Anticoagulation Therapy

Minci
• Anticoagulants –
prevent clot formation
and extension
• Antiplatelets –
interfere with platelet
activity
• Thrombolytic agent
– dissolve existing
thrombi
 How warfarin works
• inhibits vitamin K-dependent coagulation factor
synthesis (II, VII, IX, X, proteins C and S)

• Indications;
4. Prophylaxis of DVT (INR 2 – 2.5)
5. Rx of DVT and PE, AF, cardioversion,dilated
cardiomyopathy, mural thrombus following MI,
rheumatic mitral valve disease ( INR 2.5)
6. Recurrent DVT and PE, mechanical prosthetic
heart valve ( INR 3.5)
• Monitor using INR.
• Therapeutic range : 2.0 – 3.0
• Takes 5 days to achieve thrombotic effect
(prothrombin T1/2 = 60 hours)
• 1mg = brown
3mg = blue
5mg = pink
 Side effects
• Bleeding – Nose, gums, GI, GU, urine
• Easy bruising
• Persistent headaches and dizziness
• Tiredness
• Hair loss
• Nausea, vomiting, cramping, diarrhoea
• Low WBC
• Hypersensitivity, ‘purple toes syndrome’
 Prescribing
1. Start with known dose. If not, take
baseline INR and start 10mg daily.
2. Check INR on Day 4 and adjust dose.
3. Stop heparin when INR reach therapeutic
level
4. Regular INR checks
5. Patient education : Compliance, OTC,
diet, drug interaction.
 Start low dose in
• Elderly patient
• Low body weight or low albumin level
• Patients with CCF/ liver disease
• On certain medications : Amiodarone,
metronidazole, trimethoprim
• Caution in pregnant women. Give heparin
instead.
 Low INR
• Drug interaction : Barbiturates,
Carbamazepine, Propilthiouracil,
Rifampin, Methimazole.
• Hypothyroidism
 High INR
• Advanced malignancy
• Drug interaction – Abx, amiodarone,
NSAID, simvastatin.
• Taking more than prescribed
• Eating less Vitamin K rich food
• Acute diarrhoeal illness
• Alcohol
• CCF, hyperthyroidism, hepatic failure
 Mx of high INR
• Check for Sx of bleeding and if in therapeutic
range  renal /GI pathology
• INR < 6.0 but more than 0.5 units above target,
reduce dose/stop, restart when <5.0
• INR 6.0 – 8.0 (no/minor bleed). Stop and restart
when INR <5.0
• INR >8.0 (no. minor bleed). As above. Give
phytomenadione (Vitamin K1) 0.5mg slow
IV/5mg PO. For partial reversal, use 05 – 2.5 mg
IV into PO. Repeat dose if INR still too high after
24 hours.
• Major bleed –
• Stop warfarin
• Give Vitamin K1 5mg slow IV
• PCC ( Factors II, VII, IX, X) 30 – 50
units/kg
OR
FFP 15 ml/kg