, Herb and Food Consider Treating Class I and Class II as outpatient Table 8 : Management of Significantly Elevated INR With or Without Bleeding 1 INR 4.5-9.0, no significant bleeding omit 1-2 doses, reduce dose 10-20%, monitor frequently. INR > 9.0, no significant bleeding hold warfarin therapy, give vitamin K1 5.0-10mg orally, monitor daily until INR therapeutic then resume at lower dose Serious bleeding, any INR holding warfarin therapy, give vitamin K1 10mg slow IV plus fresh frozen plasma and/or PCC, repeat vitamin K1 every 12 hours as needed Life threatening bleeding, any INR hold warfarin, give PCC +/- fresh frozen plasma with vitamin K1 10mg slow IV, repeat as needed PCC = prothrombin complex concentration (Kcentra ) See guideline on UHS Clinical Intranet under Anticoagulation or Bleeding Disorders 6
Table 9: CHA2DS2-VASc Score 4 A clinical prediction tool to estimate the risk of stroke in patients with non-valvular atrial fibrillation. This is recommended to assess stroke risk over the CHADS2 score in the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation. Congestive Heart Failure Hypertension Age 75 years Diabetes mellitus Stroke/TIA/TE Vascular disease (prior MI, PAD, aortic plaque) Age 65-74 years Sex category (ie. Female sex) Maximum score 2 points 2 points 9 points CHA2DS2-VASc Acronym Stroke Rate / Yr 0 0% 1 1.3% 2 2.2% 3 3.2% 4 4.0% 5 6.7% 6 9.8% 7 9.6% 8 6.7% Score Table 11: Antithrombotic Therapy Based on CHA2DS2-VASc Score 4 0 No antithrombotic therapy 1 No therapy, or aspirin or warfarin (discuss risk of stroke vs risk of bleeding with patient) 2 Warfarin (preferred) or rivaroxaban or apixaban if meets restrictions Table 12: AFib Risks of Strokes & Bleeds 1 Table 10: HAS-BLED 4 Bleeding risk score to quantify the 1 year risk for major bleeding in patients with atrial fibrillation. HAS-BLED acronym Points Hypertension (SBP >160mmHg 1 Abnormal liver or renal function ( each) 1 or 2 Stroke history 1 Bleeding history 1 Labile INRs 1 Elderly (>65 yo) 1 Drugs that promote bleeding or 1 or 2 excess alcohol use ( 1point each) Maximum score 9 HAS-BLED Score Bleeds per 100 Patient Years 0 1.13% 1 1.02% 2 1.88% 3 3.75% 4 8.70% 5 12.5% 6 Scores > 5 were too rare to 7 determine risk in validation 8 studies. 9 October 2014 7
Table 13: Risk Assessment for Management of Anticoagulation in the Peri-Procedural Period 5 5. See Table 14 on next page for recommendations for warfarin users 8
Table 14: Warfarin Interruption and Bridging Suggestions 5 9
Invaluable Collaborators: Written / Revised by: Kourosh Jahangir MD Date Ted Arevalo MD Date Crystal Franco-Martinez PharmD, BCPS Date Oralia Bazaldua PharmD, BCPS Date Liem Du MD Date DeWayne Davidson, PharmD Date This guideline was approved by UHS P&T Committee: January 2015 References: 1) CHEST Guideline, February 2012; 141 (2 supplement), Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines 2) Annals of Internal Medicine 2003;138:714 3) American Family Physician. May 15, 2005;71:1979-82 4) 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation. Circulation published March 28,2014. 5) Managing Anticoagulation in the Peri-procedural Period (MAP). Quality Improvement Organizations, Drug Safety Resources. Accessed at www.drugsafety.ipro.org 10