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Prescription Chart For Anticoagulant Prescribing
Please complete this chart and update as necessary. Patient Details (PAS Sticker)
This chart should always remain on the ward. Discharge Instructions
• On the day of discharge send this chart to the
Weight (kg)
anticoagulation appointment and a yellow warfarin book, which will be issued by the clinic.
• Clinic personnel will contact the ward when the
Discharge Information Previous medical history and reason for admission Concurrent Medication
Please list all medicines but ensure the following
Antiplatelets (to continue once anticoagulated?)
Interacting medicines (e.g. amiodarone/steroids)
Potential problems e.g. History of alcohol/drugabuse/non-compliance
Indication for Anticoagulation with warfarin ( ✓ ONE option only as appropriate) Arrhythmia
Atrial fibrillation/Atrial flutter – INR range 2.0 – 3.0 (target 2.5) for 6 weeks (prior to cardioversion) then review
Atrial fibrillation (due to non rheumatic heart disease/rheumatic heart disease/congenital heart disease/thyrotoxicosis)/Atrial flutter – INR range 2.0 - 3.0 (target 2.5) indefinitely
Venous Thromboembolism (VTE)
Single DVT (Distal) – INR range 2.0 - 3.0 (target 2.5) for 12 weeks
Single DVT (Proximal) – INR range 2.0 – 3.0 (target 2.5) for 24 weeks
PE (first episode) – INR range 2.0 – 3.0 (target 2.5) for 24 weeks
Recurrent VTE (thromboembolism when no longer taking warfarin) - INR range 2.0 - 3.0 (target 2.5) indefinitely
Recurrent VTE (thromboembolism whilst receiving anticoagulation) - INR range 3.0 - 4.0 (target 3.5) indefinitely
Heart Valve Disease ❑
Mechanical prosthetic heart valve – INR range 3.0 – 4.0 (target 3.5) indefinitely(unless otherwise specified below)
Other indication - please specify
INR range and target:Duration of therapy:
All above fields must be completed before submission to the Anticoagulation Clinic
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Treatment of DVT/PE without haemodynamic compromise with enoxaparin (LMWH)
The enoxaparin dose banding below is based on 1.5mg per kg body weight to be given subcutaneously into the stomach ONCE daily for a minimum of 5 days. a) Do not stop enoxaparin until the INR has been > 2.0 for at least two days b) Enoxaparin syringes are graduated. However THE ENTIRE CONTENTS of the syringe must be administered. DO NOT EXPEL AIR BUBBLE FROM SYRINGE BEFORE GIVING DOSE. c) Warfarin should be started on day 1 of diagnosis of a DVT or PE.
For patients with a serum creatinine >150 micromol/l (CrCl < 30ml/min) please consult the Haematology team. Renal failure is a relative contraindication & unfractionated heparin therapy is usually preferred. RECORD OF ENOXAPARIN FOR TREATMENT OF DVT or PE Subcutaneous enoxaparin
according to weight AND Start Date Valid Period Weight (kg) Signature Sign above for each dose administered
* 140mg syringes are not available therefore use the contents of ONE 100mg syringe & ONE 40mg syringe. **160mg syringes are not available therefore use the contents of ONE 100mg syringe & ONE 60mg syringe. ***180mg syringes are not available therefore use the contents of ONE 100mg syringe & ONE 80mg syringe. Treatment of UNSTABLE ANGINA with enoxaparin (LMWH)
a) Use enoxaparin 1mg per kg of body weight by subcutaneous injection in the stomach TWICE daily. b) Enoxaparin syringes are graduated - the EXACT partial volume of a syringe must be administered. DO NOT EXPEL AIR BUBBLE FROM SYRINGE BEFORE GIVING DOSE. c) Expel excess liquid by holding needle downwards and measure dose from bottom of air bubble. For patients with a serum creatinine >150 micromol/l (CrCl < 30ml/min) please consult the Haematology team. Renal failure is a relative contraindication & unfractionated heparin therapy is usually preferred. RECORD OF ENOXAPARIN FOR TREATMENT OF UNSTABLE ANGINA Subcutaneous enoxaparin
weight AND complete dose box Injection Start Date Valid Period Volume(ml) Signature Sign above for each dose administered
For patients >95kg refer to enoxaparin
Enoxaparin monitoring – Platelet count should be checked 5 to 7 days after starting enoxaparin to exclude HIT. Routine anti-factor Xa monitoring is not required except in renal impairment, extremes of body weight and patients at high risk of bleeding. Please contact the Haematology consultant or renal team for dosing information for these patients.
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Dosing protocol for anticoagulation with warfarin NB. Lower loading doses may be required in patients with low body weight, poor nutritional status, liver disease, heart failure, in the elderly and in patients on concurrent interacting drug therapy. Warfarin dose (mg) Anticoagulation protocol for patients > 65yrs with atrial fibrillation Days 1-4: Warfarin 5mg daily at 6pm then adjust according to INR on day 5. Days 5-7: Dose according to INR as described in the King's College Hospital Formulary. Anticoagulation with warfarin – give warfarin at 6pm each day NB. Monitor the INR daily on days 1 - 4 and adjust doses according to protocol above Dose(mg) Prescriber Additional information Pharmacy
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Overanticoagulation with warfarin INR Recommendation Major Bleeding Treatment of PE with haemodynamic compromise, and other indications for unfractionated heparin a) Consider thrombolysis for PE with haemodynamic compromise. b) Give a loading dose of 5,000units of heparin. c) Immediately following loading dose, start heparin infusion: 30,000 units made up to 48mls with sodium
chloride 0.9%, infuse intravenously at a rate of 2mls per hour (over 24 hours).
d) Patients who have had recent surgery (within the previous 10 days), active peptic ulceration, recent
haemorrhagic stroke, thrombocytopenia, liver insufficiency or who weigh less than 55kg should be started on an infusion of 25,000 units over 24 hours.
e) Patients with a PE must have a therapeutic APTR (1.75 - 2.8) before warfarin therapy is initiated. f) Measure APTR 6 hours after starting the infusion on day 1 of therapy, and 6 hours after any dose changes. g) Heparin induced thrombocytopenia (HIT) usually occurs after 5 to 10 days of therapy. Monitor platelet
counts three times a week if therapy is continued for more than 5 days. Infusion rate (ml/hr) Doctor sign Nurse sign 5,000units Bolus (IV) Dose adjustment for IV heparin infusion of 30,000 units over 24 hours 1.3 - 1.74 1.75 - 2.8 2.81 - 3.2 Administer Change Dose Therapeutic 0.4 ml/hr 0.2 ml/hr 0.2 ml/hr 0.4 ml/hr Stop Infusion Repeat APTR Repeat APTR after Dose adjustment for IV heparin infusion of 25,000 units over 24 hours 1.3 - 1.74 1.75 - 2.8 2.81 - 3.2 Administer Change Dose Therapeutic 0.3 ml/hr 0.2 ml/hr 0.2 ml/hr 0.3 ml/hr Stop Infusion Repeat APTR Repeat APTR after
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