April 2012

UHS CLINICAL CARE COLLABORATION: Outpatient & Inpatient

ANTICOAGULATION GUIDELINE Y2012 Guidelines for Anticoagulation Initiation and Management Hypercoagulation Atrial Fibrillation DVT PE Mechanical valve Others

MEDICATION FLOW 2 Anticoagulation Parenteral 5mg Warfarin Start Day #1 1

PATIENT FLOW UHS Inpatient CMA Clinics Specialty Clinics Cardiology Primary Care Providers Accessibility Availability Capability Convenience

Follow-up Day #3,4,5,6

UHS Emergency Dept.

Anticoagulation Clinic EMC (Back-up)

Drug interaction Restart treatment

Follow-up 2x/wk x 2 wks 1x/wk x 2 wks

4 5

Follow-up Q 1 month [INR check can be stretched to Q 1-2 months if some stability is reached] Page | 1
Leading the Changes to Take Better Care of the Patients Tomorrow Today LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04

 These are just guidelines and do not preclude clinical judgment Anticoagulation Protocol o See attachment below Anticoagulation Decision Support for recommended target INR and duration of therapy o Hypercoagulable diseases, i.e. anti-phospholipid syndrome, anti-lupus, etc Recommendation: if the patient has an ischemic event, initiate anticoagulation therapy with warfarin, unless contraindicated o See attachment below CHADS Score for estimating risk of stroke in patients with Atrial Fibrillation Recommendation: CHAD score 1 or previous ischemic events, initiate anticoagulation therapy with Warfarin, unless contraindicated Recommendation: CHAD score = 0, initiate anticoagulation with ASA or no treatment, unless contraindicated o See attachment below PE Prognosis for estimating prognostic risk for patients with Pulmonary Embolism Recommendation: Class I and II can be treated as outpatient o Isolated calf vein or distal DVT start anticoagulation therapy x 3 months o Unprovoked 1st VTE start anticoagulation therapy x 3 months, then reassess bleeding risk o Asymptomatic lower extremity DVT anticoagulation therapy similar to symptomatic lower extremity DVT o Spontaneous superficial vein thrombosis prophylactic parenteral anticoagulation for at least 4 weeks o For symptomatic proximal DVT, use elastic compression stocking x 2yrs ankle pressure gradient 30-40mmHg if feasible o See attachment below Management of Significantly Elevated INR With or Without Bleeding Patient Flow o Anticoagulation therapy can be initiated from any locations, i.e. Emergency Center, Inpatient Care, Express Med Clinic or other clinics. o Medication Flow will be our guide to initiate, monitor and adjust the therapy o Patients started on anticoagulation therapy can be followed on regular basis by Anticoagulation Clinic or other permanent medical homes (i.e. PCP, CMA clinics, specialty clinics, etc) o Express Med Clinic can serve as back-up for Anticoagulation Clinic o Contact numbers during regular work days, Monday Friday 8AM-5PM Anticoagulation Clinic = (210) 358-3296 or Navigator for Ambulatory Connection Clinic = (210) 358-9521 Make appropriate referral to Anticoagulation Clinic using Sunrise consult note Consult (Outpatient)(Anticoag Clinic) Medication Flow o Anticoagulation therapy will be initiated with parenteral anticoagulation and Warfarin 5mg or 2.5mg , started on day #1 o Parenteral anticoagulation should be overlapped with Warfarin for at least 5 days and until 2 consecutive INRs are in therapeutic range, 24 hours apart Note: Check Anticoagulation Clinic Consult for details about anticoagulation therapy, i.e. diagnosis, start date, therapy duration, etc Note: Point-of-care INR cannot be used for patients with Hct < 30, patients currently on parenteral anticoagulation, patients with lupus anticoagulant or anti-phospholipid antibodies venous blood draw is required o Patient INRs will be followed on days #3, #4, #5 and #6. Warfarin will be adjusted according to the 5mg or 2.5mg Warfarin Initiation Nomograms (see attachments) Note: Check either Visit History or IDX to confirm Anticoagulation Clinic appointment o Patient can then be followed 2x per week x 2 weeks then 1x per week x 2 weeks Patients with stable chronic anticoagulation therapy can be followed Q1-2months if INR stability is achieved Page | 2
Leading the Changes to Take Better Care of the Patients Tomorrow Today LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04

Note: See Treatment Dosing and Monitoring Guidelines for LMWHs and Fondaparinux posted to the Clinical Intranet Note: A baseline INR should be measured before the patient received the first dose of Warfarin Note: If Warfarin is initiated inpatient, see Inpatient Warfarin INR Monitoring Policy posted to the Clinical Intranet Note: See attachment below Dose Adjustment Algorithms to help with Warfarin adjustment Note: See attachment below Warfarin (Coumadin) Interactions o Follow up protocol for patients being treated with antibiotics or other interacting medications If the prescribed antibiotics / medications have known interactions with Warfarin, the patients should be followed in 3 days, then Q4-5 days until after the antibiotic / medication course is completed and INR level is therapeutic and stable If the prescribed antibiotics / medications have minimal or no known interaction with Warfarin, the patients should be counseled to monitor for signs and symptoms of increased bleeding and follow-up as needed. Or the patients can be followed as above o Restart anticoagulation for patients needing chronic anticoagulation but were off med Mechanical valve - restart parenteral anticoagulation along with Warfarin DVT & chronic A Fib - restart parenteral anticoagulation along with Warfarin if first 3 months after DVT & CHADS 2 & INR < 1.5 Hypercoagulation state - restart parenteral anticoagulation along with Warfarin if the patient is a high risk patient
ANTICOAGULATION DECISION SUPPORT Indication DVT or PE First episode, provoked First episode, unprovoked First episode, patient with cancer Recurrent DVT Atrial Fibrillations Anticoagulation after cardioversion Target INR 2.0 3.0 2.0 3.0 2.0 3.0 2.0 3.0 Therapy Duration 3 months At least 3 months but extended therapy is preferred if no contraindications or excessive bleeding risk LMWH for 3-6 months then warfarin (Coumadin); Treat until cancer is resolved Indefinitely SORT B B B B

2.0 3.0 Indefinitely 2.0 3.0 At least 4 wks after cardioversion, patients with CHADS2 score of 0 may then be switched to aspirin or no therapy; longterm anticoagulation is recommended for patients with a CHADS2 score of 1 or greater B 2.0 3.0 2.0 3.0 2.0 3.0 2.5 3.5 3 months 3 months Indefinitely Indefinitely

Valvular Disease Bio-prosthetic valve: Aortic ASA or Warfarin Bio-prosthetic value: Mitral Warfarin Mechanical valve Mechanical valve plus one the below high risk features Mitral valve position Low EF (<50%) Caged ball valve History of TIA/stroke Atrial fibrillation

Page | 3
Leading the Changes to Take Better Care of the Patients Tomorrow Today LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04

Maintenance Dose Adjustment Algorithms

For Target INR = 2.0-3.0, no bleeding* INR < 1.5 Increase dose 10-20%, Adjustment consider extra dose Next INR 14 days 1.5-1.9 Increase dose 5-10% 7-14 days 1.5-2.4 Increase dose 5-10% 7-14 days 2.0-3.0 No change No. of consecutive in-range INR x 1wk (max 4 wks) 2.5-3.5 No change No. of consecutive in-range INR x 1wk (max 4 wks) 3.1-3.9 Decrease dose 5-10% 7-14 days 3.6-4.5 Decrease dose 5-10% 7-14 days 4.0-4.9 Hold 0-1 day Decrease dose 10% 4-8 days 4.5-6.0 Hold 0-1 day Decrease dose 10% 4-8 days >5.0 See next page See next page >6.0 See next page See next page

For Target INR = 2.5-3.5, no bleeding INR < 1.5 Increase dose 10-20%, Adjustment consider extra dose Next INR 14 days

*-See -If INR is 1.7-1.9 or 3.1-3.3, consider no change with repeat INR in 7-14 days -For example, if a patient has had 4 consecutive in-range INR values, re check in 4wks -If INR is 2.3-2.4 or 3.6-3.7, consider no change with repeat INR in 14 days

Page | 4
Leading the Changes to Take Better Care of the Patients Tomorrow Today LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04

Management of Significantly Elevated INR With or Without Bleeding INR 4.5-9.0, no significant bleeding omit 1-2 doses, reduce dose 10-20%, monitor frequently. INR > 9.0, no significant bleeding hold warfarin therapy, give vitamin K1 5.0-10mg orally, monitor daily until INR therapeutic then resume at lower dose Serious bleeding, any INR holding warfarin therapy, give vitamin K1 10mg slow IV plus fresh frozen plasma and/or PCC, repeat vitamin K1 every 12 hours as needed Life threatening bleeding, any INR hold warfarin, give PCC +/- fresh frozen plasma with vitamin K1 10mg slow IV, repeat as needed PCC = prothrombin complex concentration (Profilnine) See guideline on UHS Clinical Intranet under Bleeding Disorders

Page | 5
Leading the Changes to Take Better Care of the Patients Tomorrow Today LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04

References: 1) CHEST Guideline, February 2012; 141 (2 supplement), Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines 2) Annals of Internal Medicine 2003;138:714 3) American Family Physician. May 15, 2005;71:1979-82 Invaluable Collaborators: Dr. Deborah Cardell, Dr. Michael Johnson, Dr Kourosh Jahangir, Crystal Franco PharmD, Oralia Bazaldua PharmD Page | 6
Leading the Changes to Take Better Care of the Patients Tomorrow Today LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04

Written / Revised by: ______________________________ Liem Du MD ______________________________ Deborah Cardell MD ______________________________ Michael Johnson MD ______________________________ Kourosh Jahangir MD ______________________________ Crystal Franco PharmD, BCPS ______________________________ Oralia Bazaldua PharmD, BCPS In concurrence with: ______________________________ ______________________________ ______________________________ This guideline was approved by UHS P&T Committee on 5/11/2012 __________ Date __________ Date __________ Date __________ Date __________ Date __________ Date __________ Date __________ Date __________ Date

Page | 7
Leading the Changes to Take Better Care of the Patients Tomorrow Today LDuMD \ UH-CMA \ Vision + Plan \ UHS Anticoagulation Guideline Y12.04