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DSM: AC and warfarin management (pogge) E3

Terms in this set (22)

Warfarin therapy:

The INR should be determined at least _____ during initiation of AC therapy

INR should be done at least _____ when AC is stable
Weekly

Monthly
PK: metabolism

S isomer? What CYP?

R isomer? What CYP?
Strong; 2C9

Weaker; 1A2, 3A4
What meds will increase bleed risk but NOT INR?
ASA, NSAIDs, fish oil, garlic
What is common reason why patients are allergic to warfarin?
Dye in tablets
What does diarrhea and fever do to INR?
Increase
Intervention:

Above therapeutic but <4.5 w/o bleeding?
Lower the dose or omit dose

Monitor more freq

Administer new adjusted dose once INR is therapeutic
Intervention:

4.5-10 w/o bleeding?
Omit 1-2 doses

Monitor more freq

Administer new adjusted dose once INR is therapeutic

Rec against the use of vit K
Intervention:

>10 without bleeding? (3)
Hold warfarin and administer 2.5-5 mg oral vit K

Monitor more frequently

Administer new adjusted dose once INR is therapeutic
Bridging: step 1

Determine whether or not oral AC should be interrupted. When to stop:

Stop AC for _____ procedures with mod to high bleeding risk (5)

Interruption is NOT needed for minor _____, ____, or _____
Invasive; colonoscopy, minor and major surgery, pacemaker implantation, tumor removal, cardiac surgery

Dental, dermatological, or cataract surgery
Bridging: warfarin

D/c warfarin ____ days prior to procedure; recheck INR ____ hour prior to procedure
5

24h
Bridging: DOAC prior

DOAC with normal renal fxn (>50 ml/min): high bleed risk? Low?
High: 48 h prior

Low: stop 24 h prior
Bridging: DOAC prior

Dabigatran <50 ml/min: high bleed risk? Low?
High: 4 days prior

Low: 48 hours prior
Bridging: DOAC post

Any DOAC: high risk? Low?
High: day 2

Low: 24 h post
Bridging: do we need to provide alternative AC during the time that the patient is no longer receiving AC?
This only applies to warfarin

Dependent on indication: heart valves, AFib, VTE
Bridging: alt indication

Prosthetic heart valves: mechanical AVR w/ RF? Mechanical mitral valve?
Mechanical AVR w/ RF: INR goal 3; bridging AC during time when INR is subtherapeutic

INR goal 3; bridging AC during time when INR is subtherapeutic
Bridging: take home point

Mechanical valve?
MHV: bridge most patients, exception aortic valve with NO other RF
Bridging: alt indication

VTE?
No bridging is needed for most patients with a h/o VTE
Bridging: alt indication

VTE: what are the exceptions? (4)
VTE within the previous 3 months

Prior h/o recurrent VTE during AC therapy interruption

Severe thrombophilia

Undergoing a procedure with a high risk of VTE
Bridging: alt indication

VTE: can use therapeutic dose ____ or prophy dose
LMWH
Bridging: alt indication

Take home point for AFib?
CHADSVASc score; low risk (1-4) dont bridge

High risk (7+) bridge

Moderate risk (5-6) if bleeding risk is high then dont bridge but it prior stroke then bridge
Bridging: warfarin

Take home point?
Enoxaparin 1mg/kg q12h; VTE prophy dose 40 mg QD

Start enoxaparin on day 3 after omitting warfarin doses OR when INR <2

D/c enoxaparin 24 h prior to procedure
Bridging: warfarin

Restarting warfarin take home point?
Restart warfarin for all patients 24 h following procedure

Enoxaparin: restart at around 24h for low bleeding risk procedure; wait 48-72 h if bleeding risk is high; stop enoxaparin when INR reaches 2
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