Download VTE Management Toolkit Objective Target groups Background

VTE Management Toolkit
Objective
The VTE Management Toolkit is designed as a practical resource for physicians and
other healthcare professionals to facilitate the safe and efficient management of acute
venous thromboembolism (VTE). This toolkit also aims to support the education of
patients.
Target groups
This VTE Management Toolkit primarily targets the following health care professionals:
 ER physicians
 Hospitalists
 General internists
 Family physicians
 Pharmacists
Background
The VTE Management Toolkit is a succinct package of information designed for
clinicians, hospitals and patients to aid in the appropriate management of acute VTE.
This toolkit was developed in response to the need for evidence-based and practical
guidance when making clinical decisions about VTE management.
This toolkit is comprised of the following components:






background information about the epidemiology and complication rates of deep vein
thrombosis (DVT) and pulmonary embolism (PE)
care pathways to aid in the baseline assessment of patients with acute VTE and
selection of appropriate anticoagulation
a sample order set, discharge checklist, monitoring algorithm
patient information handouts
approaches to management of anticoagulant-associated bleeding
algorithms for periprocedure management of anticoagulated patients
Adaptability
Each component of the toolkit can be easily modified for local use. Sections that are not
relevant to your institution can be deleted.
Authors
This toolkit was compiled and reviewed by a group of physicians, pharmacists, and
nurses specializing in Thromboembolic disorders at Sunnybrook Health Sciences
Centre. The creation of this toolkit is in accordance with the Thromboembolism and
Anticoagulant Management at Sunnybrook (TEAMS) program objectives. We
welcome questions, suggested edits and enhancement of the toolkit.
Table of Contents
Introduction to
VTE...........................................................................................
Care pathway for management of acute VTE..................................................
Admission criteria for acute VTE......................................................................
Assessment of bleeding
risk.............................................................................
Acute DVT/PE order set...................................................................................
Discharge prescription.....................................................................................
Discharge checklist..........................................................................................
Anticoagulant Dosing Record..........................................................................
Pathway for long-term management of VTE: Follow-up and monitoring..........
Patient Information Forms:
Venous thromboembolism (VTE) .......................................................
Rivaroxaban.........................................................................................
Low molecular weight heparin (LMWH) ..............................................
Subcutaneous injection technique......................................................
Warfarin................................................................. ..............................
Management of bleeding in a patient receiving rivaroxaban..........................
Management of bleeding in a patient receiving warfarin.................................
Periprocedure management of rivaroxaban....................................................
Periprocedure management of LMWH.............................................................
Periprocedure management of warfarin..........................................................
1
2
3
3
4
6
7
8
9
11
13
14
15
16
18
19
20
21
22
Introduction to VTE
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary
embolism (PE), is a common cause of morbidity and mortality. It is estimated that VTE affects 1
to 3 per 1000 persons in the general population every year1. Among patients with a diagnosis of
DVT, more than half will already have PE and 30-50% will develop post-thrombotic syndrome. PE
can be rapidly fatal and a small proportion of patients develop thromboembolic pulmonary
hypertension.
Anticoagulant therapy dramatically reduces the incidence of recurrent VTE from approximately
25% to 3% during the first 6-12 months of therapy1. The latest American College of Chest
Physicians (ACCP) 2012 guidelines recommend 3 main treatment options for acute DVT/PE2:
1. Low molecular weight heparin (LMWH) bridged to warfarin maintenance therapy
2. rivaroxaban (Xarelto®)
3. LMWH alone
The traditional approach to the management of acute VTE is to initiate a LMWH for the first 5 to
10 days of therapy while bridging to therapeutic warfarin. Evidence has recently emerged to
support an additional first line option for treatment of VTE. Rivaroxaban (Xarelto®) is an oral
direct factor Xa inhibitor that has demonstrated non-inferiority to the traditional approach of
LMWH bridged to warfarin in the EINSTEIN-DVT and EINSTEIN-PE studies3,4. The third option is
to continue on a LMWH alone for the duration of anticoagulant therapy, particularly in patients
with active malignancy, pregnancy, or anticipated short duration of therapy2.
Treatment duration is generally 3 months in patients with provoked VTE when the inciting factor
has resolved2. Duration should be extended and, in some cases, should be indefinite for patients
at higher risk of recurrence including those with unprovoked VTE or those with ongoing major risk
factors.
1
References:
1. Van Es J, Kamphuisen PW, Buller HR. How to prevent, treat, and overcome current clinical challenges of VTE. J
Thromb Haemost 2011;9 (Suppl. 1):265-274.
2. Kearon C, et al. Antithrombotic Therapy for VTE Disease. ACCP 2012 guidelines. CHEST 2012; 141;2 (supplement):
e419S-e496S.
3. Bauersachs, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010;363:2499-2510.
4. Buller HR, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med
2012;366:1287-1297
Continued on next page…..
2
Care Pathway for the management of acute VTE
Patient with Confirmed
Acute DVT/PE
Consider criteria for
hospital admission
(see next page)
Assess bleeding risk
(see next page)
Is LMWH alone the most
appropriate choice?
Patient Characteristics:
 Pregnancy
 Active malignancy
 High bleeding risk
Baseline Assessment
CBC, PT, PTT, creatinine clearance, LFTs,
Consider rivaroxaban
OR warfarin
Contraindications?
AND

AND

Favours rivaroxaban*
Favours bridging to warfarin*



Patient preference
Unable/unwilling to undergo
subcutaneous injections
and/or INR testing
+ Normal renal and liver function
+ Expected good compliance
+ Willingness to pay



No history of HIT1
Severe renal dysfunction
(CrCl<30mL/min)  ↓ LMWH dose or
bridge with unfractionated heparin
Important drug-drug interaction with
rivaroxaban (see order set)
Expected low compliance
Unable to pay for rivaroxaban
No severe renal
dysfunction
YES
LMWH*
Prepare for Discharge
(see Discharge checklist)
Follow-up



(Adherence, thrombosis symptoms, bleeding,
questions answered)
Arrange patient contact the day after start of treatment
Physician appointment e.g. in 1-3 weeks and 3 months
Monthly monitoring checks: via phone/text messages/email
*See dosing options in Order sets
1HIT=
heparin-induced thrombocytopenia
3
Admission Criteria for Acute VTE


Most patients with acute VTE do not require hospital admission
Below are criteria to consider when deciding if a patient requires admission to
hospital:
PE
DVT

Hemodynamically unstable

Very high bleeding risk

Requires supplement O2 or
parenteral narcotics

Severe renal dysfunction

Catheter thrombolysis

Very high bleeding risk

Severe renal dysfunction
Assessment of Bleeding Risk
Absolute contraindications to anticoagulation:




Current active bleeding
Heparin-induced thrombocytopenia (contraindication for heparin and
LMWH)
Pregnancy (for warfarin, rivaroxaban)
Severe renal failure—CrCl ≤ 30 mL/min (for rivaroxaban; avoid or lower
dose of LMWH)
Risk factors that increase the risk of bleeding with therapeutic
anticoagulation:
(patients with these risk factors require a careful assessment of
thrombosis and bleeding risks)










Recent major bleeding
Recent intracranial bleeding
Recent GI bleeding
Major coagulopathy
Severe thrombocytopenia
Advanced age
Moderate renal dysfunction (CrCl 30-50 mL/min)
Severe liver dysfunction
Concomitant use of platelet inhibitor
Alcoholism, drug abuse
4
Acute DVT/PE Treatment
Order set
Date:_________________
Diagnosis
□ DVT
□ PE
Details: _____________________________________________________________
Details: _____________________________________________________________
Baseline Assessment
Order (if not already done)
□ CBC
□
□ Creatinine
Document
PTT
□ INR
□ ALT/ALP
Weight = ___________kg
Calculate
CrCl = __________mL/min
(CrCl = [1.2 (140-age)(weight in kg)] (x 0.85 for females)
SCr(umol/L)
Treatment Options (Assess bleeding risk and select appropriate regimen)
FOR ALL TREATMENT OPTIONS:
□ Provide written prescription (see last page)
□ Ensure follow-up in 1-3 weeks and 3 months
□ Ensure patient follow-up the following day for monitoring/compliance
Option 1: Rivaroxaban (Xarelto®)
Yes
No
Is rivaroxaban an appropriate option?
 Patient preference
 Unable/unwilling to undergo S/C injections and/or INR testing
+ Adequate renal and liver function
+ Good compliance
If YES, does the patient have any contraindications to rivaroxaban?
Yes
No
 CrCl < 30 mL/min, active bleeding, pregnant or breast feeding, clinically significant liver
disease (ALT/ALP 3x ULN), concomitant use of both strong Pgp and CYP3A4 inhibitors
(azole antifungals, HIV protease inhibitors) or CYP3A4 inducers (rifampin, phenytoin),
active cancer (role uncertain at this time)
In the absence of contraindications,
□ Ensure patient has stopped antiplatelet agents (ASA, clopidogrel, prasugrel, ticagrelor) unless strongly
indicated
Then, ORDER
□ rivaroxaban 15 mg po BID with food x 3 weeks, then 20 mg po daily with food [LU code 444]
□ Educate patient on importance of compliance and provide handouts on VTE and rivaroxaban
Option 2: LMWH bridge to warfarin
Yes
No
Is bridging LMWH to warfarin an appropriate option?
 Significant drug-drug interaction with rivaroxaban (see above)
 Massive obesity
 Expected low compliance
 Unable to pay for rivaroxaban
NOTES: If patient has severe renal dysfunction (CrCl <30 mL/min), dose reduce LMWH or use IV
unfractionated heparin to bridge to warfarin
5
If YES, select applicable LMWH regimen: (NOTE: There is no max dose! Do NOT cap dose for weight!)
Refer to Option 3: LMWH alone for available pre-filled syringe options
enoxaparin 1.5 mg/kg SC OD or 1 mg/kg SC BID for at least 5 days and until therapeutic INR (2.0-3.0) ≥ 24h.
□ enoxaparin ____________mg SC OD x at least 5 days and until INR 2.0-3.0 for at least 24h
□ enoxaparin ____________mg SC BID x at least 5 days and until INR 2.0-3.0 for at least 24h
dalteparin 200 units/kg SC OD or 100 units/kg SC BID for at least 5 days and until therapeutic INR (2.0-3.0) ≥
24h.
□ dalteparin _________units SC OD x at least 5 days and until INR 2.0-3.0 for at least 24h
□ dalteparin _________units SC BID x at least 5 days and until INR 2.0-3.0 for at least 24h
tinzaparin 175 units/kg OD for at least 5 days and until therapeutic INR (2.0-3.0) ≥ 24h.
□ tinzaparin _________units SC OD x at least 5 days and until INR 2.0-3.0 for at least 24h
AND
Initiate Warfarin on the same day:
Factors that affect warfarin dose:
Day 1 1½ x the estimated maintenance dose
Day 2 1½ x the estimated maintenance dose
Day 3 INR in the morning and re-assess
Select starting dose:
□ 2.5 mg □ 5 mg □ 7.5 mg □ 10 mg
□ Referral to anticoagulant clinic
□ Educate the patient and provide handouts on VTE,
-
age (lower dose with increasing age)
patient weight
race (patients of Asian descent generally require 50%
less warfarin while those of, African descent require
higher doses)
interacting medications (e.g. amiodarone, azole
antifungals, TMP-SMX, phenytoin, rifampin, etc)
nutritional status & supplements (vitamin K)
acute illness, fever/infection
uncorrected thyroid dysfunction
-
the specific LMWH and warfarin.
Option 3: LMWH alone
Is LMWH alone the most appropriate option?
 Uncontrolled malignancy, pregnant, patient preference, high bleeding risk AND CrCl ≥ 30
mL/min
If YES,
Yes
No
□ Educate the patient in subcutaneous injection technique (generally have the patient do the first
injection under supervision)
□ Provide patient handouts on VTE and the specific LMWH
AND
Select most appropriate dosing regimen: (NOTE: There is no max dose! Do NOT cap dose for weight!)
□
Provide patient with written prescription [LU code 188]
enoxaparin (Lovenox®)
dalteparin (Fragmin ® )
□ enoxaparin 1.5 mg/kg SC OD
□ dalteparin 200 units/kg SC OD
OR
OR
□ enoxaparin 1 mg/kg SC BID
□ dalteparin 100 units/kg SC BID


If > 100kg, use BID dosing
If >90kg, use BID dosing
Round to nearest available prefilled syringe (please circle)
Round to nearest available pre-filled
syringe (please circle)
40 mg
5,000 IU
60 mg
80 mg
100 mg 120 mg 150 mg
7,500 IU
10,000 IU
12,500 IU 15,000 IU
18,000 IU
tinzaparin (Innohep ®)
□ tinzaparin 175 units/kg SC OD
Round to the nearest available
pre-filled syringe (please circle)
3,500 IU
4,500 IU
10,000 IU
14,000 IU 18,000 IU
6
Discharge Prescription
Date:________________________
Patient Information
Dr. __________________________
Address:
Phone:
Fax:
Rx
LU Code (circle one):
444
rivaroxaban
186
dalteparin, enoxaparin, tinzaparin (maximum 3 weeks)
188
dalteparin, enoxaparin, tinzaparin (warfarin contraindicated
Physician Name (Please Print)
Pager/Phone number
Signature
7
ANTICOAGULANT DOSING
RECORD
Indication for anticoagulation: _______________________________________________
Target INR range: □ 2.0 – 3.0
Date
INR
Warfarin
dose (mg)
□ 2.5 – 3.5
Comments
8
Discharge Checklist
Has the patient received the following?
A. warfarin
□ Warfarin discharge prescription
- Use single tablet strength;
- “Sig: Take as directed”
- Generally prescribe at least a one-month supply
□ Anticoagulant Record (faxed to place of referral and/or given to patient)
□ Warfarin counseling
□ Warfarin Dosing Calendar (include patient name and tablet strength on 1st
page PLUS daily number of tablets for the relevant dates until next INR)
□ Warfarin (Coumadin®) Information for Patients handout
□ A referral for outpatient anticoagulation supervision/management:
□ Name of Anticoagulant Clinic: _________________________
□ Family Doctor/Other: ________________________________
□ Who to contact if any further questions _______________________
B. Xarelto (rivaroxaban)
□ Discharge prescription (generally prescribe at least the first 3-week supply)
□ Rivaroxaban counseling
□ Rivaroxaban Information for the VTE Patient handout
□
Arrangements for outpatient follow-up (who/date):
___________________________________________________
□ Who to contact if any further questions ________________________
C. Lovenox (enoxaparin), Fragmin (dalteparin), Innohep (tinzaparin)
□ Discharge prescription (generally prescribe at least a one-week supply if
bridging to warfarin or a one-month supply if continuing LMWH longer)
□
□
□
□
LMWH counseling
LMWH Information for Patients handout
Subcutaneous Injection Technique handout and counseling
Arrangements for outpatient follow-up (who/date):
_____________________________________________________
□ Who to contact if any further questions _________________________
9
Care Pathway for Long-Term Management of VTE:
Follow-up and Monitoring
Patient with
Confirmed DVT/PE
Treatment Initiated:
rivaroxaban, warfarin, or LMWH
Offer
Determine frequency of follow-up and
arrange appointments
1. Contact patient the day after start of
treatment AND at:
1-3 weeks AND
3 months
2. Then, every 3 months to 12 months
In case of problems, patient contacts MD
Compliance tool:





Blister pack/Dosette
Phone call
reminders
Text messages
Mobile app/reminder
e-mail
At each visit
Clinical Monitoring:
 Efficacy
(symptoms/signs of
DVT/PE)
 Bleeding?
 Other adverse
effects
 New medications?
OTC, herbal
supplements?
Interactions?
Lab Monitoring
CBC, Renal, Liver function
 yearly
If CrCl 30-50 mL/min
 Cr every 6 months
If CrCl 15-30mL/min
 Cr every 3 months
Compliance:
 Ask patient to bring
remaining pills
 Ask patient how many
doses missed
 Educate on how to
deal with missed dose
 Re-emphasize
importance
 Offer aids (blister
packs, etc)
Education:
 Answer any
questions
the patient
has
 Educate re:
importance
of
compliance
10
Patient Information
11
Venous Thromboembolism (VTE):
Information for the Patient
Venous thrombembolism (VTE) refers to an abnormal blood clot that develops in a
vein or the lung. An abnormal blood clot in the leg is called deep vein thrombosis
(DVT) and an abnormal blood clot in the lungs is called pulmonary embolism (PE).
DVT and PE are serious conditions but they are treatable.
DVT and PE
DVT is a condition in which an abnormal blood clot, also called a “thrombus”, forms in
one or more of the veins deep in the body, generally in a leg. Sometimes part of a DVT
from the leg can break off and travel to the lung, where it is known as PE.
Symptoms and Signs of DVT and PE
Common symptoms of a DVT may include:
 Swelling of the leg
 Pain and tenderness of the leg
 Warmth over the affected area
 Changes in skin colour (e.g. turning
red or purple)
Symptoms of a PE may include:
 Chest pain that is sharp and is worse
when taking a deep breath
 Sudden difficulty breathing
 Feeling light-headed, dizzy, or faint
 Sweating
 Rapid heart beat
 Coughing up blood
What are some risk factors for DVT and PE?
Certain people are more likely to develop DVT and/or PE. Risk factors include:
 Surgery
 Pregnancy
 Trauma
 Birth control pills or hormone
 Immobility or paralysis
replacement therapy
 Cancer and cancer treatments
 Obesity
 Increasing age
 Inflammatory bowel disease
 Previous DVT or PE
 Chronic kidney disease
 Family history of DVT or PE
 Prolonged travel
 Medical illness such as heart failure,
 Abnormalities of blood clotting
infection
(inherited or not inherited)
How are DVT and PE treated?
DVT and PE are treated with medicines called anticoagulants. Anticoagulants do not
dissolve existing blood clots. They keep the clot from getting bigger and prevent future
clots from developing. Some of these anticoagulants come as injections and others
come as pills.
12
There are three main methods to treat a DVT or PE:
1. Use of an anticoagulant called a low molecular weight heparin (LMWH), given for
at least 5 days. This is an injection that is given just under the skin. A tablet
anticoagulant called warfarin is usually started at the same time as the LMWH
injection and is continued in the long term. The LMWH injections are usually stopped
within the first week.
2. LMWH injections alone for the entire duration of treatment.
3. The newest option is to use an oral anticoagulant called rivaroxaban (Xarelto®),
which is taken daily for the entire duration of treatment.
Your doctor will discuss the best choice of treatment for you and how long you will need
to be treated. Most patients are treated for at least three months. Some patients need to
be treated for longer (and some are treated indefinitely).
The main side effect of anticoagulant treatment is bleeding which is not common and is
usually minor. For example, you might get:
 A nose bleed that lasts for less than 5 minutes
 Easy bruising
 Bleeding gums while brushing teeth.
Some bleeding can be more serious; however this is rare.
What happens to the DVT or PE?
Some patients will experience improvement of symptoms within days or weeks while
others may take longer. Some patients with DVT can develop post-thrombotic
syndrome, which is leg swelling and/or discomfort caused by damage to the veins.
Compression stockings will help reduce the severity of this complication.
If you had a DVT, signs that we expect there will be:
 Reduced leg swelling
 Reduced pain
 Improved ability to walk
If you had a PE, signs that we expect there will be:
 Improvement in shortness of breath and chest pain
How long it will take to see these changes is different for each person.
General tips to consider while being treated for DVT or PE:
 Take your medication every day, at
approximately the same time. Forgetting to
take your anticoagulant puts you at risk of
worsening of the clot or developing a new clot.
 Talk to your doctor if you are taking
antiplatelet medications (acetylsalicylic acid
[Aspirin®], clopidogrel [Plavix®], ticagrelor
[Brilinta®], prasugrel [Effient®]). These medications
increase your risk for bleeding and should only be
taken if strongly recommended by a doctor.

Move around! The sooner you get moving, the
faster you will feel better.

 Adopt a healthy lifestyle. Lose weight if you
are overweight. Quit smoking and control your
blood pressure. Maintain or start a healthy diet.
 Wear compression stockings if your doctor
recommends them.
 See your doctor regularly, at least at 3
months and then every 6 to 12 months.
 Talk to your doctor if you notice
unexpected bleeding including extremely dark
stools, cough up blood, bleeding in the urine or
from the rectum, large bruises on body without
being injured, and nosebleeds that won’t stop.
Exercise daily. There is no need to restrict your
activity.
13
Low molecular weight Heparin (LMWH):
Information for Patients
You are being treated with a low molecular weight heparin called __________________
You should take ____________
(drug name)
____________
(dose)
once daily OR twice daily.
(circle one)
What is a low molecular weight heparin (LMWH)?
 A low molecular weight heparin is an anticoagulant, a drug that prevents new

blood clots from developing.
Anticoagulants are sometimes called "blood thinners", but this name is
misleading. These drugs do not "thin the blood" but they do make the blood less
likely to clot when it shouldn’t.
Why do I need to take it?
Deep vein thrombosis (DVT) and/or pulmonary embolism (PE) – DVT occurs
when an abnormal blood clot develops in a vein, usually of the leg or arm. A
blood clot in a vein can break free and travel to the lungs – this is then called
pulmonary embolism.
How do LMWHs work?


LMWHs lower the activity of clotting factors in the blood to a level that makes it
less likely that harmful clots will form in the blood.
LWMHs do NOT stop the blood from clotting completely and do NOT break
down clots that are already there.
How should I take this medicine?
 This medication is given as an injection under the skin once or twice daily.
 Please see the attached Subcutaneous Injection Technique handout for
instructions
What are some possible side effects?
 The main side effect of LMWHs is increased risk of bruising, especially around

an injection site.
Bleeding can also occur but this is uncommon
Things to remember when taking a LMWH:
 It is important that you have the injection around the same time every day
 Do not stop it on your own
 Some bruising is common after some injections
 If you experience bleeding that worries you, contact your physician
14
Subcutaneous Injection Technique for
Dalteparin (Fragmin®), enoxaparin (Lovenox®), tinzaparin
(Innohep®), and fondaparinux(Arixtra®)
Administration
 Wash your hands
 Select appropriate place where you will inject the











medication (Fig.1)
Wipe the site with an alcohol swab and allow it to
dry
Remove the needle cap
Gently pinch up a 3 cm fold of skin
Hold syringe perpendicular to skinfold (Fig.2)
Insert needle slowly and completely into skinfold at
90˚angle (Fig.3) – keep pinching skinfold
Do not pull back on plunger
Inject contents of syringe
Remove syringe and dispose in sharps container
Let go of skinfold
If injection site oozes, apply gentle pressure with
gauze
Do not rub site after injection
Reminders
 Use the stomach area as a first choice of where to inject
 Move the place where you inject around
 Other places include front and sides of mid and upper thigh (Fig.1)
 Avoid injection into arms, unless absolutely necessary
 Stay about 2 cm from belly button, surgical cuts or scars, and places you have injected before
 Avoid bruised areas
15
Rivaroxaban (Xarelto®)
Information for Patients with DVT and/or PE
You are being treated with an anticoagulant called rivaroxaban.
Your dose of rivaroxaban is _________mg taken
 Twice daily until __________________________
(date: yyyy/mm/day)
AND / OR
 Once daily from ________________________
(yyyy/mm/day)
What is rivaroxaban?


Rivaroxaban is an anticoagulant, a drug that prevents new blood clots from
developing.
Anticoagulants are sometimes called "blood thinners", but this name is
misleading. These drugs do not "thin the blood" but they do make the blood less
likely to clot when it shouldn’t.
Why do I need to take it?
Deep vein thrombosis (DVT) and/or pulmonary embolism (PE)


DVT occurs when an abnormal blood clot develops in a vein, usually of
the leg or arm.
A blood clot in a vein can break free and travel to the lungs – this is then
called pulmonary embolism.
How does rivaroxaban work?


Rivaroxaban blocks one of the clotting factors in the blood to a controlled level.
This makes it less likely that harmful clots will form in the blood.
Rivaroxaban does NOT stop the blood from clotting completely and does NOT
dissolve clots that are already there.
How should I take rivaroxaban?




Take rivaroxaban once daily OR twice daily (circle one)
Take rivaroxaban with food at approximately the same time everyday.
Try not to miss any doses.
If you miss a dose
o and you take rivaroxaban 2 times a day: Take the missed dose as
soon as you remember on the same day. You may take 2 doses at the
same time to make up for the missed dose.
o and you take rivaroxaban once a day: Take rivaroxabn as soon as you
remember on the same day. Take your next dose at your regularly
scheduled time the next day. Do not take 2 doses on the same day.
What are some possible side effects?
 The main side effect of rivaroxaban is a small increase in the risk of bleeding or
bruising
16
Warfarin (Coumadin®)
Information for Patients with DVT and/or PE
You are being treated with warfarin for the following condition:


deep vein thrombosis
pulmonary embolism
What is warfarin?
 Warfarin is an anticoagulant, a drug that prevents new blood clots from

developing.
Anticoagulants are sometimes called "blood thinners", but this name is
misleading. These drugs do not "thin the blood" but they do make the blood less
likely to clot when it shouldn’t.
Why do I need to take it?
Deep vein thrombosis (DVT) and/or pulmonary embolism (PE) – DVT occurs
when an abnormal blood clot develops in a vein, usually of the leg or arm. A
blood clot in a vein can break free and travel to the lungs – this is then called
pulmonary embolism.
How does warfarin work?


Warfarin lowers the amount of clotting factors in the blood to a controlled level.
This makes the blood less likely to form harmful clots.
Warfarin does NOT stop the blood from clotting completely and does NOT break
up or dissolve clots that are already there.
How should I take this medicine?


Warfarin is taken once a day. It can be taken at any time of the day but it should
be taken around the same time every day.
It is important to record every dose of warfarin and every INR test result in
one place like a warfarin calendar. This helps to avoid mistakes in the dose.
As soon as you’ve taken your dose of warfarin “check off” the dose on your
calendar. It is also a good idea to put your daily doses for a week into a 7-day
plastic pillbox.
Why do I need blood tests?


Blood tests are needed to find the right amount of warfarin that you need to keep
abnormal blood clots from forming and to minimize the risk of bleeding.
Anticoagulation is a delicate process. If the effect of the warfarin on your blood is
too high, you increase your risk of serious bleeding. If the effect of the warfarin
on your blood is too low, you are at risk for further abnormal clotting.
These blood tests must continue to be done as long as warfarin is used because
many things can affect your response to warfarin.
17
What blood tests do I need to have?


You will have a blood test that is called INR (International Normalized Ratio). The
INR helps to measure how well warfarin is working. People who are not taking
warfarin have an INR value of about 1.0. The higher the INR value, the longer it
takes the blood to clot.
Most patients on warfarin need an INR between 2.0 and 3.0. An INR below 2.0
may lead to more abnormal clotting. An INR greater than 4.0 increases the risk of
serious bleeding. A person cannot guess whether their INR is low, high or just
right without doing the INR test.
What are the side effects associated with taking warfarin?

The main complication of taking warfarin is a somewhat increased risk of
bleeding.
What should I do if I forget to take a warfarin pill?


If you forget to take a dose at your regular time, take it as soon as you
remember and take the next dose at the usual time.
If you forget to take warfarin for 2 or 3 days in a row, DO NOT take all of the
missed doses, but call your doctor or clinic for instructions.
How do food and alcohol affect warfarin therapy?


Eating foods that have vitamin K can affect your body’s response to warfarin.
Foods that have vitamin K include spinach, broccoli, brussel sprouts, lettuce,
collard and turnip greens, cabbage, and kale. These foods are very good for you
and you should NOT avoid them. Eating about the same amount of these
foods over a week and doing INR tests regularly helps you to get the right
amount of warfarin.
Patients on warfarin can safely have one or two alcoholic drinks (beer, glass of
wine, liquor) a day. More alcohol can make the INR go too high and can be
dangerous. DO NOT binge drink.
Can I take other drugs while I’m on warfarin? What if I have a headache or a
‘cold’?


Many drugs and herbal remedies interact with warfarin and increase or
decrease its effect. It is best to check with your doctor or pharmacist BEFORE
starting or stopping any medication.
You can safely take 1 or 2 tablets of acetaminophen (Tylenol®) or ibuprofen
(Advil®, Motrin®). If you need more than that, you should talk to your doctor or
pharmacist first. You should not take aspirin (or medications with aspirin in them)
unless your doctor tells you to.
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Management of Bleeding in a Patient receiving Rivaroxaban
Pharmacologic Properties:
 Peak level = 2-4 hours
 35% renal clearance
 Half-life = 8-13 hours (longer in elderly and those with renal dysfunction)
Assessment of Bleeding in a Patient Receiving Rivaroxaban
 No proven antidote (“time is the most important antidote”)
 There is limited clinical data related to reversal of rivaroxaban  the recommendations
below may change as new evidence becomes available
Patient with bleeding on rivaroxaban
 When was last dose?
 CBC, creatinine
 PT* (not INR)
If PT > 15 sec
Mild bleeding
 Local
hemostatic
measures
 Hold 1 dose of
rivaroxaban
Moderate-severe
bleeding1
*Provides qualitative
and partial quantitative
assessment of
rivaroxaban activity.
Life-threatening
bleeding1
 Manage bleeding
(compression, surgery)
 Fluid  diuresis
 Transfuse RBCs or
platelets if needed
 Oral charcoal if overdose
<2 hrs before
 Tranexamic acid (1G
IV followed by 1G
infusion over 8
hours)
 Consider PCC2
1. DO NOT TRANSFUSE plasma or cryoprecipitate to reverse rivaroxaban
2. PCC (Octaplex / Beriplex)
References: Heidbuchel H, et al – Europace 2013;15:625-651
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Management of Bleeding in a Patient receiving Warfarin
Patient with bleeding on warfarin
INR ≥ 2.0
Mild bleeding
e.g. epistaxis
bruising
hemorrhoids
Severe or life threatening
bleed with INR ≥ 2.0
 Manage bleeding
(compression, surgery)


If INR supratherapeutic,
hold 1-2 doses of
warfarin and restart at
lower dose
Educate on preventative
measures (e.g. avoid
trauma, straining/
constipation)
 PCC (Octaplex / Beriplex)
follow hospital guidelines
 AND Vitamin K 10 mg IV
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Periprocedure Management
Periprocedure Management of Rivaroxaban
Planned procedure in patient taking therapeutic dose of rivaroxaban
Pre-op
*
Low Bleeding
Risk procedure
Hold rivaroxaban
1 day before
High Bleeding
Risk procedure
Hold rivaroxaban
2 days before
* If CrCl ≤ 30 mL/min (rivaroxaban contraindicated), should stop rivaroxaban for longer (>2
days before).
Lab Monitoring before an invasive procedure (THIS IS NOT ROUTINE)
 If the procedure requires complete reversal of anticoagulation, especially if renal function
impaired or is unknown, consider obtaining a PT test (gives a semi-quantitative result)
o If PT is normal  likely little or no significant anticoagulant effect
o If PT is elevated LIKELY an anticoagulant effect present
 high bleeding risk procedure?  elevated PT may warrant delay of the procedure.
Restarting rivaroxaban following an invasive procedure
 Patient achieves therapeutic anticoagulation approximately 2 hours after a dose.
 If the postoperative bleeding risk associated with full, therapeutic anticoagulation is not
desirable, the following options should be considered:
a) Delay resuming rivaroxaban until the bleeding risk decreases to usual
b) Bridge with a prophylactic dose (rivaroxaban 10 mg po OD) or with a LMWH until the
bleeding risk decreases to usual
21
Periprocedure Management of LMWH
Planned procedure in patient taking
therapeutic dose of LMWH
Pre-op: Hold LMWH
approx 24h before
surgery
Low risk
procedure
High risk
procedure
Resume LMWH
approximately 24h
post-op
Consider
prophylactic dose of
LMWH initially
Resume therapeutic
dose of LMWH
48-72h post-op
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Periprocedure Management of Warfarin
Patient on warfarin who
requires surgery/
invasive procedure
Interruption of
anticoagulant
required?
Yes
No
Criteria to NOT interrupt
anticoagulant*:
1. cataract surgery
2. most dental procedures
3. thoracentesis
4. paracentesis
5. arthrocentesis
6. skin biopsies
Low Risk*:

Most A-fib

Most VTE >3months

PAD

Stroke

Mechanical AVR
with no additional
risk factors
Moderate Risk*:

All mechanical MVR

Mechanical AVR
with previous
TIA/stroke or A-fib or
severe LV
dysfunction

VTE < 3months
Obtain an INR approximately
one week before procedure
to ensure not supratherapeutic

Obtain INR approx.
1 week before
procedure

Hold warfarin 5 days
before surgery (6
days if INR >3.0)

Hold warfarin 5 days
before surgery (6
days if INR >3.0)


No anticoagulant
bridging
Consider consulting
an Anticoagulant
Clinic at least 10
days pre-op

Bridge with a LMWH
No further
intervention
required
Provide patient with
advice about
anticoagulant
management
Yes
Uncertain
Risk:
Consider
consulting an
Anticoagulant
Clinic or expert
OR cancelled/
delayed?
No
Patient undergoes
procedure
* Specific patient or procedure circumstances may change the patient risk profiles and
recommendations
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