uhs anticoagulation therapy guideline y12 04

8/13/2019 UHS Anticoagulation Therapy Guideline Y12 04

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Page | 1Leading the Changes to Take Better Care of the Patients Tomorrow Today

LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04

April 2012

UHS CLINICAL CARE COLLABORATION: Outpatient & InpatientANTICOAGULATION GUIDELINE Y2012

Guidelines for Anticoagulation Initiation and Management

Hypercoagulation Mechanical valve

Atrial Fibrillation

PEDVT Others

5mg Warfarin

Start Day #1

Follow-up

Day #3,4,5,6

Follow-up

2x/wk x 2 wks1x/wk x 2 wks

Follow-up Q 1 month[INR check can be stretched to Q 1-2

months if some stability is reached]

Anticoagulation

Parenteral

UHS

Emergency Dept.

CMA Clinics

Specialty ClinicsCardiology

EMC

(Back-up)

Anticoagulation

Clinic

UHS

Inpatient

PATIENT

FLOW

MEDICATION

FLOW

Drug interaction

Restart treatment

12

3

4

5

6

Primary Care

Providers

Accessibility

Availability

Capability

Convenience


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Maintenance Dose Adjustment AlgorithmsFor 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

AdjustmentIncrease dose 10-20%,

consider extra dose

Increase dose 5-10% No change Decrease dose 5-10% Hold 0-1 day

Decrease dose 10%

See next page

Next INR 14 days 7-14 daysNo. of consecutive in-range

INR x 1wk (max 4 wks) 7-14 days 4-8 days See next page

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

AdjustmentIncrease dose 10-20%,

consider extra doseIncrease dose 5-10% No change Decrease dose 5-10%

Hold 0-1 day

Decrease dose 10%See next page

Next INR 14 days 7-14 daysNo. of consecutive in-range

INR x 1wk (max 4 wks) 7-14 days 4-8 days See next page

*-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


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Management of Significantly Elevated INR With or Without Bleeding

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 doseSerious 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 neededLife threatening bleeding, any INR hold warfarin, give PCC +/- fresh frozen plasma with vitamin K1 10mg slow IV, repeat as needed

PCC = prothrombin complex concentration (Profilnine) See guideline on UHS Clinical Intranet under Bleeding Disorders


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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;138:7143) American Family Physician. May 15, 2005;71:1979-82

Invaluable Collaborators: Dr. Deborah Cardell, Dr. Michael Johnson, Dr Kourosh Jahangir, Crystal Franco PharmD, Oralia Bazaldua PharmD


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Written / Revised by:______________________________ __________

Liem Du MD Date

______________________________ __________

Deborah Cardell MD Date

______________________________ __________Michael Johnson MD Date

______________________________ __________Kourosh Jahangir MD Date

______________________________ __________Crystal Franco PharmD, BCPS Date

______________________________ __________

Oralia Bazaldua PharmD, BCPS Date

In concurrence with:

______________________________ __________Date

______________________________ __________Date

______________________________ __________

Date

This guideline was approved by UHS P&T Committee on 5/11/2012

uhs anticoagulation therapy guideline y12 04

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