Download Counselling Patients Taking Oral Anticoagulation

Informing Patients about Their
Medications
Oral Anticoagulation Therapy
Objectives
• By the end of this session you should:
– Know why it is important to inform patients about
their medicines
– Know what points to cover when newly
prescribing a patient an oral anticoagulant
2012 National Patient Survey
30% of patients said they did not have the purpose of their
medicines fully explained to them in a way they could
understand
60% of patients said they were not fully told about which side
effects to watch out for
GMC Good practice in prescribing and managing medicines
and devices 2013
“You should reach agreement with the patient on the treatment proposed
explaining:
•
•
•
•
•
The likely benefits, risks and burdens, including serious and common side
effects
What to do in the event of a side effect or recurrence of the condition
How and when to take the medicine and how to adjust the dose if
necessary, or how to use a medical device
The likely duration of treatment
Arrangements for monitoring, follow-up and review, including further
consultation, blood tests or other investigations, processes for adjusting the
type or dose of medicine, and for issuing repeat prescriptions.
You should check that the patient has understood the information and
encourage them to ask questions to clarify any concerns or uncertainty.”
NPSA Guidance on Anticoagulation
•In 2007 the NPSA issued a patient safety alert relating
to oral anticoagulants and identified:
“Anticoagulants are one of the classes of medicines
most frequently identified to cause preventable harm
and admission to hospital”
•As a doctor you should:
– Ensure patients receive appropriate verbal and written information at
the start of therapy, at hospital discharge, on the first anticoagulant clinic
appointment and when necessary throughout the course of their
treatment.
Research
• Split into groups of three
• Research and come up with a list of the
information you would tell the patient about
warfarin when newly prescribing it to them
• You have 10 minutes!
GMC Good practice in prescribing and managing medicines
and devices 2013
“You should reach agreement with the patient on the treatment proposed
explaining:
•
•
•
•
•
The likely benefits, risks and burdens, including serious and common side
effects
What to do in the event of a side effect or recurrence of the condition
How and when to take the medicine and how to adjust the dose if
necessary, or how to use a medical device
The likely duration of treatment
Arrangements for monitoring, follow-up and review, including further
consultation, blood tests or other investigations, processes for adjusting the
type or dose of medicine, and for issuing repeat prescriptions.
You should check that the patient has understood the information and
encourage them to ask questions to clarify any concerns or uncertainty.”
The Oral Anticoagulant Therapy Pack
• Every patient taking oral anticoagulation needs a
“yellow book”
• It has four components
– Important information for patients booklet.
• For patients to keep at home for reference
– Record book to record INR and doses.
• This should be brought into hospital with the patient and to all
anticoagulant clinic appointments
– Treatment sheets
– Anticoagulant alert card
• Patients should carry this with them at all times.
• Available on line at
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61777
Reasons for Prescribing Warfarin
Patients need to know why they need to be prescribed warfarin
and the consequences of not taking.
The main indications for oral anticoagulation are:
• Deep Vein Thrombosis
• Pulmonary Embolism
• Atrial Fibrillation
• Mechanical Heart Valves
The NPSA recommends when telling patients what warfarin does
we use the phrase:
“Makes your blood take longer to clot”
Consequences include further VTE, stroke and death
Duration of Therapy
• Patients should be told how long it is likely they will be taking
warfarin
• Duration of therapy varies depending on indication and the
minimum durations are below
Calf vein thrombosis
6 weeks
PE and proximal vein
thrombosis
Recurrent VTE
3 months
AF and mechanical valves
Lifelong
6 months
How to Take Warfarin
• Patients need to be told that the dose of warfarin is individual
to them and their INR so their dose can vary
• Explain to the patient which strengths the tablets come in and
their corresponding colour.
– The yellow book has pictures to illustrate this.
• Tell the patient to take at same time each day, on an empty
stomach washed down with a full glass of water
– Patients are usually recommended to take their warfarin at 6pm so
any alterations can be made on the day.
– However anytime of the day is fine if it aids compliance as long as it is
at the same time each day.
• Patients need to be told to get further supplies from the GP
and to ensure they always have at least a weeks supply at
home
Checking Patients are Competent
• When telling patients how to take warfarin,
take this opportunity to ensure the patients
are able to calculate which tablets to take.
• A good question to ask is:
“If you were told to take 7mg of warfarin which
tablets would you take?”
• If you have any doubt about their ability and
therefore safety you may need to reconsider
this choice of treatment
Anticoagulation Clinic Visits
• Patients need to be told they will need to attend the
anticoagulation clinic after discharge to have their INR
monitored and their warfarin dosed
• Frequency of visits may vary but initially patients may need to
attend weekly but over time they will become less frequent
• Patients must be told to take their yellow book to all clinic
appointments and that they must not miss appointments.
• Anticoagulant clinics can be based in the hospital, GP
surgeries and for some patients district nurses may visit the
patients at home
Monitoring Requirements for Warfarin
• Patients need to be told the importance of having their INR
measured
• Patients should be made aware of what their INR range is and
what it signifies
• Recommended INRs are:
Indication
INR range
INR target
DVT
2–3
2.5
PE
2-3
2.5
Recurrent VTE
whilst on warfarin
3-4
3.5
AF
2–3
2.5
Mechanical
valves
Typical target is between
2.5 and 3.5
Side Effects of Warfarin
• The main side effect of concern with warfarin is haemorrhage
which can present itself as bruising and bleeding.
• Patients should be advised to seek medical attention from either
their clinic or A&E for any of the following:
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–
–
–
–
–
–
–
Prolonged bleeding from cuts
Bleeding that doesn’t stop by itself
Nose bleeds
Bleeding gums
Red or dark brown urine
Red or black stool
Bursed blood vessels in the eye
Increased bleeding during periods
• Other side effects include GI disturbances, alopecia, rash and
fatigue
What To Do If You Miss a Dose
The following rules should be explained to patients
about what to do if they miss a dose:
1) You can take the missed dose up to 6 hours late
2) Thereafter the dose should be omitted and the
appropriate dose taken as normal the next day
3) Make a note of the missed dose in your yellow book
4) Never take two doses in one day
5) If you miss 2 doses contact GP or clinic
A Few Simple Rules to Keep Patients Safe
Patients should be advised that warfarin is safe as long as
they follow a few simple rules and keep certain factors of
their lifestyle the same.
1) Diet
Patients should be advised to eat a broad diet, keeping their intake of
Vitamin K containing foods constant.
eg:Leafy green vegetables, chick peas, liver, egg yolk, cheese, avocado
and olive oil.
Cranberry juice should be avoided
Keep weight consistent. Discuss with clinic before commencing a diet
2) Alcohol Consumption
Patients should be advised to keep their weekly alcohol intake constant and
to stick to the recommended daily limits
Binge drinking is dangerous and not recommended
A Few Simple Rules to Keep Patients Safe
3)
4)
5)
Patients should be advised to inform any healthcare professional that
they are taking warfarin, this includes doctors, dentists chiropodists,
nurses etc
If the patient is female of child bearing age and may want to start a
family they need to discuss this with their doctor before becoming
pregnant
Women should be advised that their periods may become heavier
Any changes to lifestyle must be reported to the
anticoagulation clinic and if possible discussed before any
lifestyle changes are made
Most importantly you must reassure the patient and
answer any questions they may have
Other Medications and Warfarin
• Warfarin interacts with many medications so to avoid any
problems patients need to be advised to:
– Remind any healthcare professional that they are taking warfarin if
they are prescribing any medications, especially antibiotics
– Buy all non-prescription medication from a community pharmacy and
ask for advice from the pharmacist when selecting products; this
includes herbal medication
– Avoid aspirin or ibuprofen for pain relief and to use paracetamol +/codeine when necessary
– Let the anticoagulation clinic know of any changes to their medication
• Due to other co-morbidities some patients may need to take
both aspirin and warfarin, if this is the case they need to be
re-assured that the combination is safe
Your turn to practice!
• Split into groups of three
• Nominate a “doctor”, “patient” and
“observer”
• Doctor use your checklist to counsel your
patient and the observer give feedback
• Then Swap over!
What to do now
• When on the wards find a patient who is newly started on
warfarin and arrange to watch the ward pharmacist counsel
the patient
• Practice! Arrange to be observed discussing warfarin
treatment with a patient