Derbyshire Joint Area Prescribing Committee (JAPC) · Give an OAT pack and patient information...

Derbyshire JAPC Guideline ndash lsquoOral Anticoagulationrsquo Revised February 2011 Review Date February 2013 Hassan Hajat Clinical Adviser NHS Derbyshire County PCT

1

Derbyshire Joint Area Prescribing Committee (JAPC)

GUIDELINE ON ORAL ANTICOAGULATION

o This guideline is intended to be used in Derbyshire to support the level 4 anticoagulation management service commissioned in NHS Derbyshire County Only accredited practitioners who meet the service specification and sign up to the service level agreement should provide this service

o The use of 1mg strength Warfarin tablets is strongly recommended unless

patients are on doses greater then 5mg and can manage different strengths

o Avoiding more then two different strengths is recommended

o Use of 05mg is not recommended to avoid confusion

o The patient should receive verbal and written information on anticoagulant therapy from the start of treatment and an induction process followed to ensure they understand the information

o Each patient should be issued with an oral anticoagulation therapy (OAT) pack containing

a anticoagulant record booklet (yellow booklet) which should be kept up to date

o Practitioners managing oral anticoagulation should meet the required NPSA competencies

o Warfarin is classified as a ldquocritical medicinerdquo as defined by the National Patient Safety

Agency Rapid Response Report 18 Preventing fatalities from medication loading doses The use of loading doses of medicines can be complex and error prone Incorrect use of loading doses or subsequent maintenance regimens may lead to severe harm or death

o Particular attention should be placed on assessing concordance and checking changes in

medication foods and lifestyles and the impact of these on the International Normalised Ration (INR)


2

APPENDICES 1 Indications for Oral Anticoagulation page 8 2 Atrial fibrillation and Warfarin patient information leaflet page 9 3 Conditions which may cause a change in Warfarin sensitivity page 13 4 Common Warfarin drug interactions page 14 5 Guidelines for the management of over anticoagulated patients page 15 6 Induction guidelines for patients newly initiated on Warfarin page 16 7 Summary of guidelines on management of patients requiring page 18

dental surgery 8 Resources page 19 9 List of contacts for clinical support and advice page 21


3

1 General Guidance

Warfarin has a narrow therapeutic index and regular titration of the dose against the anticoagulant effect in the blood as assessed by the INR is essential

The patient should be maintained within their therapeutic range as documented in Appendix 1 Deviation from the therapeutic range is associated with an increased risk of haemorrhage or thrombosis (if too high) or increased risk of stroke (if too low)

Practitioners managing anticoagulation should meet the required NPSA competencies1 2 Indications for oral anticoagulation

The decision relating to diagnosis indication for anticoagulation and INR target and range will be made in secondary care except for stroke risk reduction in Atrial fibrillation patients

Accredited Pharmacists and nurses managing anticoagulation will not be required to make these decisions unless qualified as independent prescribers

In some patients Warfarin is started as an out-patient because immediate anticoagulation is not necessary

See Appendix 1 for detailed list of conditions target INR and range and duration of treatment

3 Initiation of Warfarin Therapy There are various schedules for initiating anticoagulation within an outpatient setting the

recommended regime is described below In primary care initiation should only be done by accredited practitioners who have successfully completed the BMJ module - lsquoStarting patients on anticoagulants how to do itrsquo

When starting Warfarin you must stop aspirin clopidogrel unless continuation is explicitly advised by a consultant in secondary care This should be documented

All new patients should receive a structured induction such as that described in Appendix 6 to ensure that all the relevant information is provided

Warfarin is classified as a ldquocritical medicinerdquo as defined by the National Patient Safety Agency Rapid Response Report 18 Preventing fatalities from medication loading doses The use of loading doses of medicines can be complex and error prone Incorrect use of loading doses or subsequent maintenance regimens may lead to severe harm or death

Starting as an out-patient in primary care 23

Protocol 1 Explain the indication and the risks and benefits of treatment 2 Prescribe 2mgs a day for 2 weeks (day 1) 3 Give an OAT pack and patient information sheet (see Appendix 2 for Atrial fibrillation) 4 Check INR after 1 week (day 8) of the new dosage to ensure patient is not oversensitive to

warfarin (see appendix 3 and 5) Do not change the dose unless the INR is greater then 3 ndash discuss options with haematologist 5 Patients should return after another week of therapy (day 15) for an INR measurement

On the basis of this result the predicted maintenance dose for target 25 plusmn 05 is prescribed from the table

Predicted maintenance dosage of warfarin based on the sex of the patient and the INR after

2 weeks of 2mgday

MALE FEMALE INR at Week 2 Maintenance Dose INR at Week 2 Maintenance Dose

10 6 mgday 10 ndash 11 5 mgday 11 ndash 12 5 mgday 12 ndash 13 4 mgday 13 ndash 15 4 mgday 14 ndash 19 3 mgday 16 ndash 21 3 mgday 20 ndash 30 2 mgday 22 ndash 30 2 mgday gt 30 1 mgday

gt 30 1 mgday


4

6 Patients should re-attend after 1 week of the new dosage (day 22) for a further INR

measurement

7 Subsequent dosage adjustment should be as follows If the INR is gt40 but there is no bleeding the warfarin should be omitted for 2 days

and then restarted at a dose 1 mg lower For bleeding complications on warfarin contact the haematologist If the INR is lt20 the dosage should not be changed but the patient should be

encouraged to return one week later for a further reading If there are two consecutive weeks where the INR is lt20 then the dosage of warfarin should be increased by 1mg

By the time the patient has been taking warfarin for 6 weeks the INR should be in the therapeutic range Fine tuning of warfarin dosage by using alternate day regimens of eg 2 mg3mg

can be used if INR fluctuates too much

Changes in warfarin dosage should be kept to a minimum as there are natural fluctuations in the INR which occur on a daily basis and because of external factors

4 Dosage Regimens

The dose required to achieve the therapeutic target is very variable between patients but usually lies between 1 and 10mg daily

Dosage decisions should be supported using approved clinical decision support software (CDSS) but clinical judgement must be applied in all cases to determine decisions

The dose should be taken once a day at a fixed time preferably 1800 hours or another regular time if more convenient to aid better compliance Patients are mostly seen during the day and a late afternoon or evening dose does enable the managing practitioner to ask the patient to miss a dose when required Management can be trickier if the patient has already taken their anticoagulant

The tablet strengths available are 05mg (white) 10mg (brown) 30mg (blue) and 50mg (pink)

The use of 1mg strength tablets only is recommended unless patients are on high doses greater than 5mg Avoiding more than two different strengths is strongly recommended

Use of 05mg is not recommended to avoid confusion The current INR and recommended dose should be recorded in the patientrsquos yellow

anticoagulant record book The recommended dose should always be specified in milligrams ie Xmg and not

number of tablets The NPSA recommends use of constant daily dosing and not alternate dosing In practice

fine tuning of dosage by using alternate day regimens of eg 2 mg3mg may need to be used if INR fluctuates too much

If a patient misses a dose of Warfarin they should be told not to take double the dose the next day but continue with their normal dose If the patient is very sensitive to changes or at high risk if under dosed they should contact the service provider as soon as possible Other patients may be asked to arrange earlier monitoring if their appointment is not due for more some time depending on stability of patient and clinical judgement of managing practitioner

5 Monitoring

This service is based on near patient testing and venous samples should only be used in exceptional circumstances stated in the service specification

The frequency of monitoring will vary but patients should have their INR checked at least every 10 -12 weeks Every patient must be seen at least once every 12 weeks Less stable and new patients will require more frequent tests


5

Recall dates will be suggested by the dosing support software however if the patientrsquos clinical condition is changing or there have been alterations in other medication then the INR should be checked more frequently and clinical judgement should override the CDSS

When determining the frequency of recall it is helpful to remember that the full effect of a change in dose of warfarin on the INR may take 3 days to become apparent

Many clinical factors or drugs may affect the sensitivity of the patient to the effects of warfarin Some of these are documented in Appendix 3

Particular attention should be placed on checking changes in medication foods and lifestyles and the impact of these on the International Normalised Ration (INR)

Records should be comprehensive and specific alert flags should be considered to highlight a specific warning or a patientrsquos particular sensitivity

A full list of various drugs which may interact with anticoagulants is given in the back of the latest BNF (Drug Interactions under coumarins) Appendix 4 gives a very useful summary of common drug interactions

Drugs that are liver enzyme inhibitors can increase the INR They act very quickly (can be within 24 hours) and if the drug is withdrawn the effect disappears quickly depending on the drug half-life The INR should if possible be monitored within 72 hours of starting the interacting drug and on withdrawal

Drugs that are liver enzyme inducers can decrease the INR They act more slowly (up to a week) with peak effect at 2-3 weeks and can persist for up to 4 weeks after stopping depending on drug half-life The INR will need checking after 1 week of concurrent therapy

Some drugs may have other mechanisms that affect the INR Even commonly used medicines such as paracetamol can affect the INR at doses greater than 2g per day or when the patient is particularly sensitive to the medicine

If a patient on Warfarin is started on ANY other new medication a repeat INR after 1 week would be a sensible precaution

Service providers should discuss concordance and as with all prescribed medications have mechanisms in place to regularly check compliance

A robust system should be in place to ensure all DNAs (did not attends) are followed up and monitored effectively It must be stressed to the patient that careful monitoring of Warfarin therapy is essential in order to avoid complications Where patients repeatedly fail to attend then the risks of continuing therapy should be considered against the benefits Advice should be sought from the GP or specialist

6 Management of Bleeding and or Over-Anticoagulation

Coagulometers using capillary blood may not be accurate when the INR is elevated For CoaguChek XS plus when the INR is gt 8 the capillary blood INR result should be confirmed with a second test and in addition a sample obtained by venepuncture and sent to the laboratory to determine the exact INR reading The therapeutic decision around dosing and clinical management of the patient should not be delayed until the laboratory result is obtained Clinical management will depend on whether there is bleeding or not which will also indicate need for vitamin K

The risk of haemorrhage increases significantly when the INR is gt 50 The recommendations on the management of over anticoagulated patients can be found

below All patients with bleeding should be evaluated to determine whether there is a local

anatomical cause for the haemorrhage A PGD for administration of oral vitamin k (Konakion Paediatric) is available for use by

accredited practitioners within NHS Derbyshire County PCT

See appendix 5 Guideline for management of over anticoagulated patients


6

7 Contraindications to Anticoagulation This is seldom absolute and each patient must be individually evaluated Pregnancy exposure of the embryo to warfarin during the 6th to 12th weeks of gestation

may be associated with the development of an embryopathy and throughout gestation there is a continuing risk of foetal haemorrhage

Patients who could potentially get pregnant must be warned of the risks and told to seek an early pregnancy test if they suspect a risk

Any patient taking Warfarin who becomes pregnant must stop Warfarin and be referred urgently for hospital evaluation and management

8 Exclusions

Patients with the following conditionsproblems should be excluded from the primary care service

A known hereditary or acquired bleeding disorder Children under 16 Pregnant Other conditions the Consultant Haematologist considers should exclude the patient from

management in primary care Excluded patients will continue to be managed by secondary care clinicians

9 Cautions There are certain conditionsproblems where caution should be taken when monitoring patients and where required advice from the Haematology department should be sought These include severe heart failure liver failure DVT PE in the previous month and chronic alcoholic Risk factors of bleeding should be considered The following patient characteristics are indicative of a high risk for bleeding Age gt70 Hypertension Diabetes Renal Failure Previous MI Previous CVA Previous GI Bleed Patients with Liver Disease

10 Anticoagulation in special circumstances

All practitioners providing this service should be aware of special circumstances and know how to manage these patients and ask for specialist advice when required These are circumstances such as Protein C deficiency Protein S deficiency Antisphospholipid syndrome Factor V Leiden The pre-workshop booklet distributed as part of the NHS Derbyshire County PCT accreditation programme (Management of patient anticoagulation therapy) briefly covers these circumstances and should be used in conjunction with other national guidelines

Anticoagulation in Cancer Patients Patients with cancer who are receiving antithrombotic therapy are thought to be at higher risk of bleeding than patients without cancer For practical purposes the recommended therapeutic levels of anticoagulation remain the same as long as patients are educated about the risks and the anticoagulation levels are strictly monitored Patients with cancer are at a higher risk than non-cancer patients of recurrence of thromboembolism despite adequate anticoagulation Patients with cancer who develop thromboembolism should be considered for treatment with long term Low molecular weight heparin It is preferable to use heparin in this circumstance and therapeutic anticoagulation with heparin therapy reduces the risk of recurrent events compared with Warfarin therapy (BCSH guidelines on oral anticoagulation4)


7

Anticoagulation in dental surgery The British Committee for Standards in Haematology (BCSH) has published a document to provide healthcare professionals including primary care dental practitioners with clear guidance on the management of patients on oral anticoagulants requiring dental surgery (See Appendix 7)

11 Discontinuation of Warfarin Therapy

The duration of required anticoagulation should always be stated in the medical notes when the patient is first started on therapy

Concern of a lsquorebound hypercoagulable statersquo after stopping oral anticoagulant therapy has resulted in uncertainty as to whether treatment should be stopped abruptly or gradually

Having considered the evidence the current BCSH guidelines4 state that there is no need for gradual withdrawal of anticoagulant therapy The guidelines recommend that oral anticoagulant therapy can be discontinued abruptly when the duration of therapy is completed

Where there are further risks involved 75mg Aspirin should be considered

1Work competences for anticoagulant therapy Available from the NPSA Website httpwwwnpsanhsuk

o initiating anticoagulant therapy maintaining oral anticoagulant therapy managing anticoagulants in patients requiring dental surgery reviewing the safety and effectiveness of an anticoagulant service

2 Oates A Jackson PR Austin CA Channer KS A new regimen for starting anticoagulation in out-patients British Journal of Clinical Pharmacology 1998 46 157-171

3Channer Kevin S Starting as an outpatient BJGP 2002 52 238-9

4Guidelines on oral anticoagulation third edition- 2005 update British Committee for Standards in Haematology httpwwwbcshguidelinescompdforalanticoagulationpdf


8

APPENDIX 1

Indications for Oral Anticoagulation

Indication Target INR amp Range

Duration

Pulmonary embolus 25 20-30 6 months

Proximal DVT 25 20-30 6 months

Distal DVT Non-surgical with no persistent risk

factors Surgical with no persistent risk factors

Consider increasing duration of anticoagulation if any risk factors persist

25

25

20-30

20-30

3 months

6 weeks

Recurrent events PE amp or DVT Off warfarin or sub-therapeutic INR On warfarin within therapeutic range

25 35

20-30 30-40

Long term Long term

Non-rheumatic AF with at least one additional risk factor

Previous thromboembolism Systolic hypertension Congestive heart failure Abnormal LV function on

echocardiography

25

20-30

Long term

AF secondary to rheumatic heart disease 25 20-30 Long term

Cardioversion for AF 25 20-30 Minimum 3 weeks before to 4 weeks after

Rheumatic mitral valve disease 25 20-30 Long term

Dilated cardiomyopathy 25 20-30 Long term

LV mural thrombus post MI +- LV aneurysm 25 20-30 3 months Mechanical prosthetic heart valve If low risk

Low thrombogenicity valve eg AVR Sinus rhythm Normal LA size

Consider decreased intensity

35

30

30-40

25-35

Long term

Long term

Bioprosthetic heart valve AVR MVR

If high risk AF Intracardiac thrombus Previous systemic embolism

Consider

25 25

25

20-30 20-30

20-30

3-6 months 3-6 months

Long term

Inherited thrombophillia with DVT amp or PE 25 20-30 Variable

Antiphospholipid syndrome Recurrent events whilst therapeutically anticoagulated

25

35

20-30

30-40

Long term

Long term Reference Haemostasis amp Thrombosis Taskforce of the British Committee for Standards in Haematology Guidelines on oral anticoagulation British Journal of Haematology 1998 101 174-187


9

APPENDIX 2

PATIENT INFORMATION LEAFLET

Atrial Fibrillation and Warfarin

Warfarin reduces the risk of people with atrial fibrillation (AF) having a stroke

What is atrial fibrillation Another leaflet discusses atrial fibrillation (AF) in more detail Briefly people with untreated AF have a heartbeat that is fast and erratic Treatment in most cases is to bring the heart rate down to normal This usually eases most symptoms However in many cases the heart rhythm remains erratic even if the rate is brought down to normal It is this erratic rhythm of the heartbeat that sometimes leads to the complication of a stroke Why is a stroke a possible complication of atrial fibrillation The erratic heart rhythm of AF causes turbulent blood flow within the heart chambers This sometimes leads to a small blood clot forming in a heart chamber A clot can then travel in the blood vessels until it gets stuck in a smaller blood vessel in the brain (or sometimes in another part of the body) Part of the blood supply to the brain may then be cut off which causes a stroke Therefore the main complication of AF is an increased risk of having a stroke The risk of developing a blood clot and having a stroke varies depending on various factors The level of risk is divided into three categories high medium and low risk

High risk means that without treatment you have about a 6-12 in 100 chance (sometimes higher) of having a stroke in the next year People in the high risk group include those o who have already had a stroke or known blood clot or o are aged 75 years or older who also have one of the following risk factors high blood

pressure diabetes or a cardiovascular disease (such as angina heart attack peripheral vascular disease) or

o who have a heart valve problem or o who have heart failure or poor heart function shown on a heart scan

Moderate risk means that you have about a 3-5 in 100 chance of having a stroke in the next year People in the moderate risk group include those o aged 65 years or older (with no high risk factors) or o who are of any age (up to age 75 when the risk is high) but who also have one of the

following risk factors high blood pressure diabetes or a cardiovascular disease (such as angina heart attack peripheral vascular disease)

Low risk means that you have about a 1-2 in 100 chance or less of having a stroke in the next year People in the low risk group are all people with AF aged less than 65 and who do not have any risk factors that put them in the high or moderate risk category

What does Warfarin do and how effective is it Warfarin interferes with certain chemicals in the blood to prevent blood clots forming so easily This is known as anticoagulation Some people call anticoagulation thinning the blood although the blood is not actually made any thinner Warfarin is the most commonly used anticoagulant drug Recent studies which looked at people with AF have shown that by taking Warfarin the risk of having a stroke is greatly reduced


10

Overall Warfarin reduces the risk of stroke by nearly two-thirds In other words Warfarin treatment can prevent about 6 in 10 strokes that would have occurred in people with AF The greatest benefit is seen in those people who are in the high risk category of having a stroke (described above) For example

For people with AF who are at high risk of stroke about 80-90 strokes will be prevented each year for every thousand people treated with Warfarin

For people with AF who are at moderate risk of stroke about 25 strokes will be prevented each year for every thousand people treated with Warfarin

Are there any risks with taking Warfarin As with most treatments there is some risk if you take Warfarin The main risk is that a bleeding problem may develop as the blood will not clot so well For every thousand people with AF who take Warfarin about nine people per year are likely to have a serious bleeding problem from the treatment For example you could develop a bleeding ulcer in your intestines (guts) or suffer a bleed into the brain (a cerebral haemorrhage) If you have a serious bleed you are likely to need to be admitted to hospital often needing a blood transfusion and it can even result in death Most people with AF who have a high or medium risk of having a stroke are advised to take Warfarin However some people with a moderate risk may be treated with aspirin rather than Warfarin (see below) particularly if the risks of taking Warfarin are higher than average People with a low risk of having a stroke are not usually advised to take Warfarin This is because the benefit does not usually outweigh the risk of serious bleeding problems with taking Warfarin In short the decision to take Warfarin is a joint decision between you and your doctor It involves weighing up the risk of having a stroke against the small risk of a complication from taking Warfarin

Aspirin is another drug that helps to prevent blood clots forming It is not as effective as Warfarin but is less likely to cause serious problems It is usually advised if you only have a low risk of stroke or if you cannot take Warfarin or do not wish to take Warfarin What does Warfarin treatment involve Most people who take Warfarin attend a Warfarin clinic This may be at your GP practice or at the local hospital The clinic is run by a health professional specially trained in anticoagulation He or she may be a doctor specialist nurse trained pharmacist etc

You will need regular blood tests to check on how quickly your blood clots when you are taking Warfarin Blood tests (and clinic visits) may be needed quite often at first but should reduce in frequency quite quickly The aim is to get the dose of Warfarin just right so your blood does not clot as easily as normal but not so much as to cause bleeding problems

You will be advised on how to take Warfarin and if it affects any other medication that you take For example the following are commonly advised

You should aim to take Warfarin at the same time each day If you accidentally miss a dose NEVER take a double dose to catch up (unless

specifically advised by a doctor or by the person who runs the Warfarin clinic) Seek advice promptly if you think that you have taken too much Warfarin by mistake or

have missed any doses Other medication whilst taking Warfarin If you are prescribed or buy any other drug then tell a doctor nurse or pharmacist that you are on Warfarin This is because some drugs interfere with the way Warfarin works and your dose of Warfarin may need to be altered Also if you stop another drug or change the dose seek advice from a doctor or nurse as your dose of Warfarin may need to be altered


11

Diet If you have a major change in your diet or the foods that you eat then seek advice from the Warfarin clinic A major change in diet may mean that you need more closer monitoring and may need a change in Warfarin dose In particular if you eat a vitamin K-rich diet you should not change your eating habits without at the same time reducing the dose of Warfarin Two other commonly eaten foods that are known to interact with Warfarin are cranberry and grapefruit To make things easier it is probably best simply to avoid foods that contain cranberry or grapefruit

Women of childbearing age Seek advice promptly if you become pregnant or are planning a pregnancy For safety reasons Warfarin is likely to be stopped and an alternative drug called heparin is likely to be used instead What if I bleed whilst taking Warfarin An indication that the dose of Warfarin is too high is that you may bleed or bruise easily Also if you bleed the bleeding may not stop as quickly as normally For example you may have bleeding gums nosebleeds prolonged bleeding from cuts blood in the urine If you cut yourself or have any other bleeding seek medical help as soon as possible if the bleeding does not stop as quickly as you would expect If you injure an arm or leg which is bleeding until you get medical help then ideally keep the affected part raised above the level of your heart If you vomit blood get medical help immediately - ring for an ambulance Some other general points about taking Warfarin

Always carry with you the yellow anticoagulant treatment booklet which will be given to you This is in case of emergencies and a doctor needs to know that you are on Warfarin and at what dose

If you have surgery or an invasive test you may need to temporarily stop taking Warfarin Tell your dentist that you take Warfarin Most dental work does not carry a risk of

uncontrollable bleeding However for dental extractions and surgery you may need to temporarily stop taking Warfarin

You should limit the amount of alcohol that you drink to a maximum of one or two units a day and never binge drink

o One unit of alcohol is about equal to half a pint of ordinary strength beer or lager (3-4 alcohol by volume) or a small pub measure (25 ml) of spirits (40 alcohol by volume) or a standard pub measure (50 ml) of fortified wine such as sherry or port

(20 alcohol by volume) o There are one and a half units of alcohol in

a small glass (125 ml) of ordinary strength wine (12 alcohol by volume) or a standard pub measure (35 ml) of spirits (40 alcohol by volume)

Ideally try to avoid activities that may cause abrasion bruising or cuts (for example contact sports) Even gardening sewing etc can put you at risk of cuts Do be careful and wear protection such as proper gardening gloves when gardening

Take extra care when brushing teeth or shaving to avoid cuts and bleeding gums Consider using a soft toothbrush and an electric razor

Try to avoid insect bites Use a repellent when you are in contact with insects

Further help and advice

British Heart Foundation 14 Fitzhardinge Street London W1H 6DH Tel (Heart Help Line) 08450 70 80 70 Web httpwwwbhforguk

Anticoagulation Europe PO Box 405 Bromley Kent BR2 9WP Tel 020 8289 6875 Web httpwwwanticoagulationeuropeorg A charity providing information and advice to people on oral anticoagulation treatment

References

Atrial fibrillation Clinical Knowledge Summaries (2007) The management of atrial fibrillation NICE Clinical Guideline (Jun 2006) Mant J Hobbs FD Fletcher K et al Warfarin versus aspirin for stroke prevention in an

elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study BAFTA) a randomised controlled trial Lancet 2007 Aug 11370(9586)493-503 [abstract]

Lip GY Hart RG Conway DS Antithrombotic therapy for atrial fibrillation BMJ 2002 Nov 2325(7371)1022-5

Leaflets from Patient UK Atrial fibrillation and Warfarin httpwwwpatientcoukpdfpilsL211pdf Atrial Fibrillation httpwwwpatientcoukpdfpilsL10pdf Disclaimer This article is for information only and should not be used for the diagnosis or treatment of medical conditions EMIS and PiP have used all reasonable care in compiling the information but make no warranty as to its accuracy Consult a doctor or other health care professional for diagnosis and treatment of medical conditions For details see our conditions copy EMIS and PiP 2008 Updated 17 Mar 2008 DocID 4386 Version 38


12


13

Appendix 3

Conditions which May Cause a Change in Warfarin Sensitivity

The following conditions may increase sensitivity to Warfarin and therefore warrant a decrease in Warfarin dose

Hepatic dysfunction and or jaundice Alcohol abuse particularly ldquobinge drinkingrdquo Congestive heart failure Anorexia Diarrhoea Hyperthyroidism Acute pyrexial episode Changes in diet which reduce the intake of vitamin K Dietary components Cranberry juice Drugs (this list is not exhaustive)

Allopurinol NSAIDs Amiodarone Marked effect Antibiotics Unpredictable almost any antibiotic Antifungals Disulfiram Tamoxifen Statins Thyroid hormones Cimetidine Antiplatelet agents Increased risk of bleeding

The following conditions may cause a decrease in sensitivity and therefore warrant an increase in Warfarin dose

Hypothyroidism Changes in diet which increase the intake of vitamin K Dietary components Dasheen Herbal remedies St Johnrsquos Wort Gingko biloba Drugs (this list is not exhaustive)

Anti-convulsants Barbiturates Rifampicin Estrogens amp progestogens Sucralfate

Note When these drugs are discontinued the dose must be reduced to avoid dangerous over-anticoagulation

The following foods and supplements are rich in vitamin K Dark green vegetables spinach kale spring greens cabbage brussels sprouts broccoli asparagus watercress parsley beef liver rapeseed oil green tea


14

Appendix 4 COMMON WARFARIN DRUG INTERACTIONS12 The drugs in this list are more usually associated with loss of INR control in patients already established on warfarin This list is not exhaustive - refer to the British National Formulary (BNF) for further information If any of the drugs below are to be started in these patients then the use of alternatives in the same therapeutic class may be considered If this is not possible then the patientrsquos INR should be monitored as detailed below Those drugs highlighted in bold are significant interactions and should be avoided or used with caution Drugs marked are liver enzyme inhibitors and increase the INR They act very quickly (can be within 24

hours) and if the drug is withdrawn the effect disappears quickly depending on the drug half-life The INR should if possible be monitored within 72 hours of starting the interacting drug and on withdrawal

Drugs marked $ are liver enzyme inducers and decrease the INR They act more slowly (up to a week) with peak effect at 2-3 weeks and can persist for up to 4 weeks after stopping depending on drug half-life The INR will need checking after

1 week of concurrent therapy Drugs with neither have other mechanisms which affect the INR NB If a patient on warfarin were started on ANY other new medication a repeat INR after 1 week would be a sensible

Drugs that increase the INR and risk of bleed Gastrointestinal cimetidine omeprazole and possibly other PPIs Cardiovascular amiodarone (liver enzyme inhibition is slow and may persist long

after withdrawal requiring weekly monitoring over 4 weeks) fibrates ezetimibe propafenone propranolol statins ndash no clinically relevant interaction will normally be seen however it is prudent to check INR in the weeks after initiation and at any dose change

CNS fluvoxamine SNRIs SSRIs tramadol Anti-infectives (anti-infectives in general may cause raised INRrsquos)

azole antifungals (esp miconazole including oral gel and vaginal) co-trimoxazol macrolides (can be serious but unpredictable) metronidazole quinolones (can be serious but unpredictable) tetracyclines influenza vaccine

Endocrine anabolic steroids (and danazol) high dose corticosteroids glucagon (high dose 50mg+ over 2 days) flutamide levothyroxine

NSAIDs

Ibuprofen at lowest effective dose (+-PPI) is probably safest if NSAID is required

NB All NSAIDs can increase the risk of bleeds and should be avoided if possible

Antiplatelets ndash increased bleed risk Aspirin clopidogrel and dipyridamole

Miscellaneous Alcohol (acute) allopurinol benzbromarone colchicine disulfiram fluorouracil interferon paracetamol (prolonged use at high dose) sulfinpyrazone tamoxifen topical salicylates zafirlucast

Herbal preparationsFood supplements

Carnitine chamomile cranberry juice curbicin dong quai fenugreek fish oils garlic gingo biloba glucosamine grapefruit juice lycium mango quilinggao

Drugs that decrease the INR Miscellaneous Alcohol$ (chronic) azathioprine barbiturates$ bosentan$ carbamazepine$ carbimazole

griseofulvin$ mercaptopurine nevirapine$ OCPHRT propylthiouracil raloxifene rifampicin$(most potent inducer) trazodone

Herbal preparations etc Avocado co-enzyme Q10 green tea natto soya beans St Johns wort$ (avoid) Binding agents Colestyramine sucralfate Warfarin antagonist

Vitamin K

Drugs that increase or decrease the INR Miscellaneous Ginseng phenytoin quinidine

1British National Formularly 55 Edition March 2008 2 Stockleyrsquos Drug Interactions Edition Eight Pharmaceutical Press November 2007 Based on original by Julian Holmes Nottingham University Hospitals Trust and further adapted by NHS Derbyshire County PCT Updated by Aiste Baltramaityte and David Anderton Derby Hospitals NHS Foundation Trust


15

APPENDIX 5

Guideline for the management of over anticoagulated patients

1 Introduction The main adverse effect of all oral anticoagulants is hemorrhage Checking the INR and omitting doses when appropriate is essential if the anticoagulant is stopped but not reversed the INR should be measured 2ndash3 days later to ensure that it is falling Check in 24hrs if vitamin k given

Remember Warfarin has a long half-life and the INR may still extend for 48 hours after a last dose Depending on the INR patients may need to omit Warfarin for a period of 1 ndash 3 days for the anticoagulant effects to be adequately reversed if no Vitamin K is administered Try to identify the cause for loss of control in all cases of over-anticoagulation Enquire about drug compliance additional drug therapy and dietary changes and consider co-morbidities

The risk of bleeding associated with excess anticoagulation is a function of both the level of the INR and the duration of time the patient is exposed to this excessive anticoagulation

The following patient characteristics are indicative of a high risk for bleeding Age gt70 Hypertension Diabetes Renal Failure Previous MI Previous CVA Previous GI Bleed Liver disease

2 Guideline

The following recommendations (which take into account the recommendations of the British Society for Haematology(1)) are based on the result of the INR and whether there is major or minor bleeding the recommendations apply to patients taking warfarin

Major bleeding mdashstop warfarin give phytomenadione (vitamin K1) 5ndash10 mg by slow intravenous injection give dried prothrombin complex (factors II VII IX and Xmdash BNF section 211) 30ndash50 unitskg or fresh frozen plasma 15 mLkg (if dried prothrombin complex not available) Seek specialist advice as required

INR ge 80 no bleeding mdashstop warfarin restart when INR lt 50 if minor bleeding or there are other risk factors for bleeding give phytomenadione 20 mg (using the intravenous preparation orally ndash a PDG is available in NHS Derbyshire County) repeat dose of phytomenadione if INR still too high after 24 hours [If INRge 8 during induction (ie before patient is stabilised with 3 consecutive INRs within range) then 2mg phytomenadione orally should be considered]

If high risks and full reversal required quickly consider giving phytomenadione (vitamin K1) 500 micrograms by slow intravenous injection or 5 mg by mouth

INR ge6 major bleeding or minor bleed plus more then one risk factorndash give phytomenadione 2mg orally

INR 60ndash80 no bleeding or minor bleeding mdashstop warfarin restart when INR lt 50 INR lt 60 but more than 05 units above target valuemdashreduce dose or stop warfarin restart

when INR lt 50 Unexpected bleeding at therapeutic levelsmdashalways investigate possibility of underlying

cause eg unsuspected renal or gastro-intestinal tract pathology Seek specialist advice

IV Vitamin K administration leads to INR reversal within 4 ndash 6 hours and is the fastest means of INR reversal Do not give IM injections This can cause a muscle haematoma The oral route (Konakion paediatric 2mg per 02ml ampoule) being slower - Up to 24 hours This will readily reverse INRs within 16 to 24 hours to therapeutic doses

Relevant references

1 Guidelines on oral anticoagulation third edition British Journal of Haematology 1998 101 374 - 387

2 Effective reversal of Warfarin induced excessive anticoagulation with Low Dose Vitamin K Thrombosis and Haemostasis 1992 67 (1) 13 ndash15

3 Warfarin Reversal J Clin Pathol 2004 57 1132 ndash 1139


16

APPENDIX 6

Induction guidelines for patients newly initiated on Warfarin The aim of is to provide standard information and induction for all patients that are newly prescribed The patient may not remember much information if you provide all the information at the first session or when they are too ill to take it in If necessary check with the patient as to whether it would be appropriate for a second person to be present during the counselling eg the patientrsquos carer Ensure every patient is given the new oral anticoagulation treatment (OAT) pack developed by the NPSA and this is recorded in the notes 1 Explain what anti-coagulant is for

Oral Anti-coagulants are used to lsquothinrsquo the blood Certain patients are at risk from clot formation inside blood vessels Anti-coagulants reduce

this risk

2 Explain Dosing Colour of different strength tablets On discharge pharmacy supply tablets of 1mg strength only When to take them ie at 600 pm(or another regular time if more convenient)) Length of treatment (if known)

3 Explain importance of compliance

It is very important to take the prescribed dose Taking to much or too little is potentially harmful

Too much Blood may be over-thinned bruising and bleeding may occur Too little Blood may not be thinned enough and so clots may form more readily 4 Explain the importance of regular blood tests as directed by your doctor

Blood test Blood is taken to check that it has been lsquothinnedrsquo by the right amount The number dose of tablets may change depending on the result of this test Ascertain who will be monitoring therapy GP or other clinic eg day hospital

5 Explain what to do if dose is missed or forgotten

It is very important to inform the ClinicGP on the next visit of all doses missed If unsure if dose has been taken do NOT take an extra dose If more than one dose has been missed ask advice of own Doctor or the anticoagulant

clinic 6 Inform patient of potential side effects Seek medical help if any bleeding or bruising problems are experienced eg

spontaneous bruising bleeding from cuts which is slow to stop bleeding that will not stop by itself nose bleeds bleeding gums red dark brown urine red black stools in women - increased menstrual bleeding or unexplained vaginal bleeding


17

7 Other medicines Do not take aspirin unless a doctor who knows you are receiving anti-coagulant therapy

prescribes it since it can make you more prone to bruising or bleeding Many cold lsquoflu and pain medicines contain aspirin so if in doubt ASK your pharmacist or

doctor Paracetamol may be taken in normal doses while on anti-coagulants Inform ClinicGP of any changes in medication as these may also affect the blood test

result Check with the patient to see if they have any other medication at home that is not on the

treatment card especially analgesics herbal remedies cod liver oil or garlic pearls Check for any interactions and advise the patient appropriately Patients should be advised to avoid all herbal preparations (unknown effects on Warfarin) to not take garlic pearls (garlic is a natural anticoagulant) and only take one cod liver capsule per day (higher doses may increase vitamin K intake)

8 Dietary advice

Speak to your Doctor nurse or pharmacist at the clinic about changes in diet Eat a balanced diet Do NOT drink more than moderate amounts of alcohol (1 pint of ordinary strength beer per

day or the equivalent in pub measures of wine spirits) as this can have an effect on blood clotting

9 Oral anticoagulation treatment (OAT) pack (includes Yellow booklet)

Complete the first page of details in the anticoagulant treatment record book Give patient OAT pack and encourage them to read it thoroughly Reassure patient that most of the information you have given them is in the patient

information booklet Advise patient to carry booklet and the alert card with them at all times so that they can

show it to a Doctor or Dentist if obtaining treatment or to a Pharmacist at the point of dispensing and if buying medicines

10 Check patient understanding and repeat the main messages for the patient to take away with them

Number of tablets When to take them - ie 600 pm (or another regular time if more convenient) What to do if they miss a dose Length of treatment Signs of bruisingbleeding to look for and what to do in case They should check before receiving any treatment that the Drdentistpharmacist knows

about their Warfarin 11 Ensure that the patient has a contact telephone number for the clinic managing their blood tests in their booklet (if appropriate)

Plus the contact number of the lead clinician where appropriate Plus the number for the AampE department where appropriate

12 Assess current medication

Where appropriate document any concurrently prescribed and purchased (OTC) medication which may interfere with anticoagulant therapy in the patientrsquos anticoagulant booklet Remember to explain that this advice is not intended to be fully comprehensive Should the patient request any further advice or information outside your scope please refer them as appropriate

13 Ask if there are any questions


18

APPENDIX 7

Summary of Guideline for management of patients requiring dental surgery Full text can be found on httpwwwbcshguidelinescompdfWarfarinandOralSurgery26407pdf

The British Committee for Standards in Haematology (BCSH) has published a document to provide healthcare professionals including primary care dental practitioners with clear guidance on the management of patients on oral anticoagulants requiring dental surgery

Summary of Key recommendations The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the

therapeutic range 2-4 (ie lt4) is very small and the risk of thrombosis may be increased in patients in whom oral anticoagulants are temporarily discontinued Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental surgery including dental extraction

Most cases of postoperative bleeding are easily treated with local measures such as packing with a haemostatic dressing suturing and pressure -Stopping warfarin increases the risk of thromboembolic events the risk of thromboembolism after withdrawal of warfarin therapy outweighs the risk of oral bleeding as bleeding complications while inconvenient do not carry the same risks as thromboembolic complications -Stopping warfarin is no guarantee that the risk of postoperative bleeding requiring intervention will be eliminated as serious bleeding can occur in non-anticoagulated patients (httpwwwnelmnhsukenNeLM-AreaEvidenceMedicines-Q--ASurgical-management-of-the-primary-care-dental-patient-on-warfarinquery=tranexamicamprank=5)

For patients stably anticoagulated on Warfarin (INR 2-4) and who are prescribed a single dose of antibiotics as prophylaxis against endocarditis there is no necessity to alter their anticoagulant regimen

Antibacterial prophylaxis and chlorhexidine mouthwash are not recommended for the prevention of endocarditis in patients undergoing dental procedures Such prophylaxis may expose patients to the adverse effects of antimicrobials when the evidence of benefit has not been proven (BNF 56 P287)

Patients at risk of endocarditis(1) should be advised to maintain the highest possible standards of oral hygiene in order to reduce the need for dental extractions or other surgery chances of severe bacteraemia if dental surgery is needed and possibility of lsquospontaneousrsquo bacteraemia 1) Patients at risk of endocarditis include those with valve replacement acquired valvular heart disease with stenosis or regurgitation structural congenital heart disease (including surgically corrected or palliated structural conditions but excluding isolated atrial septal defect fully repaired ventricular septal defect fully repaired patent ductus arteriosus and closure devices considered to be endothelialised) hypertrophic cardiomyopathy or a previous episode of infective endocarditis

For patients who are stably anticoagulated on Warfarin a check INR is recommended 72 hours prior to dental surgery

Patients taking Warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors as analgesia following dental surgery

What constitutes dental treatment Many procedures performed in the primary care setting are relatively non-invasive and would not therefore require measurement of the INR Such procedures would include prosthodontics [construction of dentures] scalingpolishing and some conservation work [fillings crowns bridges] Potentially invasive procedures performed in primary care would include Endodontics [root canal treatment] Local anaesthesia [infiltrations inferior alveolar nerve block mandibular blocks] Extractions [single and multiple] Minor oral surgery Periodontal surgery Biopsies Subgingival scaling


19

APPRENDIX 8

Resources

Resources available from the NPSA Website httpwwwnpsanhsuk

Or try httpwwwnpsanhsukhealthdisplaycontentId=5754 Patient safety alert 18 Actions that can make anticoagulant therapy safer Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harms and admissions to hospitals The NPSA has produced the following patient safety alert and support materials to help manage the risks associated with anticoagulants and reduce the risks of patients being harmed in the future

All templates and exemplar documents provided as supporting materials for all patient safety alerts are drafts intended for local adaptation Organisations should ensure that they are adapted locally and that they meet the requirements of specialist clinical areas and services and are ratified prior to use

2 Patient safety alert (pdf 294KB) 3 Patient briefing (pdf 97KB) 4 Patient briefing - Welsh (pdf 155KB) 5 Template service audit form (pdf 187KB) 6 E-learning modules

o Starting patients on anticoagulants (BMJ learning website - free registration required)

o Maintaining patients on anticoagulants (BMJ learning website - free registration required)

7 Work competences for anticoagulant therapy o initiating anticoagulant therapy (pdf 40KB) o maintaining oral anticoagulant therapy (pdf 115KB) o managing anticoagulants in patients requiring dental surgery (pdf 174KB) o dispensing oral anticoagulants (pdf 91KB) o preparing and administering heparin therapy (pdf 119KB) o reviewing the safety and effectiveness of an anticoagulant service (pdf 109KB)

8 Summary of stakeholder consultation that was undertaken January-March 2006 (Word 431KB)

9 Anticoagulant therapy information for community pharmacists (Pharmaceutical Journal insert) (pdf 202KB)

10 Managing patients who are taking and undergoing dental treatment_Poster for dental practices (pdf 109KB)

Standards and Guidelines British Society of Haematology Standards for Anticoagulants

o Safety indicators for anticoagulant services o Oral anticoagulants 3rd edition -2005 update o Oral anticoagulants 3rd edition 1998 o Guidelines on the use and monitoring of heparin

E- learning modules - Registration with BMJ Learning is required - registration is free

Starting patients on anticoagulants how to do it httpwwwbmjlearningcomplanrecordservletResourceSearchServletkeyWord=AllampresourceId=5004325ampviewResource=

Maintaining patients on anticoagulants how to do it httpwwwbmjlearningcomplanrecordservletResourceSearchServletkeyWord=AllampresourceId=5004429ampviewResource


20

Information for Patients and Carers

Anticoagulant Alert Card (pdf 73KB) Oral anticoagulant therapy(OAT) Important information for patients (booklet)

o English (pdf 442KB) o Welsh (pdf 300KB) o Bengali (pdf 329KB) o Cantonese (pdf 443KB) o Gujarati (pdf 315KB) o Polish (pdf 304KB)

Also available in other languages Anticoagulant treatment record form (pdf 47KB)

Anticoagulant treatment record booklet (pdf 147KB) Oral anticoagulant therapy Important information for dental patients (leaflet) (pdf 186KB)

The complete OAT pack or individual items such as the yellow record book can be obtained from Derwent shared care services Unit 7 Outrams Wharf Alfreton Road Little Eaton DE21 5EL Direct line 01332 622450 Orders only by fax ( 01332 622422) or e-mail lynnjudgederwentsharedservicesnhsuk or in writing on letter head Risk assessment reports

Risk assessment of anticoagulant therapy (pdf 269KB) Appendix - Risk assessment grid (pdf 117KB)

NPSA report

Safety in doses improving the use of medicines in the NHS (pdf 474KB) Other Resources

Available at wwwbcshguidelinescom British Committee for Standards in Haematology Guidelines for oral anticoagulants Third Edition British Journal of Haematology 1998 101 374-387 Training ndash a selection of courses available Anticoagulation managing patients prescribing and problems CPPE 2007 An open learning resource httpwwwcppemanchesteracuk

Atrial Fibrillation Applying New Guidelines in Clinical Practice for Doctors nurses and pharmacists June 2007httpwwwmedscapecomviewprogram7372src=mp

Starting patients on anticoagulants how to do it httpwwwbmjlearningcomplanrecordservletResourceSearchServletkeyWord=AllampresourceId=5004325ampviewResource



21

APPENDIX 9

List of contacts for clinical support and advice Chesterfield Royal Hospital Foundation Trust (CRHFT) Dr Rod Collin Consultant Haematologist (rodcollinchesterfieldroyalnhsuk) Direct dial telephone number 01246 512253 or via switch board 01246 277271 If there are problems out of hours then the individual would be able to access advice either directly from Dr Rod Collin if he is on-call or one of the other haematologists if they are on-call via the hospital switchboard which is what happens when GPs currently need help Derby Hospitals NHS Foundation TRUST Dr Angela Mckernan Consultant Haematologist (angelamckernanderbyhospitalsnhsuk) Tel 01332 254770 Derby Hospitals Anticoagulation Team Suzey Joseph 01332 789422 Gary Herbert 01332 789420 Hermine King 01332 789423 Other Hospitals Burton Hospital tel 01283 511511 anticoag ext 4040 fax 01283 593064 Nottingham Hospitals QMC Campustel 0115 9249924 anticoag ext 68412 fax 0115 8754600 tel direct line 0115 9194413 Nottingham anticoag service Manager Steve Davidson 01159249924 Bleep 808274 Sheffield Teaching Hospitals ndash Royal Hallamshire Hospital Dr Rhona Maclean Consultant Haematologist (rhonamacleansthnhsuk) Tel 0114 2711900 Northern General Hospital anticoagulation clinic ndash Tel 0114 2714399 Out of Hours Derbyshire Health United (DHU) direct line for health professionals - 01246 550818 Central Nottinghamshire Clinical Services based at Byron House Kingsmill Hospital 01623 622515 ext 3601 NHS Derbyshire County PCT Leads PCT Clinical lead and Medical director ndash Dr Paul Cook (paulcooknhsnet) Clinical Adviser ndash Hassan Hajat ndash 01246 514939 (HassanHajatderbyshirecountypctnhsuk) Karen Martin - Head of Clinical Quality for Independent Contractors (Karenmartinderbyshirecountypctnhs) Derby City PCT contact Medicines Management Team Derby City PCT 01332 203102 (Please note the new level 4 anticoagulation management service LES is currently only commissioned by Derbyshire county PCT)



1 General Guidance

APPENDIX 1


Target INR amp Range



Aspirin clopidogrel and dipyridamole

Vitamin K

The following patient characteristics are indicative of a high risk for bleeding

Age gt70 Hypertension Diabetes Renal Failure

Induction guidelines for patients newly initiated on Warfarin

Colour of different strength tablets

On discharge pharmacy supply tablets of 1mg strength only

Training ndash a selection of courses available

Anticoagulation managing patients prescribing and problems CPPE 2007 An open learning resource httpwwwcppemanchesteracuk


Maintaining patients on anticoagulants how to do it httpwwwbmjlearningcomplanrecordservletResourceSearchServletkeyWord=AllampresourceId=5004429ampviewResourceAPPENDIX 9

List of contacts for clinical support and advice

Derby Hospitals NHS Foundation TRUST


2

APPENDICES 1 Indications for Oral Anticoagulation page 8 2 Atrial fibrillation and Warfarin patient information leaflet page 9 3 Conditions which may cause a change in Warfarin sensitivity page 13 4 Common Warfarin drug interactions page 14 5 Guidelines for the management of over anticoagulated patients page 15 6 Induction guidelines for patients newly initiated on Warfarin page 16 7 Summary of guidelines on management of patients requiring page 18

dental surgery 8 Resources page 19 9 List of contacts for clinical support and advice page 21


3

1 General Guidance


















2 weeks of 2mgday



gt 30 1 mgday


4


measurement







4 Dosage Regimens











5 Monitoring




5





















6





8 Exclusions









7













8

APPENDIX 1



Duration






25

25

20-30

20-30

3 months

6 weeks


25 35

20-30 30-40

Long term Long term



echocardiography

25

20-30

Long term








35

30

30-40

25-35

Long term

Long term



Consider

25 25

25

20-30 20-30

20-30


Long term



25

35

20-30

30-40

Long term



9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













3

1 General Guidance


















2 weeks of 2mgday



gt 30 1 mgday


4


measurement







4 Dosage Regimens











5 Monitoring




5





















6





8 Exclusions









7













8

APPENDIX 1



Duration






25

25

20-30

20-30

3 months

6 weeks


25 35

20-30 30-40

Long term Long term



echocardiography

25

20-30

Long term








35

30

30-40

25-35

Long term

Long term



Consider

25 25

25

20-30 20-30

20-30


Long term



25

35

20-30

30-40

Long term



9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













4


measurement







4 Dosage Regimens











5 Monitoring




5





















6





8 Exclusions









7













8

APPENDIX 1



Duration






25

25

20-30

20-30

3 months

6 weeks


25 35

20-30 30-40

Long term Long term



echocardiography

25

20-30

Long term








35

30

30-40

25-35

Long term

Long term



Consider

25 25

25

20-30 20-30

20-30


Long term



25

35

20-30

30-40

Long term



9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













5





















6





8 Exclusions









7













8

APPENDIX 1



Duration






25

25

20-30

20-30

3 months

6 weeks


25 35

20-30 30-40

Long term Long term



echocardiography

25

20-30

Long term








35

30

30-40

25-35

Long term

Long term



Consider

25 25

25

20-30 20-30

20-30


Long term



25

35

20-30

30-40

Long term



9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













6





8 Exclusions









7













8

APPENDIX 1



Duration






25

25

20-30

20-30

3 months

6 weeks


25 35

20-30 30-40

Long term Long term



echocardiography

25

20-30

Long term








35

30

30-40

25-35

Long term

Long term



Consider

25 25

25

20-30 20-30

20-30


Long term



25

35

20-30

30-40

Long term



9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













7













8

APPENDIX 1



Duration






25

25

20-30

20-30

3 months

6 weeks


25 35

20-30 30-40

Long term Long term



echocardiography

25

20-30

Long term








35

30

30-40

25-35

Long term

Long term



Consider

25 25

25

20-30 20-30

20-30


Long term



25

35

20-30

30-40

Long term



9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













8

APPENDIX 1



Duration






25

25

20-30

20-30

3 months

6 weeks


25 35

20-30 30-40

Long term Long term



echocardiography

25

20-30

Long term








35

30

30-40

25-35

Long term

Long term



Consider

25 25

25

20-30 20-30

20-30


Long term



25

35

20-30

30-40

Long term



9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













9

APPENDIX 2













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













10












11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













11
















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K















References






12


13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













13

Appendix 3











14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













14










NSAIDs










Vitamin K




15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













15

APPENDIX 5






2 Guideline










Relevant references





16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













16

APPENDIX 6



this risk











17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













17






8 Dietary advice















18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













18

APPENDIX 7













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













19

APPRENDIX 8

Resources

















20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













20








NPSA report







21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K













21

APPENDIX 9




1 General Guidance

APPENDIX 1






Vitamin K












Derbyshire Joint Area Prescribing Committee (JAPC) · Give an OAT pack and patient information...

Documents

Transcript of Derbyshire Joint Area Prescribing Committee (JAPC) · Give an OAT pack and patient information...