Warfarin Warranted
You're the pharmacist performing a med rec for a newly-admitted patient. They mention being on warfarin, but only remember that it's peach-colored.
What strength tablet of warfarin is this patient taking?
5mg
A patient on warfarin informs you that they "had a little too much to drink" this past holiday weekend.
How would you expect their INR to change at this visit?
INR would increase
What are the two classifications of DVT that help clinicians determine the length of anticoagulation?
Provoked and unprovoked.
Define these and their duration of treatment.
Name 3 advantages and disadvantages to utilizing the DOACs
Advantages: No monitoring, minimal patient variability, "less" DDIs, increasing evidence supporting safety vs. warfarin
Disadvantages: cost, some BID dosing (adherence), limited/no evidence in renal Dx, BBW for abrupt D/C
True or False: all patients in Afib require anticoagulation
False - based on CHADS2-VAsc score
You're counseling a patient who is initiating warfarin therapy. Explain to the patient it's mechanism of action.
"Your body uses vitamin K to create blood clots/make your blood thick. This medicine works by blocking the effects of vitamin K and making it harder for your blood to clot." (or similar explanation...)
A patient on warfarin calls to tell you they will be on Bactrim DS for 10 days to treat a UTI. How do you handle this?
Due to increase in INR from DDI, decreasing the dose and closer monitoring is warranted.
What are some other medications that can affect the INR?
What would you recommend for a patient treated for multiple myeloma who develops a DVT in their left leg?
LMWH (enoxaparin)
When do you need to adjust the dose for a patient taking apixaban?
Patient that has 2 of the following:
Age >80, Wgt <60 kg, SCr >1.5
BONUS: Is this for ALL indications?
Explain to a patient how Afib puts them at increased risk for a stroke and/or PE.
The atria of the heart is quivering and not pumping all of the blood out efficiently. Some blood is able to pool and potentially form a clot. If this clot gets pushed out by the heart in the blood vessels, it can block blood to the brain or lungs. (or similar verbiage)
You are seeing an established patient in the anticoagulation clinic that is taking warfarin as an APPE student. Your preceptor reminds you to review the "5 D's" with this patient.
What are the 5 D's?
Drugs, Diet, Diagnoses, Doses, Drinking (EtOH)
A patient your following has an INR of 2.4 on day 3 of warfarin therapy (there first number in therapeutic range). The attending calls you asking for a recommendation on when to stop the patient's enoxaparin therapy.
How do you respond to the attending? Is this patient anti-coagulated?
4 more therapeutic INRs are needed before the patient is considered fully anti-coagulated.
A 28 YOF presents to the ED with an acute DVT in the LLE. What could be potential risk factors that led to her developing a DVT?
Genetics, potentially pregnant, use of hormonal contraceptives (esp. if smoking), recent trauma/injury.
BONUS: How do you want to treat her DVT?
A patient in clinic is afraid to start taking Xarelto due to the "black box warning" they heard about. What warning are they talking about?
Hint: they are not having any planed procedures coming up
Abrupt discontinuation may lead to hyper coagulable state.
How can you can address these concerns for the patient?
A 67-YOF with DM who recently quit smoking (CHA2DS2-VASc of 3) is ready to explore options for anticoagulation. What patient-specific factors do you need to consider when selecting an anticoagulant?
Bleeding risk (what tool can we use?)
Renal dysfunction, concomitant meds, adherence, ability to adequately monitor thearpy, insurance status, etc.
The initial dose for most patients starting on warfarin in 5mg daily.
When would you use a lower dose (name 3)?
Elderly, malnourished, CHF, liver disease, Interacting medications, high bleeding risk
What else can affect a patient's INR BESIDES Leafy vegetables and other prescription medications?
Mutivitamins, fruits (esp. mangoes and cranberries), nutritional shakes (Boost, Ensure), Rubbing Alchohol, Muscle Rubs (IcyHot, Bengay), Smoking...
You receive an urgent consult for a 44 YOM with ESRD on dialysis who presents with a DVT of the right femoral vein. What anticoagulant would you recommend (both acute and upon discharge) and for how long?
Acute: UFH then overlap/transition to warfarin
A 59 YOM s/p MVR on Pradaxa for stroke prevention secondary to Afib presents to your clinic for MTM.
What changes/additions would you recommend for this patient?
Switch from Pradaxa to warfarin.
HOW will you transition this patient?
Ms. Frizzie (PMH of AFib and Halitosis) is scheduled for a tooth extraction next week and currently takes warfarin 5mg daily except 2.5mg Tue+Sat (INR = 2.9).
Her dentist calls asking for assistance transitioning them to LMWH prior to this procedure. What is your recommendation?
TRICKY!
"Bridging" therapy is not necessary for patients at therapeutic INR for dental procedures.
What are some of our "high-risk" procedures?
Patient Case!
Did they get it...?
Which DOAC would you pick for a patient with a history of TIA and upper GI bleed and why?
Apixaban would be preferred - lower incidence of bleeding in than the other agents
Patient Case!
How'd they do?