Warfarin Dosing & Indications
When dose adjusting for chronically anticoagulated patients, we should consider
the total weekly dose
Patients with missed appointments at the Anticoagulation Clinic will be informed by
a letter and phone call informing them to call and reschedule their appointment
Candidates for PST home INR devices must meet the following criteria (name at least 3/5):
Warfarin is clearly indicated
Have access to a reliable home telephone or cellular phone
Willing or have a caregiver willing to perform PST
Possess adequate cognitive and language skills to follow instructions from Anticoagulation Clinic staff
Willing to perform weekly PST of INR
Anticoagulation Clinic staff performing ancillary testing (e.g. point-of-care INR testing) will undergo a proficiency survey to stay certified every
3 months
TSOAC stands for
Target Specific Oral AntiCoagulants
the duration of Warfarin for a patient with unprovoked/first event (proximal) DVT or PE
indefinite
Prior to Warfarin initiation, the patient should have baseline
PT/INR and CBC
Outpatient self-testers are scheduled for follow-up appointments at the Loma Linda VA Anticoagulation Clinic at least every
3 OR 6 months
In patients with mild or moderately elevated INRs WITHOUT bleeding, IF Vitamin K is indicated, the recommended route of administration is
Orally
The long term monitoring parameters for all TOSAC's are
CrCl at start of therapy and every 3-6 months or as clinically indicated
Hgb/Hct and platelets as clinically indicated
the INR goal of a patient with mitral valve (tilting disk) replacement is
3 (2.5-3.5)
A patient with an INR of 1.6 (INR goal 2-3) should be instructed to
Take an extra dose and/or increase weekly dose by 5-15%
A patient's "home testing diary" should consist of
weekly INR results and other significant events i.e. bleeds, medication changes, etc
If a patient has an INR of 4.8, the clinician should
Lower the dose, omit a dose, monitor more frequently, and resume therapy at an appropriately adjusted dose when INR is at a therapeutic level.
If associated with a transient causative factor, no dose reduction may be required.
Prior to invasive or surgical procedures, Apixaban must be held for at LEAST
24 hours
If the patient's INR is 3.6 – 4.0, then we should
Hold 0-1 dose
or
Decrease by 5 – 15%
The content of the Anticoagulation Patient Education Class consists of ....
1. Indication(s) for anticoagulation therapy
2. Warfarin tablet identification
3. The importance of medication adherence
4. Daily dosage
5. The management of missed doses
6. Monitoring requirements
7. Management of temporary discontinuation of warfarin for an invasive procedure
8. Interactions (drug, diet, and disease)
9. Lifestyle modifications
10. Awareness of potential for tablet dosing error and multiple names for warfarin if using warfarin from different sources (e.g. non-VA, community pharmacy, warfarin from a different country)
11. Signs and symptoms of bleeding and thromboembolic events
12. Risks associated with falling
13. Purpose of the Anticoagulation Clinic and follow-up procedures
Each patient/caregiver will undergo a training program on PST principles that include:
- Correct use of the home INR meter
- Importance of performing liquid controls if required by the manufacturer of the home INR device
- How to fill out a “home testing diary”
- Importance of contacting Anticoagulation Clinic staff when INR is out of range
In a patient with an INR of 10.2 and NO significant bleeding, the patient should be instructed to
Hold warfarin and take Vitamin K (2.5 to 5mg) orally with the expectation that the INR will be reduced substantially in 24-48 hours
In AFib, Edoxaban may not be used in patients with a CrCl >
95 mL/min
It is recommended that the first INR is obtained from the initial warfarin dose
3-7 days
Patients with INR >5.0 should return to clinic within
1 week
After the patient's initial training, the patient’s competence with the INR monitor will be evaluated within ______ depending on patient’s convenience or availability to return to clinic following PST initial training.
A month
If a patient has an INR of 6.7 WITH serious bleeding, the clinician can...
hold warfarin and give vitamin K 10 mg IV, Kcentra, or recombinant VIIa, may repeat Vitamin K every 12 hours
Andexxa is the antidote for
Apixaban and Rivaroxaban