Anticoagulation Therapy

Minci

• Anticoagulants – prevent clot formation and extension • Antiplatelets – interfere with platelet activity • Thrombolytic agent – dissolve existing thrombi

How warfarin works
• inhibits vitamin K-dependent coagulation factor synthesis (II, VII, IX, X, proteins C and S)

Indications; 4. Prophylaxis of DVT (INR 2 – 2.5) 5. Rx of DVT and PE, AF, cardioversion,dilated cardiomyopathy, mural thrombus following MI, rheumatic mitral valve disease ( INR 2.5) 6. Recurrent DVT and PE, mechanical prosthetic heart valve ( INR 3.5)

• Monitor using INR. • Therapeutic range : 2.0 – 3.0 • Takes 5 days to achieve thrombotic effect (prothrombin T1/2 = 60 hours) • 1mg = brown 3mg = blue 5mg = pink

Side effects
• • • • • • • • Bleeding – Nose, gums, GI, GU, urine Easy bruising Persistent headaches and dizziness Tiredness Hair loss Nausea, vomiting, cramping, diarrhoea Low WBC Hypersensitivity, ‘purple toes syndrome’

Prescribing
1. Start with known dose. If not, take baseline INR and start 10mg daily. 2. Check INR on Day 4 and adjust dose. 3. Stop heparin when INR reach therapeutic level 4. Regular INR checks 5. Patient education : Compliance, OTC, diet, drug interaction.

Start low dose in
• • • • Elderly patient Low body weight or low albumin level Patients with CCF/ liver disease On certain medications : Amiodarone, metronidazole, trimethoprim • Caution in pregnant women. Give heparin instead.

Low INR
• Drug interaction : Barbiturates, Carbamazepine, Propilthiouracil, Rifampin, Methimazole. • Hypothyroidism

High INR
• Advanced malignancy • Drug interaction – Abx, amiodarone, NSAID, simvastatin. • Taking more than prescribed • Eating less Vitamin K rich food • Acute diarrhoeal illness • Alcohol • CCF, hyperthyroidism, hepatic failure

Mx of high INR
• Check for Sx of bleeding and if in therapeutic range  renal /GI pathology • INR < 6.0 but more than 0.5 units above target, reduce dose/stop, restart when <5.0 • INR 6.0 – 8.0 (no/minor bleed). Stop and restart when INR <5.0 • INR >8.0 (no. minor bleed). As above. Give phytomenadione (Vitamin K1) 0.5mg slow IV/5mg PO. For partial reversal, use 05 – 2.5 mg IV into PO. Repeat dose if INR still too high after 24 hours.

• • • •

Major bleed – Stop warfarin Give Vitamin K1 5mg slow IV PCC ( Factors II, VII, IX, X) 30 – 50 units/kg OR FFP 15 ml/kg