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LMWH and select direct oral anticoagulants can be used for anticoagulation therapy initiation on an outpatient basis. Vitamin K antagonists (e.g., warfarin [Coumadin]), unfractionated heparin, low-molecular-weight heparin (LMWH), and direct oral anticoagulants are commonly used for the prevention and treatment of systemic embolism associated with atrial fibrillation, stroke, and venous thromboembolism (VTE). The ACCP provides recommendations for managing supratherapeutic INRs (Table 3).4. VA.gov | Veterans Affairs Core Elements of Anticoagulation VA Salt Lake City Health Care . LMWH is derived from unfractionated heparin and has an increased affinity for factor Xa relative to thrombin.4 LMWH's anticoagulant effect is primarily from factor Xa inhibition because of its smaller size and its lessened ability to inactivate thrombin compared with unfractionated heparin. This website contains UW Medicine recommendations, guidelines and protocols for the treatment and prevention of venous and arterial thrombosis, and the clinical use of antithrombotic agents in ambulatory and inpatient settings.. UW Medicine Anticoagulation Services is operated by the UW Medicine Department of Pharmacy, and collaborates with multidisciplinary specialties and providers across UW . <> 1232 0 obj <>stream Chapter 5 How to Process VA Loans and Submit them to VA. Chapter 6 Refinancing Loans. PDF Anticoagulation Management Tool Technical Manual (Patch OR*3.0*447) endobj Compared with vitamin K antagonists, direct oral anticoagulants have fewer overall drug-drug interactions, a comparable (if not lower) bleeding rate, a shorter half-life, and fixed dosing based on indication, drug interactions, and renal or hepatic function. Although LMWH has a similar bleeding risk and lower heparin-induced thrombocytopenia risk compared with unfractionated heparin, a patient with a history of heparin-induced thrombocytopenia should not take LMWH.1. Safe and Effective Anticoagulation in the Outpatient Setting NOTE: Algorithms must be evidence-based, approved by the VA medical facility Pharmacy and Therapeutics VA-TRICARE Network Agreements, 10BVA-DoD - VA/DoD Health Affairs 06/28/2019: 06/30/2024: 1163.04: Family Services in Mental Health, 11MHSP - Mental Health and Suicide Prevention 06/17/2019: 06/30/2024: 1413: Requirements for the Administration of Chemotherapy and Other Anti-Cancer Drugs, 11SPEC - Specialty Care Services 2 0 obj Patients receiving vitamin K antagonist therapy should be treated using a systematic process to optimize effectiveness and minimize adverse effects. 4. Aug 2011;140(2):359-365. 2010;30(4):330-338. First episode of unprovoked proximal DVT or PE not attributed to a reversible risk factor: Low or moderate bleeding risk: extended use (lifelong) recommended over three months (grade 2B); high bleeding risk: three months recommended over extended use (grade 1B); recommend reassessing bleeding risk annually. 3 Anticoagulation Management Tool User Manual February 2018 Steps for Using this Tool First Visit 1. 3. endobj Centralized Anticoagulation Hub Appears Promising for VA Data Sources: A PubMed search was completed in Clinical Queries using the key terms outpatient, anticoagulation, warfarin, dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, heparin, low-molecular-weight heparin, dalteparin, enoxaparin, patient self-monitor, and INR. 3. Pocket Card . %PDF-1.5 Rudd KM, Dier JG. Ann Thorac Surg 2018;105:650-62. ",#(7),01444'9=82. Pre-Conditions Note: It is advisable that ALL users of the AMT software be signed off the system before Characteristics of these anticoagulants are provided in Table 5913 and eTable B. Reg Anesth Pain Med 2018; 43:263. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Use anticoagulant cases as grand rounds and teaching cases for medical, nursing and pharmacy staff, Establish a food and drug interaction program / policy which addresses enteral feedings and warfarin administration, Establish a pharmacy based inpatient anticoagulation service to improve monitoring, follow up and transitioning to warfarin, Establish double check systems to verify correct pump settings and calculations, Limit the availability of anticoagulant drugs from floor stock to reduce misadministration and force review of the order before drug administration, Limit the availability of reversal agent drugs from floor stock to reduce misadministration, Use manufacturer's pre-made solutions to reduce compounding and labeling errors, Standardize on one size /concentration of IV bag for continuous IV heparin using an even number of units per ml [e.g. Of note, 18% of patients had a thrombotic event during 30 days of follow-up, highlighting the potential prothrombotic risk that this agent carries. These include various patient factors including patient age, underlying illness, duration of ECMO, heparin dose, target antithrombin activity, and risk of thrombotic or bleeding events. The targeted INR range depends on indication for use and, at times, patient comorbidities. Subcutaneous LMWH has a predictable absorption and degree of anticoagulation, so monitoring with antifactor Xa levels is not routinely recommended. Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, Chief Resident in Quality and Patient Safety, About the National Center for Patient Safety, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations), Call TTY if you PDF Anticoagulation During Cardiopulmonary Bypass - STS QUALIFYING STATEMENTS . Do not administer plasma or prothrombin complex concentrates for nonemergent reversal of vitamin K antagonists (i.e., outside of the setting of major bleeding, intracranial hemorrhage, or anticipated emergent surgery). Major bleeding should be treated with vitamin K and 4-factor prothrombin complex concentrate for patients already being treated with a vitamin K antagonist. Chapter 1 Lender Approval Guidelines. Idarucizumab has been effective for reversing the anticoagulant effects of dabigatran, and andexanet alfa has been effective for reversing the effects of rivaroxaban and apixaban. 1 0 obj Uf+MYU5lM8KyVyY\_nAxQB9/H|3PXs W0DLxnz,h#=&H7-R>y?$TL ZqG*tyXdZtt)"])*3 IPTu$\M*,]#-?6Q'`V This guideline will briefly describe some of the issues that should be addressed when providing anticoagulation during ECLS applications. Lenders Handbook - VA Pamphlet 26-7 - Web Automated Reference Material ), Develop self-learning modules or CE programs on anticoagulant safety, Review out of range INR/ PTT results on a periodic basis as a group to identify system issues before they result in injury, Flowchart and redesign the hospital's process for anticoagulation focusing on vulnerability elimination and simplification. Some patients may have higher risk of bleeding that may not be outweighed by the benefit of anticoagulation. Anticoagulation for Valvular Heart Disease - American College of Cardiology Direct oral anticoagulants have fewer overall drug-drug interactions (Table 65,913 ); a comparable (if not lower) bleeding rate; a shorter half-life; and fixed dosing based on indication, drug interactions, and renal or hepatic function. have hearing loss, Multiple methods to order anticoagulants (CPRS, protocols, text orders, etc), Failure to appreciate half lives and peak effect times of various drugs (e.g. Vitamin K antagonists are subject to many drug interactions. <>>> Idarucizumab (Praxbind) is a monoclonal antibody fragment that binds directly to dabigatran, leading to 88% to 98% of patients having concentrations of unbound dabigatran in safe levels within 15 minutes of administration and hemostasis restoration at a median of 11.4 hours.29 For patients taking dabigatran, idarucizumab is recommended for life-threatening or ongoing bleeding, as well as the need to reverse for emergent procedures. value: results from the Veterans Affairs study to improve anticoagulation. Compared with vitamin K antagonists, direct oral anticoagulants are associated with a reduction in the incidence of stroke of 21% to 35% and a reduction in the incidence of intracranial hemorrhage of 33% to 60%.2225, One comparative effectiveness analysis looked at the treatment of patients with atrial fibrillation who may not have been well-represented in clinical trials because of multiple comorbidities.26 This study used Medicare data to compare vitamin K antagonists with dabigatran and rivaroxaban in patients with atrial fibrillation and multiple chronic conditions. ACCP risk factors for VTE (e.g., advanced age, cancer, renal or hepatic failure) and an associated scoring system to categorize low (no risk factors), moderate (one risk factor), and high (two or more risk factors) risk should be used to determine treatment decisions.1, The ACCP and AAFP recommend using the HAS-BLED (hypertension, abnormal renal function and liver function, stroke, bleeding, labile INR, elderly [older than 65 years], drugs and alcohol) scoring tool (https://www.mdcalc.com/has-bled-score-major-bleeding-risk) to assess risk of bleeding for patients with atrial fibrillation.19,21 Because of the overlap in risk of ischemic stroke and bleeding, patients with the highest risk of ischemic stroke will commonly also have high bleeding risk. Direct oral anticoagulants should be used as first-line agents for the treatment of venous thromboembolism and the prevention of stroke in patients with nonvalvular atrial fibrillation and a CHA, Bleeding risk assessment should be performed, any modifiable risk factors addressed during each visit, Vitamin K antagonists should be used for the prevention of stroke in patients with atrial fibrillation with moderate-to-severe mitral stenosis and a CHA. 1. Low-molecular-weight heparin is recommended as the anticoagulant of choice in patients with cancer and venous thromboembolism; however, direct oral anticoagulants may be appropriate in select situations. Effect of a simple two-step warfarin dosing algorithm on anticoagulant control as measured by time in therapeutic range: a pilot study. Their recommendations include a loading dose of approximately 50 IU/kg followed by a continuous infusion rate of 800 to 1,500 IU/h.. "/> tcl android tv universal remote . Majority of ACCs in the VA Boston Healthcare System are currently staffed with clinical pharmacists (CPs). Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. If you are in crisis or having thoughts of suicide, The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of Extra-Corporeal Technology: clinical practice guidelinesanticoagulation dur-ing cardiopulmonary bypass. The challenge of safe anticoagulation therapy requires a good balance between thrombosis and bleeding in order to assure that patients receive the most benefit from therapy. An advantage to evening administration is the ability to adjust or hold the dose the same day that the INR result becomes available. Chest. <> $.' Older patients and persons with liver disease, poor nutritional status, or heart failure may require lower initiation dosages.4 Diarrhea, fever, and hyperthyroidism can also potentiate the effect of vitamin K antagonists. First episode of distal DVT attributed to a surgery or reversible risk factor: If without severe symptoms or risk factors of extension, suggest serial ultrasonography surveillance for two weeks instead of anticoagulation (grade 2C); if surveillance shows extension, recommend anticoagulation (grade 2C if it does not extend into proximal vessels; grade 1B if it extends into proximal vessels), If severe symptoms or risk factors of extension, recommend three months treatment over extended use (grade 1B), Risk factors for extension: unexplained D-dimer results; extensive DVT (> 5 cm) and/or involving multiple veins; close to proximal vein; unprovoked; cancer; previous VTE; inpatient, In the liver, vitamin K antagonists inhibit the cyclic interconversion of vitamin K, indirectly reducing clotting and synthesis for factors II, VII, IX, and X. Vitamin K antagonists also decrease levels of vitamin Kdependent anticoagulation proteins C and S; therefore, carboxylation inhibition can result in a paradoxical increased clotting risk when vitamin K antagonist therapy is initiated. Close monitoring for success and failures and adjustment of protocol as Prophylaxis for stroke and systemic embolism in nonvalvular atrial fibrillation: Child-Pugh Class A: do not need dose adjustment, Refer to usual dosage section for impact of lower weight, Starter pack for initial dosing for treatment of DVT and PE, VTE prophylaxis in adults hospitalized for an acute medical illness, VTE prophylaxis in at-risk, acutely ill, hospitalized patients: 160 mg with food for first dose, then 80 mg per day with food for 35 to 42 days, Not recommended in patients with hepatic impairment, Appropriate standard direct oral anticoagulant dosing in patients with a BMI 40 kg per m, Take with food when used for VTE prophylaxis, Limited data in patients with hepatic impairment; no specific dosing adjustment recommended, Appropriate standard direct oral anticoagulant dosing in patients with a BMI 40 kg per m, Discontinue in patients who develop acute renal failure on rivaroxaban, Avoid with combined P-glycoprotein inducer, Reduce dose or avoid use with combined P-glycoprotein, No information available for concurrent use with P-glycoprotein, Reduce dose with P-glycoprotein inhibitors, Avoid concurrent use with P-glycoprotein inducers, Reduce dose for deep venous thrombosis or pulmonary embolism treatment if on select P-glycoprotein inhibitors, Avoid with combined P-glycoprotein inhibitor. The ACCP guidelines recommend assessing bleeding risk for patients with VTE or atrial fibrillation as an essential step to guiding treatment decisions such as the duration of treatment. VHA Publications - Veterans Affairs Validated bleeding risk assessments such as HAS-BLED should be performed at each visit and modifiable factors should be addressed. 2 0 obj 2.Gogarten W, Vandermuelen E, Van Aken H, et al. Staff working in anticoagulation clinics (ACCs) must manage various tasks: face-to-face (F2F) consultation with new patients, managing F2F and over the phone patient follow-ups, and other clinical and administrative tasks. Copyright 2022 American Academy of Family Physicians. it is a reversible, direct-acting p2y12 inhibitor that has a more rapid onset of action compared with clopidogrel, while also allowing a higher level of platelet inhibition and more rapid reversal compared with clopidogrel as well. <> Direct oral anticoagulants are first-line agents for eligible patients for the treatment of VTE and prevention of stroke in patients with nonvalvular atrial fibrillation. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. Cost can limit availability and use of andexanet alfa. hb``` ,s@( 1205 0 obj <> endobj An outpatient basis depends on indication for use and, at times, patient comorbidities outweighed. Et al User Manual February 2018 Steps for Using this Tool First Visit 1 evening administration is the to! 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