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Derbyshire Joint Area Prescribing Committee (JAPC)

GUIDELINE ON ORAL ANTICOAGULATION

o This guideline is intended to be used across Derbyshire and supports the new
level 4 anticoagulation management service being rolled out in Derbyshire County
PCT

o The use of 1mg strength Warfarin tablets is strongly recommended unless


patients are on doses greater then 5mg and can manage different strengths

o Avoiding more then two different strengths is recommended

o Use of 0.5mg is not recommended to avoid confusion

o The patient should receive verbal and written information on anticoagulant therapy from
the start of treatment and an induction process followed to ensure they understand the
information

o Each patient should be issued with an oral anticoagulation therapy (OAT) pack containing
a anticoagulant record booklet (yellow booklet) which should be kept up to date.

o Practitioners managing oral anticoagulation should meet the required NPSA


competencies

Derbyshire JAPC Guideline Oral Anticoagulation 1


Revised: January 2009
Review Date January 2011
APPENDICES

1: Indications for Oral Anticoagulation page 8

2. Atrial fibrillation and Warfarin patient information leaflet page 9

3. Conditions which may cause a change in Warfarin sensitivity page 13

4. Common Warfarin drug interactions page 14

5. Guidelines for the management of over anticoagulated patients. page 15

6. Induction guidelines for patients newly initiated on Warfarin. page 16

7. Summary of guidelines on management of patients requiring page 18


dental surgery

8. Resources page 19

9. List of contacts for clinical support and advice. page 21

Derbyshire JAPC Guideline Oral Anticoagulation 2


Revised: January 2009
Review Date January 2011
1. General Guidance
Warfarin has a narrow therapeutic index and regular titration of the dose against the
anticoagulant effect in the blood, as assessed by the INR, is essential.
The patient should be maintained within their therapeutic range as documented in
Appendix 1. Deviation from the therapeutic range is associated with an increased risk of
haemorrhage or thrombosis (if too high) or increased risk of stroke (if too low).
Practitioners managing anticoagulation should meet the required NPSA competencies1.

2. Indications for oral anticoagulation


The decision relating to diagnosis, indication for anticoagulation and INR target and range
will be made in secondary care except for stroke risk reduction in Atrial fibrillation patients.
Accredited Pharmacists and nurses managing anticoagulation will not be required to make
these decisions unless qualified as independent prescribers.
In some patients Warfarin is started as an out-patient because immediate anticoagulation
is not necessary.

See Appendix 1 for detailed list of conditions, target INR and range and duration of treatment.

3. Initiation of Warfarin Therapy


There are various schedules for initiating anticoagulation within an outpatient setting; the
recommended regime is described below. In primary care initiation should only be done by
accredited practitioners who have successfully completed the BMJ module - Starting
patients on anticoagulants: how to do it.
When starting Warfarin you must stop aspirin / clopidogrel unless continuation is explicitly
advised by a consultant in secondary care. This should be documented.
All new patients should receive a structured induction such as that described in Appendix 6
to ensure that all the relevant information is provided.

Starting as an out-patient in primary care 2,3.


Protocol
1. Explain the indication and the risks and benefits of treatment.
2. Prescribe 2mgs a day for 2 weeks (day 1)
3. Give an OAT pack and patient information sheet (see Appendix 2 for Atrial fibrillation)
4. Check INR after 1 week (day 8) of the new dosage to ensure patient is not oversensitive to
warfarin (see appendix 3 and 5)
Do not change the dose unless the INR is greater then 3 discuss options with haematologist.
5. Patients should return after another week of therapy (day 15) for an INR measurement.
On the basis of this result the predicted maintenance dose for target 2.5 0.5 is
prescribed from the table.

Predicted maintenance dosage of warfarin based on the sex of the patient and the INR after
2 weeks of 2mg/day.

MALE FEMALE
INR at Week 2 Maintenance Dose INR at Week 2 Maintenance Dose
1.0 6 mg/day 1.0 1.1 5 mg/day
1.1 1.2 5 mg/day 1.2 1.3 4 mg/day
1.3 1.5 4 mg/day 1.4 1.9 3 mg/day
1.6 2.1 3 mg/day 2.0 3.0 2 mg/day
2.2 3.0 2 mg/day > 3.0 1 mg/day
> 3.0 1 mg/day

6. Patients should re-attend after 1 week of the new dosage (day 22) for a further INR
measurement.

Derbyshire JAPC Guideline Oral Anticoagulation 3


Revised: January 2009
Review Date January 2011
7. Subsequent dosage adjustment should be as follows:
If the INR is >4.0 but there is no bleeding, the warfarin should be omitted for 2 days
and then restarted at a dose 1 mg lower
For bleeding complications on warfarin contact the haematologist.
If the INR is <2.0 the dosage should not be changed but the patient should be
encouraged to return one week later for a further reading. If there are two
consecutive weeks where the INR is <2.0 then the dosage of warfarin should be
increased by 1mg.
By the time the patient has been taking warfarin for 6 weeks the INR should be in
the therapeutic range.
Fine tuning of warfarin dosage by using alternate day regimens of eg, 2 mg/3mg
can be used if INR fluctuates too much.

Changes in warfarin dosage should be kept to a minimum as there are natural fluctuations
in the INR which occur on a daily basis and because of external
factors.

4. Dosage Regimens
The dose required to achieve the therapeutic target is very variable between patients, but
usually lies between 1 and 10mg daily.
Dosage decisions should be supported using approved clinical decision support software
(CDSS) but clinical judgement must be applied in all cases to determine decisions.
The dose should be taken once a day at a fixed time, preferably 18.00 hours, or another
regular time if more convenient to aid better compliance. Patients are mostly seen during
the day and a late afternoon or evening dose does enable the managing practitioner to ask
the patient to miss a dose, when required. Management can be trickier if the patient has
already taken their anticoagulant.
The tablet strengths available are:
0.5mg (white), 1.0mg (brown), 3.0mg (blue) and 5.0mg (pink).
The use of 1mg strength tablets only is recommended unless patients are on high doses
greater than 5mg. Avoiding more than two different strengths is strongly recommended.
Use of 0.5mg is not recommended to avoid confusion.
The current INR and recommended dose should be recorded in the patients yellow
anticoagulant record book.
The recommended dose should always be specified in milligrams, i.e. Xmg, and not
number of tablets.
The NPSA recommends use of constant daily dosing and not alternate dosing. In practice,
fine tuning of dosage by using alternate day regimens of eg, 2 mg/3mg may need to be
used if INR fluctuates too much.
If a patient misses a dose of Warfarin they should be told not to take double the dose the
next day but continue with their normal dose. If the patient is very sensitive to changes or
at high risk if under dosed they should contact the service provider as soon as possible.
Other patients may be asked to arrange earlier monitoring if their appointment is not due
for more some time depending on stability of patient and clinical judgement of managing
practitioner.

5. Monitoring
The frequency of monitoring will vary but patients should have their INR checked at least
every 10 -12 weeks. Every patient must be seen at least once every 12 weeks. Less
stable and new patients will require more frequent tests
Recall dates will be suggested by the dosing support software; however, if the patients
clinical condition is changing, or there have been alterations in other medication, then the
INR should be checked more frequently and clinical judgement should override the CDSS.

Derbyshire JAPC Guideline Oral Anticoagulation 4


Revised: January 2009
Review Date January 2011
When determining the frequency of recall it is helpful to remember that the full effect of a
change in dose of warfarin on the INR may take 3 days to become apparent.
Many clinical factors or drugs may affect the sensitivity of the patient to the effects of
warfarin . Some of these are documented in Appendix 3.
A full list of various drugs which may interact with anticoagulants is given in the back of the
latest BNF (Drug Interactions, under coumarins). Appendix 4 gives a very useful summary
of common drug interactions.
Drugs that are liver enzyme inhibitors can increase the INR. They act very quickly (can be
within 24 hours) and if the drug is withdrawn the effect disappears quickly depending on
the drug half-life. The INR should if possible be monitored within 72 hours of starting the
interacting drug and on withdrawal.
Drugs that are liver enzyme inducers can decrease the INR. They act more slowly (up to a
week) with peak effect at 2-3 weeks and can persist for up to 4 weeks after stopping
depending on drug half-life. The INR will need checking after 1 week of concurrent
therapy.
Some drugs may have other mechanisms that affect the INR.
If a patient on Warfarin is started on ANY other new medication a repeat INR after 1 week
would be a sensible precaution.
A robust system should be in place to ensure all DNAs (did not attends) are followed up
and monitored effectively. It must be stressed to the patient that careful monitoring of
Warfarin therapy is essential in order to avoid complications. Where patients repeatedly fail
to attend, then the risks of continuing therapy should be considered against the benefits.
Advice should be sought from the GP or specialist.

6. Management of Bleeding and / or Over-Anticoagulation


Coagulometers using capillary blood may not be accurate when the INR is elevated. For
CoaguChek XS plus, when the INR is > 8 the capillary blood INR result should be
confirmed with a second test and in addition a sample obtained by venepuncture and sent
to the laboratory to determine the exact INR reading. The therapeutic decision around
dosing and clinical management of the patient should not be delayed until the laboratory
result is obtained. Clinical management will depend on whether there is bleeding or not
which will also indicate need for vitamin K.
The risk of haemorrhage increases significantly when the INR is > 5.0.
The recommendations on the management of over anticoagulated patients can be found
below.
All patients with bleeding should be evaluated to determine whether there is a local
anatomical cause for the haemorrhage.
A PGD for administration of oral vitamin k (Konakion Paediatric) is available for use by
accredited practitioners within Derbyshire county PCT.

See appendix 5 Guideline for management of over anticoagulated patients.

7. Contraindications to Anticoagulation
This is seldom absolute and each patient must be individually evaluated.
Pregnancy: exposure of the embryo to warfarin during the 6th to 12th weeks of gestation
may be associated with the development of an embryopathy and throughout gestation
there is a continuing risk of foetal haemorrhage.
Patients who could potentially get pregnant must be warned of the risks and told to seek
an early pregnancy test if they suspect a risk.
Any patient taking Warfarin who becomes pregnant must stop Warfarin and be referred
urgently for hospital evaluation and management.

Derbyshire JAPC Guideline Oral Anticoagulation 5


Revised: January 2009
Review Date January 2011
8. Exclusions
Patients with the following conditions/problems should be excluded from the primary care
service:
A known hereditary or acquired bleeding disorder;
Children under 16;
Pregnant;
Other conditions the Consultant Haematologist considers should exclude the patient from
management in primary care.

Excluded patients will continue to be managed by secondary care clinicians.

9. Cautions
There are certain conditions/problems where caution should be taken when monitoring
patients and where required advice from the Haematology department should be sought.
These include severe heart failure, liver failure, DVT /PE in the previous month and chronic
alcoholic.

Risk factors of bleeding should be considered. The following patient characteristics are
indicative of a high risk for bleeding: Age >70, Hypertension, Diabetes, Renal Failure,
Previous MI, Previous CVA, Previous GI Bleed, Patients with Liver Disease.

10. Anticoagulation in special circumstances


All practitioners providing this service should be aware of special circumstances and know
how to manage these patients and ask for specialist advice when required. These are
circumstances such as Protein C deficiency, Protein S deficiency, Antisphospholipid
syndrome, Factor V Leiden. The pre-workshop booklet distributed as part of the Derbyshire
County PCT accreditation programme (Management of patient anticoagulation therapy)
briefly covers these circumstances and should be used in conjunction with other national
guidelines.

Anticoagulation in Cancer Patients:


Patients with cancer who are receiving antithrombotic therapy are thought to be at higher risk
of bleeding than patients without cancer. For practical purposes, the recommended
therapeutic levels of anticoagulation remain the same as long as patients are educated about
the risks and the anticoagulation levels are strictly monitored.

Patients with cancer are at a higher risk than non-cancer patients of recurrence of
thromboembolism despite adequate anticoagulation.

Patients with cancer who develop thromboembolism should be considered for treatment with
long term Low molecular weight heparin. It is preferable to use heparin in this circumstance,
and therapeutic anticoagulation with heparin therapy reduces the risk of recurrent events
compared with Warfarin therapy (BCSH guidelines on oral anticoagulation4)

Anticoagulation in dental surgery:


The British Committee for Standards in Haematology (BCSH) has published a document to
provide healthcare professionals, including primary care dental practitioners, with clear
guidance on the management of patients on oral anticoagulants requiring dental surgery.
(See Appendix 7)

Derbyshire JAPC Guideline Oral Anticoagulation 6


Revised: January 2009
Review Date January 2011
11. Discontinuation of Warfarin Therapy
The duration of required anticoagulation should always be stated in the medical notes
when the patient is first started on therapy.
Concern of a rebound hypercoagulable state after stopping oral anticoagulant therapy has
resulted in uncertainty as to whether treatment should be stopped abruptly or gradually.
Having considered the evidence the current BCSH guidelines4 state that there is no need
for gradual withdrawal of anticoagulant therapy. The guidelines recommend that oral
anticoagulant therapy can be discontinued abruptly when the duration of therapy is
completed.
Where there are further risks involved 75mg Aspirin should be considered

1
Work competences for anticoagulant therapy: Available from the NPSA Website:
http://www.npsa.nhs.uk/

o initiating anticoagulant therapy ; maintaining oral anticoagulant therapy ;managing


anticoagulants in patients requiring dental surgery ; reviewing the safety and effectiveness
of an anticoagulant service

2,
Oates A, Jackson PR, Austin CA, Channer KS A new regimen for starting anticoagulation in
out-patients British Journal of Clinical Pharmacology 1998; 46: 157-171
3,
Channer Kevin S. Starting as an outpatient. BJGP 2002; 52 : 238-9
4
Guidelines on oral anticoagulation : third edition- 2005 update British Committee for Standards in
Haematology http://www.bcshguidelines.com/pdf/oralanticoagulation.pdf

Derbyshire JAPC Guideline Oral Anticoagulation 7


Revised: January 2009
Review Date January 2011
APPENDIX 1
Indications for Oral Anticoagulation
Indication Target INR & Duration
Range
Pulmonary embolus 2.5 2.0-3.0 6 months
Proximal DVT 2.5 2.0-3.0 6 months
Distal DVT
Non-surgical with no persistent risk 2.5 2.0-3.0 3 months
factors *
Surgical with no persistent risk factors * 2.5 2.0-3.0 6 weeks
*Consider increasing duration of
anticoagulation if any risk factors persist

Recurrent events PE & / or DVT


Off warfarin or sub-therapeutic INR 2.5 2.0-3.0 ? Long term
On warfarin within therapeutic range 3.5 3.0-4.0 ? Long term

Non-rheumatic AF with at least one additional 2.5 2.0-3.0 Long term


risk factor:
Previous thromboembolism
Systolic hypertension
Congestive heart failure
Abnormal LV function on
echocardiography

AF secondary to rheumatic heart disease 2.5 2.0-3.0 Long term


Cardioversion for AF 2.5 2.0-3.0 Minimum 3 weeks before
to 4 weeks after
Rheumatic mitral valve disease 2.5 2.0-3.0 Long term
Dilated cardiomyopathy 2.5 2.0-3.0 Long term
LV mural thrombus post MI +/- LV aneurysm 2.5 2.0-3.0 3 months

Mechanical prosthetic heart valve 3.5 3.0-4.0 Long term


If low risk:
Low thrombogenicity valve eg. AVR
Sinus rhythm
Normal LA size
Consider decreased intensity 3.0 2.5-3.5 Long term

Bioprosthetic heart valve:


AVR 2.5 2.0-3.0 3-6 months
MVR 2.5 2.0-3.0 3-6 months
If high risk:
AF
Intracardiac thrombus
Previous systemic embolism
Consider 2.5 2.0-3.0 Long term

Inherited thrombophillia with DVT & / or PE 2.5 2.0-3.0 Variable


Antiphospholipid syndrome 2.5 2.0-3.0 Long term
Recurrent events whilst therapeutically
anticoagulated 3.5 3.0-4.0 Long term

Reference: Haemostasis & Thrombosis Taskforce of the British Committee for Standards in Haematology,
Guidelines on oral anticoagulation, British Journal of Haematology, 1998, 101, 174-187

Derbyshire JAPC Guideline Oral Anticoagulation 8


Revised: January 2009
Review Date January 2011
APPENDIX 2

PATIENT INFORMATION LEAFLET


Atrial Fibrillation and Warfarin

Warfarin reduces the risk of people with atrial fibrillation (AF) having a stroke.

What is atrial fibrillation?


Another leaflet discusses atrial fibrillation (AF) in more detail. Briefly, people with untreated AF
have a heartbeat that is fast and erratic. Treatment in most cases is to bring the heart rate down to
normal. This usually eases most symptoms. However, in many cases the heart rhythm remains
erratic even if the rate is brought down to normal. It is this erratic rhythm of the heartbeat that
sometimes leads to the complication of a stroke.

Why is a stroke a possible complication of atrial fibrillation?


The erratic heart rhythm of AF causes turbulent blood flow within the heart chambers. This
sometimes leads to a small blood clot forming in a heart chamber. A clot can then travel in the
blood vessels until it gets stuck in a smaller blood vessel in the brain (or sometimes in another
part of the body). Part of the blood supply to the brain may then be cut off, which causes a stroke.
Therefore, the main complication of AF is an increased risk of having a stroke.

The risk of developing a blood clot and having a stroke varies, depending on various factors. The
level of risk is divided into three categories: high, medium and low risk.
High risk means that, without treatment, you have about a 6-12 in 100 chance (sometimes
higher) of having a stroke in the next year. People in the high risk group include those:
o who have already had a stroke or known blood clot, or
o are aged 75 years or older who also have one of the following 'risk factors': high blood
pressure, diabetes or a cardiovascular disease (such as angina, heart attack,
peripheral vascular disease), or
o who have a heart valve problem, or
o who have heart failure or poor heart function shown on a heart scan.
Moderate risk means that you have about a 3-5 in 100 chance of having a stroke in the
next year. People in the moderate risk group include those:
o aged 65 years or older (with no high risk factors), or
o who are of any age (up to age 75 when the risk is high) but who also have one of the
following 'risk factors': high blood pressure, diabetes or a cardiovascular disease (such
as angina, heart attack, peripheral vascular disease).
Low risk means that you have about a 1-2 in 100 chance or less of having a stroke in the
next year. People in the low risk group are all people with AF aged less than 65 and who
do not have any risk factors that put them in the high or moderate risk category.

What does Warfarin do and how effective is it?


Warfarin interferes with certain chemicals in the blood to prevent blood clots forming so easily.
This is known as anticoagulation. Some people call anticoagulation 'thinning the blood' although
the blood is not actually made any thinner. Warfarin is the most commonly used anticoagulant
drug. Recent studies which looked at people with AF have shown that by taking Warfarin the risk
of having a stroke is greatly reduced.

Derbyshire JAPC Guideline Oral Anticoagulation 9


Revised: January 2009
Review Date January 2011
Overall, Warfarin reduces the risk of stroke by nearly two-thirds. In other words, Warfarin
treatment can prevent about 6 in 10 strokes that would have occurred in people with AF. The
greatest benefit is seen in those people who are in the 'high risk' category of having a stroke
(described above). For example:
For people with AF who are at high risk of stroke, about 80-90 strokes will be prevented
each year for every thousand people treated with Warfarin.
For people with AF who are at moderate risk of stroke, about 25 strokes will be prevented
each year for every thousand people treated with Warfarin.

Are there any risks with taking Warfarin?


As with most treatments, there is some risk if you take Warfarin. The main risk is that a bleeding
problem may develop as the blood will not clot so well. For every thousand people with AF who
take Warfarin, about nine people per year are likely to have a serious bleeding problem from the
treatment. For example, you could develop a bleeding ulcer in your intestines (guts), or suffer a
bleed into the brain (a cerebral haemorrhage). If you have a serious bleed you are likely to need to
be admitted to hospital, often needing a blood transfusion, and it can even result in death.

Most people with AF who have a high or medium risk of having a stroke are advised to take
Warfarin. However, some people with a moderate risk may be treated with aspirin rather than
Warfarin (see below), particularly if the risks of taking Warfarin are higher than average. People
with a low risk of having a stroke are not usually advised to take Warfarin. This is because the
benefit does not usually outweigh the risk of serious bleeding problems with taking Warfarin. In
short, the decision to take Warfarin is a joint decision between you and your doctor. It involves
weighing up the risk of having a stroke against the small risk of a complication from taking
Warfarin.
Aspirin is another drug that helps to prevent blood clots forming. It is not as effective as Warfarin,
but is less likely to cause serious problems. It is usually advised if you only have a low risk of
stroke, or if you cannot take Warfarin or do not wish to take Warfarin.

What does Warfarin treatment involve?


Most people who take Warfarin attend a 'Warfarin clinic'. This may be at your GP practice, or at
the local hospital. The clinic is run by a health professional specially trained in anticoagulation. He
or she may be a doctor, specialist nurse, trained pharmacist, etc.
You will need regular blood tests to check on how quickly your blood clots when you are taking
Warfarin. Blood tests (and clinic visits) may be needed quite often at first, but should reduce in
frequency quite quickly. The aim is to get the dose of Warfarin just right so your blood does not
clot as easily as normal, but not so much as to cause bleeding problems.
You will be advised on how to take Warfarin, and if it affects any other medication that you take.
For example, the following are commonly advised:
You should aim to take Warfarin at the same time each day.
If you accidentally miss a dose, NEVER take a double dose 'to catch up' (unless
specifically advised by a doctor or by the person who runs the Warfarin clinic).
Seek advice promptly if you think that you have taken too much Warfarin by mistake, or
have missed any doses.

Other medication whilst taking Warfarin


If you are prescribed or buy any other drug then tell a doctor, nurse or pharmacist that you are on
Warfarin. This is because some drugs interfere with the way Warfarin works and your dose of
Warfarin may need to be altered. Also, if you stop another drug or change the dose, seek advice
from a doctor or nurse as your dose of Warfarin may need to be altered.

Derbyshire JAPC Guideline Oral Anticoagulation 10


Revised: January 2009
Review Date January 2011
Diet
If you have a major change in your diet or the foods that you eat then seek advice from the
Warfarin clinic. A major change in diet may mean that you need more closer monitoring and may
need a change in Warfarin dose. In particular, if you eat a vitamin K-rich diet you should not
change your eating habits without at the same time reducing the dose of Warfarin. Two other
commonly eaten foods that are known to interact with Warfarin are cranberry and grapefruit. To
make things easier, it is probably best simply to avoid foods that contain cranberry or grapefruit.

Women of childbearing age


Seek advice promptly if you become pregnant or are planning a pregnancy. For safety reasons
Warfarin is likely to be stopped and an alternative drug called heparin is likely to be used instead.

What if I bleed whilst taking Warfarin?


An indication that the dose of Warfarin is too high is that you may bleed or bruise easily. Also, if
you bleed, the bleeding may not stop as quickly as normally. For example, you may have:
bleeding gums; nosebleeds; prolonged bleeding from cuts; blood in the urine.

If you cut yourself, or have any other bleeding, seek medical help as soon as possible if the
bleeding does not stop as quickly as you would expect. If you injure an arm or leg which is
bleeding, until you get medical help then ideally keep the affected part raised above the level of
your heart. If you vomit blood, get medical help immediately - ring for an ambulance.

Some other general points about taking Warfarin


Always carry with you the yellow anticoagulant treatment booklet which will be given to
you. This is in case of emergencies and a doctor needs to know that you are on Warfarin,
and at what dose.
If you have surgery or an invasive test, you may need to temporarily stop taking Warfarin.
Tell your dentist that you take Warfarin. Most dental work does not carry a risk of
uncontrollable bleeding. However, for dental extractions and surgery you may need to
temporarily stop taking Warfarin.
You should limit the amount of alcohol that you drink to a maximum of one or two units a
day, and never binge drink.
o One unit of alcohol is about equal to:
 half a pint of ordinary strength beer or lager (3-4% alcohol by volume), or
 a small pub measure (25 ml) of spirits (40% alcohol by volume), or
 a standard pub measure (50 ml) of fortified wine such as sherry or port
(20% alcohol by volume).
o There are one and a half units of alcohol in:
 a small glass (125 ml) of ordinary strength wine (12% alcohol by volume), or
 a standard pub measure (35 ml) of spirits (40% alcohol by volume).

Ideally, try to avoid activities that may cause abrasion, bruising, or cuts (for example,
contact sports). Even gardening, sewing, etc, can put you at risk of cuts. Do be careful and
wear protection such as proper gardening gloves when gardening.
Take extra care when brushing teeth or shaving to avoid cuts and bleeding gums.
Consider using a soft toothbrush and an electric razor.
Try to avoid insect bites. Use a repellent when you are in contact with insects.

Derbyshire JAPC Guideline Oral Anticoagulation 11


Revised: January 2009
Review Date January 2011
Further help and advice
British Heart Foundation
14 Fitzhardinge Street, London, W1H 6DH
Tel (Heart Help Line): 08450 70 80 70 Web: http://www.bhf.org.uk/

Anticoagulation Europe
PO Box 405, Bromley, Kent, BR2 9WP
Tel: 020 8289 6875
Web: http://www.anticoagulationeurope.org/
A charity providing information and advice to people on oral anticoagulation treatment.
References
Atrial fibrillation, Clinical Knowledge Summaries (2007)
The management of atrial fibrillation, NICE Clinical Guideline (Jun 2006)
Mant J, Hobbs FD, Fletcher K, et al; Warfarin versus aspirin for stroke prevention in an
elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation
Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007 Aug
11;370(9586):493-503. [abstract]
Lip GY, Hart RG, Conway DS; Antithrombotic therapy for atrial fibrillation. BMJ. 2002 Nov
2;325(7371):1022-5.

Leaflets from Patient UK:

Atrial fibrillation and Warfarin: http://www.patient.co.uk/pdf/pilsL211.pdf

Atrial Fibrillation : http://www.patient.co.uk/pdf/pilsL10.pdf

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS and PiP have
used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional
for diagnosis and treatment of medical conditions. For details see our conditions.
EMIS and PiP 2008 Updated: 17 Mar 2008 DocID: 4386 Version: 38

Derbyshire JAPC Guideline Oral Anticoagulation 12


Revised: January 2009
Review Date January 2011
Appendix 3

Conditions which May Cause a Change in Warfarin Sensitivity

The following conditions may increase sensitivity to Warfarin and therefore warrant a
decrease in Warfarin dose:
Hepatic dysfunction and / or jaundice
Alcohol abuse particularly binge drinking
Congestive heart failure
Anorexia
Diarrhoea
Hyperthyroidism
Acute pyrexial episode
Changes in diet which reduce the intake of vitamin K *
Dietary components: Cranberry juice
Drugs (this list is not exhaustive):
Allopurinol
NSAIDs
Amiodarone Marked effect
Antibiotics Unpredictable / almost any antibiotic
Antifungals
Disulfiram
Tamoxifen
Statins
Thyroid hormones
Cimetidine
Antiplatelet agents Increased risk of bleeding

The following conditions may cause a decrease in sensitivity and therefore warrant an
increase in Warfarin dose:
Hypothyroidism
Changes in diet which increase the intake of vitamin K *
Dietary components: Dasheen
Herbal remedies: St Johns Wort, Gingko biloba
Drugs (this list is not exhaustive):
Anti-convulsants
Barbiturates
Rifampicin
Estrogens & progestogens
Sucralfate
Note: When these drugs are discontinued the dose must be reduced to avoid
dangerous over-anticoagulation.

*The following foods and supplements are rich in vitamin K:


Dark green vegetables: spinach, kale, spring greens, cabbage, brussels sprouts,
broccoli, asparagus, watercress, parsley, beef liver, rapeseed oil, green tea.

Derbyshire JAPC Guideline Oral Anticoagulation 13


Revised: January 2009
Review Date January 2011
Appendix 4
COMMON WARFARIN DRUG INTERACTIONS1,2
The drugs in this list are more usually associated with loss of INR control in patients already established on warfarin.
This list is not exhaustive - refer to the British National Formulary (BNF) for further information. If any of the drugs below
are to be started in these patients then the use of alternatives in the same therapeutic class may be considered. If this is
not possible then the patients INR should be monitored as detailed below. Those drugs highlighted in bold are
significant interactions and should be avoided or used with caution.

Drugs marked * are liver enzyme inhibitors and increase the INR. They act very quickly (can be within 24
hours) and if the drug is withdrawn the effect disappears quickly depending on the drug half-life. The INR
should if possible be monitored within 72 hours of starting the interacting drug and on withdrawal.
Drugs marked $ are liver enzyme inducers and decrease the INR. They act more slowly (up to a week) with
peak effect at 2-3 weeks and can persist for up to 4 weeks after stopping depending on drug half-life. The
INR will need checking after
1 week of concurrent therapy.
Drugs with neither have other mechanisms, which affect the INR.
N.B. If a patient on warfarin were started on ANY other new medication a repeat INR after 1 week would be a
sensible
Drugs that increase the INR and risk of bleed
Gastrointestinal cimetidine*, omeprazole* and possibly other PPIs
Cardiovascular amiodarone* (liver enzyme inhibition is slow and may persist long
after withdrawal requiring weekly monitoring over 4 weeks),
fibrates, ezetimibe, propafenone*, propranolol,
statins no clinically relevant interaction will normally be seen
however it is prudent to check INR in the weeks after initiation and
at any dose change
CNS fluvoxamine*, SNRIs, SSRIs*, tramadol
Anti-infectives (anti- azole antifungals* (esp. miconazole including oral gel and
infectives in general may vaginal), co-trimoxazol*, macrolides* (can be serious but unpredictable),
cause raised INRs) metronidazole*, quinolones* (can be serious but unpredictable),
tetracyclines, influenza vaccine
Endocrine anabolic steroids (and danazol), high dose corticosteroids,
glucagon (high dose 50mg+ over 2 days), flutamide,
levothyroxine
NSAIDs Ibuprofen at lowest effective dose (+/-PPI) is probably safest if NSAID is required

N.B. All NSAIDs can increase the risk of bleeds and should be avoided if possible
Antiplatelets increased
bleed risk Aspirin, clopidogrel and dipyridamole
Miscellaneous Alcohol (acute), allopurinol*, benzbromarone*, colchicine, disulfiram, fluorouracil, interferon
paracetamol (prolonged use at high dose), sulfinpyrazone, tamoxifen, topical salicylates,
zafirlucast*
Herbal preparations/Food Carnitine, chamomile, cranberry juice*, curbicin, dong quai, fenugreek, fish oils, garlic, gingo
supplements biloba, glucosamine, grapefruit juice*, lycium*, mango, quilinggao

Drugs that decrease the INR


$ $ $ $
Miscellaneous Alcohol (chronic), azathioprine, barbiturates , bosentan , carbamazepine , carbimazole,
$ $
griseofulvin , mercaptopurine, nevirapine , OCP/HRT, propylthiouracil, raloxifene,
$
rifampicin (most potent inducer), trazodone
$
Herbal preparations etc Avocado, co-enzyme Q10, green tea, natto, soya beans, St Johns wort (avoid)
Binding agents Colestyramine, sucralfate
Warfarin antagonist
Vitamin K

Drugs that increase or decrease the INR


Miscellaneous Ginseng, phenytoin, quinidine
1
British National Formularly 55 Edition March 2008
2
Stockleys Drug Interactions. Edition Eight. Pharmaceutical Press. November 2007

Based on original by Julian Holmes, Nottingham University Hospitals Trust, and further adapted by Derbyshire County
PCT
Updated by Aiste Baltramaityte and David Anderton Derby Hospitals NHS Foundation Trust.

Derbyshire JAPC Guideline Oral Anticoagulation 14


Revised: January 2009
Review Date January 2011
APPENDIX: 5

Guideline for the management of over anticoagulated patients


1. Introduction
The main adverse effect of all oral anticoagulants is hemorrhage. Checking the INR and
omitting doses when appropriate is essential; if the anticoagulant is stopped but not
reversed, the INR should be measured 23 days later to ensure that it is falling. Check in
24hrs if vitamin k given.
Remember Warfarin has a long half-life and the INR may still extend for 48 hours after a last dose.
Depending on the INR patients may need to omit Warfarin for a period of 1 3 days for the
anticoagulant effects to be adequately reversed if no Vitamin K is administered.
Try to identify the cause for loss of control, in all cases of over-anticoagulation. Enquire about drug
compliance, additional drug therapy, and dietary changes and consider co-morbidities.

The risk of bleeding associated with excess anticoagulation is a function of both the level of
the INR and the duration of time the patient is exposed to this excessive anticoagulation.

The following patient characteristics are indicative of a high risk for bleeding:
Age >70 Hypertension Diabetes Renal Failure
Previous MI Previous CVA Previous GI Bleed Liver disease

2. Guideline
The following recommendations (which take into account the recommendations of the British
Society for Haematology(1)) are based on the result of the INR and whether there is major or
minor bleeding; the recommendations apply to patients taking warfarin:
Major bleeding stop warfarin; give phytomenadione (vitamin K1) 510 mg by slow
intravenous injection; give dried prothrombin complex (factors II, VII, IX, and X BNF
section 2.11), 3050 units/kg or fresh frozen plasma 15 mL/kg (if dried prothrombin complex
not available). Seek specialist advice as required.
INR > 8.0, no bleeding stop warfarin, restart when INR < 5.0; if minor bleeding or there
are other risk factors for bleeding give phytomenadione 2.0 mg (using the intravenous
preparation orally a PDG is available in Derbyshire county); repeat dose of
phytomenadione if INR still too high after 24 hours.
If high risks and full reversal required quickly consider giving phytomenadione (vitamin K1)
500 micrograms by slow intravenous injection or 5 mg by mouth.
INR >6 major bleeding or minor bleed plus more then one risk factor give phytomenadione
2mg orally
INR 6.08.0, no bleeding or minor bleeding stop warfarin, restart when INR < 5.0
INR < 6.0 but more than 0.5 units above target valuereduce dose or stop warfarin, restart
when INR < 5.0
Unexpected bleeding at therapeutic levelsalways investigate possibility of underlying
cause e.g. unsuspected renal or gastro-intestinal tract pathology. Seek specialist advice.
IV Vitamin K administration leads to INR reversal within 4 6 hours, and is the fastest means
of INR reversal. Do not give IM injections. This can cause a muscle haematoma.
The oral route (Konakion paediatric 2mg per 0.2ml ampoule) being slower - Up to 24 hours.
This will readily reverse INRs within 16 to 24 hours to therapeutic doses.

Relevant references:
1. Guidelines on oral anticoagulation third edition
British Journal of Haematology 1998 101 374 - 387
2. Effective reversal of Warfarin induced excessive anticoagulation with Low Dose Vitamin K.
Thrombosis and Haemostasis 1992. 67. (1) 13 15.
3. Warfarin Reversal. J. Clin Pathol. 2004; 57 1132 1139

Derbyshire JAPC Guideline Oral Anticoagulation 15


Revised: January 2009
Review Date January 2011
APPENDIX: 6

Induction guidelines for patients newly initiated on Warfarin


The aim of is to provide standard information and induction for all patients that are newly
prescribed. The patient may not remember much information if you provide all the information at
the first session or when they are too ill to take it in. If necessary, check with the patient as to
whether it would be appropriate for a second person to be present during the counselling e.g. the
patients carer. Ensure every patient is given the new oral anticoagulation treatment (OAT) pack
developed by the NPSA and this is recorded in the notes.

1. Explain what anti-coagulant is for


Oral Anti-coagulants are used to thin the blood
Certain patients are at risk from clot formation inside blood vessels; Anti-coagulants reduce
this risk

2. Explain Dosing
Colour of different strength tablets
On discharge, pharmacy supply tablets of 1mg strength only
When to take them i.e. at 6.00 p.m.(or another regular time if more convenient))
Length of treatment (if known)

3. Explain importance of compliance


It is very important to take the prescribed dose
Taking to much or too little is potentially harmful
Too much: Blood may be over-thinned; bruising and bleeding may occur
Too little: Blood may not be thinned enough and so clots may form more readily

4. Explain the importance of regular blood tests as directed by your doctor


Blood test: Blood is taken to check that it has been thinned by the right amount.
The number / dose of tablets may change, depending on the result of this test.
Ascertain who will be monitoring therapy: GP or other clinic, e.g. day hospital.

5. Explain what to do if dose is missed or forgotten


It is very important to inform the Clinic/GP on the next visit of all doses missed.
If unsure if dose has been taken, do NOT take an extra dose.
If more than one dose has been missed ask advice of own Doctor or the anticoagulant
clinic.

6. Inform patient of potential side effects


Seek medical help if any bleeding or bruising problems are experienced e.g.
spontaneous bruising
bleeding from cuts which is slow to stop
bleeding that will not stop by itself
nose bleeds
bleeding gums
red / dark brown urine
red / black stools
in women - increased menstrual bleeding or unexplained vaginal bleeding

Derbyshire JAPC Guideline Oral Anticoagulation 16


Revised: January 2009
Review Date January 2011
7. Other medicines
Do not take aspirin unless a doctor who knows you are receiving anti-coagulant therapy
prescribes it, since it can make you more prone to bruising or bleeding.
Many cold, flu and pain medicines contain aspirin, so if in doubt, ASK your pharmacist or
doctor.
Paracetamol may be taken in normal doses while on anti-coagulants.
Inform Clinic/GP of any changes in medication as these may also affect the blood test
result.
Check with the patient to see if they have any other medication at home that is not on the
treatment card, especially analgesics, herbal remedies, cod liver oil or garlic pearls. Check
for any interactions and advise the patient appropriately. Patients should be advised to
avoid all herbal preparations (unknown effects on Warfarin), to not take garlic pearls (garlic
is a natural anticoagulant) and only take one cod liver capsule per day (higher doses may
increase vitamin K intake).

8. Dietary advice
Speak to your Doctor, nurse or pharmacist at the clinic about changes in diet.
Eat a balanced diet.
Do NOT drink more than moderate amounts of alcohol (1 pint of ordinary strength beer per
day or the equivalent in pub measures of wine / spirits), as this can have an effect on blood
clotting.

9. Oral anticoagulation treatment (OAT) pack (includes Yellow booklet)


Complete the first page of details in the anticoagulant treatment record book,
Give patient OAT pack and encourage them to read it thoroughly.
Reassure patient that most of the information you have given them is in the patient
information booklet.
Advise patient to carry booklet and the alert card with them at all times so that they can
show it to a Doctor or Dentist if obtaining treatment, or to a Pharmacist at the point of
dispensing and if buying medicines.

10. Check patient understanding and repeat the main messages for the patient to take
away with them
Number of tablets
When to take them - i.e. 6.00 p.m. (or another regular time if more convenient)
What to do if they miss a dose
Length of treatment
Signs of bruising/bleeding to look for and what to do in case
They should check before receiving any treatment that the Dr/dentist/pharmacist knows
about their Warfarin

11. Ensure that the patient has a contact telephone number for the clinic managing
their blood tests in their booklet (if appropriate)
Plus the contact number of the lead clinician where appropriate
Plus the number for the A&E department where appropriate

12. Assess current medication


Where appropriate, document any concurrently prescribed and purchased (OTC)
medication, which may interfere with anticoagulant therapy in the patients anticoagulant
booklet. Remember to explain that this advice is not intended to be fully
comprehensive. Should the patient request any further advice or information outside
your scope please refer them as appropriate.

13. Ask if there are any questions

Derbyshire JAPC Guideline Oral Anticoagulation 17


Revised: January 2009
Review Date January 2011
APPENDIX: 7

Summary of Guideline for management of patients requiring dental surgery


Full text can be found on :http://www.bcshguidelines.com/pdf/WarfarinandOralSurgery26407.pdf
The British Committee for Standards in Haematology (BCSH) has published a document to
provide healthcare professionals, including primary care dental practitioners, with clear guidance
on the management of patients on oral anticoagulants requiring dental surgery.
Summary of Key recommendations:
The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the
therapeutic range 2-4 (i.e. <4) is very small and the risk of thrombosis may be increased in
patients in whom oral anticoagulants are temporarily discontinued. Oral anticoagulants should
not be discontinued in the majority of patients requiring out-patient dental surgery including
dental extraction.
Most cases of postoperative bleeding are easily treated with local measures such as packing with
a haemostatic dressing, suturing and pressure. -Stopping warfarin increases the risk of
thromboembolic events; the risk of thromboembolism after withdrawal of warfarin therapy
outweighs the risk of oral bleeding as bleeding complications, while inconvenient, do not carry the
same risks as thromboembolic complications. -Stopping warfarin is no guarantee that the risk of
postoperative bleeding requiring intervention will be eliminated as serious bleeding can occur in
non-anticoagulated patients (http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--
A/Surgical-management-of-the-primary-care-dental-patient-on-
warfarin/?query=tranexamic&rank=5)
For patients stably anticoagulated on Warfarin (INR 2-4) and who are prescribed a single dose
of antibiotics as prophylaxis against endocarditis, there is no necessity to alter their
anticoagulant regimen.
Antibacterial prophylaxis and chlorhexidine mouthwash are not recommended for the
prevention of endocarditis in patients undergoing dental procedures. Such prophylaxis may
expose patients to the adverse effects of antimicrobials when the evidence of benefit has not
been proven. (BNF 56 P287)
Patients at risk of endocarditis(1) should be advised to maintain the highest possible standards
of oral hygiene in order to reduce the need for dental extractions or other surgery; chances of
severe bacteraemia if dental surgery is needed and possibility of spontaneous bacteraemia.
1)
Patients at risk of endocarditis include those with valve replacement, acquired valvular heart
disease with stenosis or regurgitation, structural congenital heart disease (including surgically
corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully
repaired ventricular septal defect, fully repaired patent ductus arteriosus, and closure devices
considered to be endothelialised), hypertrophic cardiomyopathy, or a previous episode of
infective endocarditis.
For patients who are stably anticoagulated on Warfarin, a check INR is recommended 72
hours prior to dental surgery
Patients taking Warfarin should not be prescribed non-selective NSAIDs and COX-2
inhibitors as analgesia following dental surgery
What constitutes dental treatment?
Many procedures performed in the primary care setting are relatively non-invasive and would not,
therefore, require measurement of the INR. Such procedures would include prosthodontics
[construction of dentures], scaling/polishing and some conservation work [fillings, crowns,
bridges]. Potentially invasive procedures performed in primary care would include: Endodontics
[root canal treatment]; Local anaesthesia [infiltrations, inferior alveolar nerve block, mandibular
blocks]; Extractions [single and multiple]; Minor oral surgery Periodontal surgery; Biopsies;
Subgingival scaling.
Derbyshire JAPC Guideline Oral Anticoagulation 18
Revised: January 2009
Review Date January 2011
APPRENDIX: 8

Resources
Resources available from the NPSA Website: http://www.npsa.nhs.uk/
Or try http://www.npsa.nhs.uk/health/display?contentId=5754.
Patient safety alert 18: Actions that can make anticoagulant therapy safer
Anticoagulants are one of the classes of medicines most frequently identified as causing
preventable harms and admissions to hospitals. The NPSA has produced the following patient
safety alert and support materials to help manage the risks associated with anticoagulants and
reduce the risks of patients being harmed in the future.
All templates and exemplar documents provided as supporting materials for all patient safety
alerts are drafts intended for local adaptation. Organisations should ensure that they are adapted
locally and that they meet the requirements of specialist clinical areas and services and are
ratified prior to use.

2 Patient safety alert (pdf 294KB)


3 Patient briefing (pdf 97KB)
4 Patient briefing - Welsh (pdf 155KB)
5 Template service audit form (pdf 187KB)
6 E-learning modules
o Starting patients on anticoagulants (BMJ learning website - free registration
required)
o Maintaining patients on anticoagulants (BMJ learning website - free registration
required)
7 Work competences for anticoagulant therapy:
o initiating anticoagulant therapy (pdf 40KB)
o maintaining oral anticoagulant therapy (pdf 115KB)
o managing anticoagulants in patients requiring dental surgery (pdf 174KB)
o dispensing oral anticoagulants (pdf 91KB)
o preparing and administering heparin therapy (pdf 119KB)
o reviewing the safety and effectiveness of an anticoagulant service (pdf 109KB)
8 Summary of stakeholder consultation that was undertaken January-March 2006 (Word
431KB)
9 Anticoagulant therapy: information for community pharmacists (Pharmaceutical Journal
insert) (pdf 202KB)
10 Managing patients who are taking and undergoing dental treatment_Poster for dental
practices (pdf 109KB)

Standards and Guidelines


British Society of Haematology Standards for Anticoagulants:

o Safety indicators for anticoagulant services


o Oral anticoagulants 3rd edition -2005 update
o Oral anticoagulants 3rd edition 1998
o Guidelines on the use and monitoring of heparin

E- learning modules - Registration with BMJ Learning is required - registration is free.

Starting patients on anticoagulants: how to do it


http://www.bmjlearning.com/planrecord/servlet/ResourceSearchServlet?keyWord=All&resou
rceId=5004325&viewResource=
Maintaining patients on anticoagulants: how to do it
http://www.bmjlearning.com/planrecord/servlet/ResourceSearchServlet?keyWord=All&resou
rceId=5004429&viewResource
Derbyshire JAPC Guideline Oral Anticoagulation 19
Revised: January 2009
Review Date January 2011
*Information for Patients and Carers

Anticoagulant Alert Card (pdf 73KB)


Oral anticoagulant therapy(OAT): Important information for patients (booklet)
o English (pdf 442KB)
o Welsh (pdf 300KB)
o Bengali (pdf 329KB)
o Cantonese (pdf 443KB)
o Gujarati (pdf 315KB)
o Polish (pdf 304KB)

Also available in other languages


Anticoagulant treatment record form (pdf 47KB)

Anticoagulant treatment record booklet (pdf 147KB)


Oral anticoagulant therapy: Important information for dental patients (leaflet) (pdf 186KB)

The complete OAT pack or individual items such as the yellow record book can be obtained from
Derwent shared care services: Unit 7 Outrams Wharf, Alfreton Road, Little Eaton, DE21 5EL

Direct line 01332 622450


Orders only by fax ( 01332 622422) or e-mail lynn.judge@derwentsharedservices.nhs.uk
or in writing on letter head

Risk assessment reports


Risk assessment of anticoagulant therapy (pdf 269KB)
Appendix - Risk assessment grid (pdf 117KB)

NPSA report
Safety in doses: improving the use of medicines in the NHS (pdf 474KB)

Other Resources:
Available at: www.bcshguidelines.com
British Committee for Standards in Haematology. Guidelines for oral anticoagulants, Third Edition.
British Journal of Haematology. 1998; 101: 374-387.

Training a selection of courses available


Anticoagulation: managing patients, prescribing and problems. CPPE 2007. An open learning
resource. http://www.cppe.manchester.ac.uk
Atrial Fibrillation: Applying New Guidelines in Clinical Practice; for Doctors, nurses and
pharmacists. June 2007.http://www.medscape.com/viewprogram/7372?src=mp
Starting patients on anticoagulants: how to do it
http://www.bmjlearning.com/planrecord/servlet/ResourceSearchServlet?keyWord=All&resourceId
=5004325&viewResource
Maintaining patients on anticoagulants: how to do it
http://www.bmjlearning.com/planrecord/servlet/ResourceSearchServlet?keyWord=All&resourceId
=5004429&viewResource

Derbyshire JAPC Guideline Oral Anticoagulation 20


Revised: January 2009
Review Date January 2011
APPENDIX: 9

List of contacts for clinical support and advice


Chesterfield Royal Hospital Foundation Trust (CRHFT)
Dr Rod Collin, Consultant Haematologist (rod.collin@chesterfieldroyal.nhs.uk)
Direct dial telephone number 01246 512253 or via switch board 01246 277271.

If there are problems out of hours then the individual would be able to access advice either directly
from Dr Rod Collin, if he is on-call, or one of the other haematologists if they are on-call via the
hospital switchboard, which is what happens when GPs currently need help.

Derby Hospitals NHS Foundation TRUST


Dr Angela Mckernan, Consultant Haematologist (angela.mckernan@derbyhospitals.nhs.uk)
Tel 01332 254770

Derby Hospitals Anticoagulation Team:


Suzey Joseph 01332 789422
Gary Herbert 01332 789420
Hermine King 01332 789423

Other Hospitals:
Burton Hospital tel 01283 511511, anticoag ext 4040, fax 01283 593064.

Nottingham Hospitals QMC Campus..tel 0115 9249924, anticoag ext 68412, fax 0115 8754600,
tel direct line 0115 9194413.

Nottingham anticoag service Manager: Steve Davidson 01159249924 Bleep 808274

Sheffield Teaching Hospitals Royal Hallamshire Hospital


Dr Rhona Maclean, Consultant Haematologist (rhona.maclean@sth.nhs.uk) Tel 0114 2711900
Northern General Hospital anticoagulation clinic Tel. 0114 2714399

Out of Hours
Derbyshire Health United (DHU) direct line for health professionals - 01246 550818

Central Nottinghamshire Clinical Services based at Byron House,


Kingsmill Hospital 01623 622515 ext 3601

Derbyshire County PCT Leads:

Clinical lead Hassan Hajat 01246 514939 (Hassan.Hajat@derbyshirecountypct.nhs.uk)

Karen Martin - Head of Clinical Quality for Independent Contractors


(Karen.martin@derbyshirecountypct,nhs)

PCT director lead Dr Alan Meakin (Alan.Meakin@derbyshirecountypct.nhs.uk)

Derby City PCT contact:


Laraine Tuplin
Assistant Director Medicines Management and Accountable Officer for Controlled Drugs Derby
City PCT 01332 203102 Ext 6335 (laraine.tuplin@derbycitypct.nhs.uk)
(Please note the new level 4 anticoagulation management service LES is currently only commissioned by
Derbyshire county PCT)

Derbyshire JAPC Guideline Oral Anticoagulation 21


Revised: January 2009
Review Date January 2011