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warfarin education

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on 20 September 2014

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Transcript of warfarin education

Patient education highlights

What is warfarin?

What is an INR?

Signs and symptoms of bleeding or clotting

Drug-drug interactions

Drug-nutrient interactions

Administration information






Consistency is key!
Dietary
Administration
Same time of day
Evening preferred
Are your warfarin tablets a different color than usual?
Warfarin tablets are colored by strength
E.g. warfarin 5mg tablets are always peach
Drug-Drug Interactions
Antibiotics
OTC pain relievers
Antibiotics
Herbals
Adverse Events
Bleeding
Clotting
Education-Warfarin
New Anticoagulant
Education-Rivaroxaban
Adverse Events
Bleeding
Clotting

Administration Information
15mg and 20mg doses
Administer with a meal
Smaller doses
Administer without regards to food

Drug-Drug Interactions
Report starting or stopping medications

Drug-Nutrient Interactions
No drug nutrient interactions reported

Presentation put together by: Cara Laslovich, PharmD Candidate 2015
Anticoagulants-Warfarin, Dabigatran, Rivaroxaban, Apixaban

Rivaroxaban
Classification
Brand Name: Xarelto

Direct factor Xa inhibitor

Oral anticoagulant
Indications
Atrial fibrillation
Non-valvular

DVT thrombosis

DVT prophylaxis
Orthopedic surgery

Pulmonary embolism

Stroke prophylaxis
Dosing
Atrial Fibrillation
20mg daily with an evening meal
DVT or PE
15mg twice daily with food x 21 days, then 20mg once daily x 6 months
DVT prophylaxis
Knee replacement
10mg daily x 12 days
Hip replacement
10mg daily x 35 days

Renal dose adjustments specific per indication being treated
Patient Safety
No Routine Monitoring Required
There is still a risk for bleeding and clotting

Drug-Drug interactions
Medications that increase the risk of bleeding
Aspirin, NSAIDS, etc.
CYP344 inhibitors and inducers
Ketoconazole, st. john’s wort, carbamazepine, etc.
Black Box Warning
Epidural or spinal hematomas
May result in long-term or permanent paralysis
Discontinuation in AFIB
Premature discontinuation increases risk of thrombosis

Always consult with a provider or pharmacist before starting a new medication including OTC, herbals, and vitamins/supplements!
Administration
15mg and 20mg tablets may be crushed and mixed with apple sauce

15mg and 20mg tablets should be administered with food
Preferably with an evening meal
Increases the absorption substantially

No dietary restrictions are necessary
Labeled Indications

Antiphospholipid Antibody Syndrome
AFIB
Cardiomyopathy
DVT treatment and prophylaxis
MI prophylaxis
Prosthetic heart valves
Pulmonary embolism
Arterial thromboembolism prophylaxis
Coronary artery thrombosis prophylaxis
Postmyocardial infarction
Stroke prophylaxis
Thrombosis prophylaxis
Warfarin
Classification
-Coumarin Anticoagulant
Inhibits the production of vitamin K-dependent clotting factors (II, VII, IX, X)

Indications

Monitoring - INR testing
INR-International Normalized Ratio
Test performed to assess the coagulation effect on blood
The goal INR is usually between 2-3
A number > 3, blood is too "thin" (risk for bleeding)
A number < 2, blood is too "thick" (risk for clotting)


Learning Goals & Objectives
List at least 3 patient safety goals

Understand ways to help improve medication compliance and limit risks to patients

Understand the importance of proper documentation of a patient's current warfarin dose

List at least 3 reasons documentation is important

Identify common side effects and known when to notify a medical provider
Warfarin, Dabigatran, Rivaroxaban, Apixaban
Usual starting dose- 5 mg by mouth daily
Use warfarin 5mg tablets

Dosage adjustments are made to meet INR goals

How adjustments are made
Step 1: Total Weekly dose
Step 2: Increase or decrease weekly dose by 10-20%
Step 3: Other instructions may include holding warfarin for 1-2 doses or increasing dose x 1 -2 doses

Reason to instruct patient to take warfarin in the evening

Importance of documentation of a patient's current warfarin dose!!



What to Watch for?
Patient Safety & Adverse Events
Bleeding
Blood in the urine
Blood in the stool
Bleeding gums
Bloody noses
Abnormal Bruising
Head trauma
Occupational hazards, contact sports
Report any signs and symptoms of bleeding to a healthcare provider immediately
Clotting
Shortness of breath
Fatigue
Swelling of an extremity
Usually uni-lateral
Red
Hot to the touch
Report any signs and symptoms of clotting to a healthcare provider immediately
Common Dosages
Documentation
Warfarin Interactions
Drug-Drug
Rx Medications- Antibiotics!!
OTC- pain relievers
Herbals
Energy drinks
Vitamins and Supplements
Drug-Nutrients
Vitamin K rich foods (e.g. dark leafy greens)
Increase the "thickness" of the blood
Alcohol
Consistency is key!
Common "Myth"- patient on warfarin cannot eat any Vitamin K containing foods

Dabigatran


Brand Name: Pradaxa

Oral anticoagulant

Direct thrombin inhibitor
• AFIB, non-valvular

• DVT

• DVT prophylaxis

Hip and knee replacement

• PE

• PE prophylaxis



Dosing

• Atrial fibrillation, non-valvular
150mg by mouth twice daily

• VTE treatment
Patients treated with a parenteral anticoagulant for a duration of 5-10 days
After, dabigatran 150mg twice daily

• VTE prophylaxis
Hip Replacement
150mg or 220mg once daily x 28-35 days
Knee Replacement
150mg or 220mg once daily x 6-10 days

Renal dose adjustments are based on specific indications and concomitant medication use

Administration

Leave in original container

Open one bottle at a time, close tightly after opening

Use within 4 months after opening

Take without regards to food, swallow whole


Patient Safety

No routine monitoring required
There is still a risk for bleeding and clotting

Drug-Drug interactions
Other medications that increase the risk of bleeding
Aspirin, NSAIDS, anti-platelets, etc.
Black Box Warning
Epidural or spinal hematomas
May result in long-term or permanent paralysis
Discontinuation in AFIB
Premature discontinuation increases risk of thrombosis

Always consult with a provider or pharmacist before starting a new medication including OTC, herbals, and vitamins/supplements

Apixaban

Classification
Brand Name: Eliquis

Oral anticoagulant

Direct factor Xa inhibitor

Indications

o AFIB-Nonvalvular

o DVT

o DVT prophylaxis
Hip or knee replacement

o PE

o PE prophylaxis



Dosing

AFIB, non-valvular
5mg by mouth twice daily
Patients older than 80 years, body weight less than or equal to 60kg or SrCr greater than or equal to 1.5mg/dl
Dose reduction to 2.5mg twice daily

VTE treatment
10mg by mouth twice daily x 7 days, then 5 mg twice daily for a minimum of 6 months

VTE prophylaxis
2.5mg twice daily after VTE treatment
35 days -Hip replacement
12 days- Knees replacement

Administration

Take without regards to food

If missed dose, take as soon as possible on the same day to maintain twice daily dosing. Do not double up on doses.

Patient Safety
No Routine Monitoring Required
There is still a risk for bleeding and clotting

Drug-Drug interactions
Other medications that increase the risk of bleeding
Aspirin, NSAIDS, anti-platelets, etc.
Metabolized primarily by CYP3A4
Caution CYP3A4 inhibitors and inducers
Black Box Warning
Epidural or spinal hematomas
May result in long-term or permanent paralysis
Discontinuation in AFIB
Premature discontinuation increases risk of thrombosis
Always consult with a provider or pharmacist before starting a new medication including OTC, herbals, and vitamins/supplements
Patient Name: ---- Provider: ------
Indication: ---- INR Goal: --- Duration: ----- Stop Date:----

INR results:----
Current Weekly Dose:-----
New Weekly Dose: ----
Dosage Schedule: (e.g. MWF- 5mg, Sat and Sun- 2.5mg)
Next INR:----

Other information

Changes in diet/activity Missed/extra doses
New meds/otc/herbals S/S of bleeding/clotting
Has the patient been sick



What is rivaroxaban?

Signs and symptoms of bleeding or clotting

Drug-drug interactions

Administration information


Patient Education Highlights
Education-Dabigatran
Adverse Events
Bleeding
Clotting

Administration
Without regards to food
Stress Compliance

Drug-Drug Interactions
Report starting or stopping medications

Drug-Nutrient Interactions
No nutrient interactions reported

What is dabigatran?

Signs and symptoms of bleeding or clotting

Drug-drug interactions

Administration information


Patient Education Highlights
Education-Apixaban
Adverse Events
Bleeding
Clotting

Administration
Without regards to food
Stress Compliance

Drug-Drug Interactions
Report starting or stopping medications

Drug-Nutrient Interactions
No nutrient interactions reported
What is apixaban?

Signs and symptoms of bleeding or clotting

Drug-drug interactions

Administration information


Patient Education Highlights
Indications
Classifications
Does your patient have any upcoming surgeries or procedures?


Warfarin may need to be stopped up to 5 days in advance for a procedure to ensure patient safety
Advantages and Disadvantages of the Newer Oral Anticoagulants Compared to Warfarin
Advantage
Newer oral anticoagulants do not have the same monitoring requirements, drug and nutrient interactions as warfarin

Disadvantage
No antidote exists to reversal the newer oral anticoagulants

Reversal may be needed for emergency surgery, overdose, or major bleeding

Interventions include, mechanical compression, supportive care, charcoal, and blood product transfusions
References
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1. Clinical Pharmacology [database online]. Tampa, FL:Gold Standard, Inc.;2014. URL: http://www.clinicalpharmacology.com.
2. Coumadin [package insert]. Princeton, New Jersey; 2011 October.
3. Xarelto [package insert]. Titusville, New Jersey; 2011.
4. Eliquis [package insert]. Princeton, New Jersey; 2012 December.
5. Pradaxa [package insert]. Ridgefield, Connecticut; 2011.
6. Heidbuchel H, Verhamme P, Alings M, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-2106.
Full transcript