2.5 Other Hematology Consult:

Transcription

1 The Warfarin Order Sheet has been approved by the P & T committee to be implemented by pharmacists. These orders are not used to treat patients with serious hemorrhagic complications. WARFARIN TARGET INR 2-3 PATIENT NAME: DIAGNOSIS: WEIGHT: kg HEIGHT: cm ALLERGIES: INR Range Target INR Indications: Prophylaxis of venous thrombosis (VTE) Treatment of venous thrombosis (VTE) Pulmonary embolism (PE) Atrial flutter/fibrillation Recurrent systemic embolism Acute/subacute thrombo-embolic stroke Cerebral sinovenous thrombosis Other Hematology Consult: Notify LIP Patient is receiving other medications that can affect warfarin. Patient has liver disease, protein C deficiency or Fontan. Patient is an infant Other Concerns for bleeding: guaiac positive, drop in platelet count or HgB, headache or change in neuro exam Laboratory Patient starting therapy: Tests: Prior to first dose obtain: PT/INR Dosing: CBC Beta HCG for females greater than or equal to 12 years of age or post-menarche. INR every morning. CBC every 3 days. Patient is on maintenance therapy: INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week. INR weekly if patient is stabilized at goal INR: most recent INR Date RPh will refer to the dosing nomogram below to calculate and document warfarin dose daily Continue patient s therapeutic home dose of mg PO daily at Loading dose Initial loading dose: mg (0.2 mg/kg) warfarin (max dose 10 mg) PO daily at Liver disease or protein C deficiency: Initial loading dose: mg (0.1 mg/kg) warfarin (max dose 5 mg) PO daily at Other initial loading dose: mg warfarin (max dose 10 mg) PO daily at Orders to be written by patient s LIP according to the warfarin policy and guideline. Ongoing dosing and labs to be ordered by pharmacy according to nomogram. *INITIAL DOSING (days 2-4) for INR goal 2-3 MAINTENANCE DOSING (5 days or more) for INR goal 2-3 INR Dosing INR Dosing Repeat initial dose(consider bridge therapy) Increase total weekly dose by 20% Give 50% of initial dose Increase total weekly dose by 10% Give 50% of initial dose Continue current dose Give 25% of initial dose Decrease total weekly dose by 10% Greater than 3.5 Hold dose until INR less than 3.5, then restart at 20% less than previous dose. Notify LIP if greater than 3.5 for two days Greater than 3.5 Hold dose until INR less than 3.5, then restart at 20% less than previous dose. Notify LIP if greater than 3.5 for two days Signature: (MD/LIP) Date: Time: Print Name: Signature: (RN) Date: Time: Signature: (HUC) Date: Time: WARFARIN GUIDELINE TARGET INR 2-3 (Page 1 of 2)

2 TREATMENT OR PROPHYLAXIS FOR Venous thromboembolism (VTE) Pulmonary embolism CONTRAINDICATIONS (Consider Hematology Consult) Active bleeding or significant bleeding within the last 24 hours INR greater than 2 Received thrombolytic therapy within the last 12 hours Known or suspected hemorrhagic stroke Monotherapy with recently diagnosed HIT Risk for intracranial/intraocular hemorrhage NOTIFY LIP if the patient develops any of the following: Bleeding or positive stool guaiac INR greater than 3.5 for two days Platelet count less than 100,000/cumm or 2-gram drop in Hgb Unusual headache or change in neurological exam Interacting Medications Atrial flutter/fibrillation Other Hemorrhagic disorders Epidural anesthesia Active TB (use with caution) Pregnancy (teratogenic) Hypersensitivity to warfarin Hematuria DAILY CARE Consider discontinuing aspirin containing products and anti-inflammatory medications (NSAIDS). No intramuscular injections/ Avoid unnecessary venous or arterial punctures. Guaiac stools that appear black, tarry, or contain frank blood. No vitamin K supplements or foods rich in vitamin K (dietary to be alerted of patients on warfarin). BRIDGING GUIDELINE WARFARIN GUIDELINE TARGET INR 2-3 PEDIATRIC Medication Enoxaparin Warfarin Aspirin Heparin Clopidogrel Rivaroxaban When last dose should be given prior to procedure (Minimium) 24 hours 2 days (dental) 5 days (all other) Goal INR less than days 4-6 hours Goal Anti Xa less than days 24 hours LABS Prior to first dose draw (if not within last 24 hours) PTT, PT/INR, fibrinogen and CBC. Draw a Beta HCG for females older than 12 yr or post-menarche. Draw an INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week. Draw an INR every morning until stable for 2 days and then weekly. Draw a CBC every three days for two weeks then weekly. Increase frequency of monitoring with evidence of bleeding Dosage and Administration of Warfarin If initial labs are appropriate, order a 0.2 mg/kg dose of warfarin (max dose 10 mg) to be given at o Average dose to obtain INR 2-3 is 0.33mg/kg for infants and 0.09mg/kg for teens Consider hematology consult for possible dose adjustments if: o Patient is receiving other medications that interact with warfarin. o Patient has underlying liver dysfunction or Fontan procedures consider 0.1mg/kg (max dose 5 mg). o If unable to achieve therapeutic levels consider switching to low molecular weight heparin. Once INR is therapeutic, calculate the average daily dose by summing the total loading dose (up to 7 days) and dividing by the number of days needed to load CONVERSION TO ORAL ANTICOAGULANT THERAPY: Continue enoxaparin/heparin for at least five days in combination with warfarin therapy. Ensure INR is therapeutic for at least two days prior to stopping Enoxaparin/heparin. These are intended to be a guide to common clinical circumstances, and may not apply to certain patients and situations. The treating clinician must use judgment in application of guidelines to the care of individual patients. WARFARIN GUIDELINE TARGET INR 2-3 (Page 2 of 2)

3 The Warfarin Order Sheet has been approved by the P & T committee to be implemented by pharmacists. These orders are not used to treat patients with serious hemorrhagic complications. WARFARIN TARGET INR -3.5 PATIENT NAME: DIAGNOSIS: WEIGHT: kg HEIGHT: cm ALLERGIES: INR Range Target INR Indications: Hematology Consult: Notify LIP Mechanical prosthetic valves (high risk) Other Patient is receiving other medications that can affect warfarin. Patient has liver disease, protein C deficiency or Fontan. Patient is an infant Other Concerns for bleeding: guaiac positive, drop in platelet count or HgB, headache or change in neuro exam Laboratory Patient starting therapy: Tests: Prior to first dose obtain: PT/INR Dosing: CBC Beta HCG for females greater than or equal to 12 years of age or post-menarche. INR every morning. CBC every 3 days. Patient is on maintenance therapy: INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week. INR weekly if patient is stabilized at goal INR: most recent INR Date RPh will refer to the dosing nomogram below to calculate and document warfarin dose on Patient Order Form each day for administration at Continue patient s therapeutic home dose of mg PO daily at Loading dose Initial loading dose: mg (0.2 mg/kg) warfarin (max dose 10 mg) PO daily at Liver disease or protein C deficiency: Initial loading dose: mg (0.1 mg/kg) warfarin (max dose 5 mg) PO daily at Other initial loading dose: mg warfarin (max dose 10 mg) PO daily at Warfarin anticoagulation therapy to be managed and orders written by patient s physician/lip according to the Anticoagulation Policy and warfarin guideline. Ongoing dosing and labs to be ordered by pharmacy according to nomogram. INITIAL DOSING (days 2-4) for goal INR -3.5 MAINTENANCE DOSING (5 days or more ) for goal INR -3.5 INR Dosing INR Dosing Repeat initial dose and (consider bridge therapy) Consider bridging with LMWH or UFH Give 50% of initial dose Increase daily dose by 20% -3.5 Give 25% of initial dose Increase daily dose by 10% Give 10% of initial dose -3.5 Continue current dose Greater than 4.6 Hold dose until INR less than 4, then restart at 20% less than previous dose Decrease daily dose by 10% One dose at 50% less/decrease daily dose by 20% Contact LIP for INR greater than 4 for longer than two days Hold 1 dose. Restart at 20% less than previous daily dose Greater than 5 Hold dose until INR < 3.5, and contact Hematology service Signature: (MD/LIP) Date: Time: Print Name: Signature: (RN) Date: Time: Signature: (HUC) Date: Time: WARFARIN GUIDELINE TARGET INR -3.5 (Page 1 of 2)

4 WARFARIN GUIDELINE TARGET INR -3.5 PEDIATRIC TREATMENT OR PROPHYLAXIS FOR Mechanical prosthetic valves (high risk) Other CONTRAINDICATIONS (Consider Hematology Consult) Active bleeding or significant bleeding within the last 24 hours INR greater than 2 Received thrombolytic therapy within the last 12 hours Known or suspected hemorrhagic stroke Monotherapy with recently diagnosed HIT Hematuria NOTIFY LIP if the patient develops any of the following: Bleeding or positive stool guaiac INR greater than 4 for two days Platelet count less than 100,000/cumm or 2-gram drop in Hgb Unusual headache or change in neurological exam Interacting Medications Hemorrhagic disorders Epidural anesthesia Active TB (use with caution) Pregnancy (teratogenic) Hypersensitivity to warfarin Risk for intracranial/intraocular hemorrhage DAILY CARE Consider discontinuing aspirin containing products and anti-inflammatory medications (NSAIDS). No intramuscular injections. Avoid unnecessary venous or arterial punctures. Guaiac stools that appear black, tarry, or contain frank blood. No vitamin K supplements or foods rich in vitamin K (dietary to be alerted of patients on warfarin). BRIDGING GUIDELINE Medication Enoxaparin Warfarin Aspirin Heparin Clopidogrel Rivaroxaban When last dose should be given prior to procedure (Minimium) 24 hours 2 days (dental) 5 days (all other) Goal INR less than days 4-6 hours Goal Anti Xa less than days 24 hours LABS Prior to first dose draw (if not within last 24 hours) PTT, PT/INR, fibrinogen and CBC. Draw a Beta HCG for females older than 12 yr or post-menarche. Draw an INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week. Draw an INR every morning until stable for 2 days and then weekly. Draw a CBC every three days for two weeks then weekly. Increase frequency of monitoring with evidence of bleeding Dosage and Administration of Warfarin If initial labs are appropriate, order a 0.2 mg/kg dose of warfarin (max dose 10 mg) to be given at Consider hematology consult for possible dose adjustments if: o Patient is receiving other medications that interact with warfarin. o Patient has underlying liver dysfunction consider 0.1mg/kg (max dose 5 mg). o If unable to achieve therapeutic levels consider switching to low molecular weight heparin. Once INR is therapeutic, calculate the average daily dose by summing the total loading dose (up to 7 days) and dividing by the number of days needed to load CONVERSION TO ORAL ANTICOAGULANT THERAPY: Continue enoxaparin/heparin for at least five days in combination with warfarin therapy. Ensure INR is therapeutic for at least two days prior to stopping Enoxaparin/heparin. These are intended to be a guide to common clinical circumstances, and may not apply to certain patients and situations. The treating clinician must use judgment in application of guidelines to the care of individual patients. WARFARIN GUIDELINE TARGET INR -3.5 (Page 2 of 2)

5 The Warfarin Order Sheet has been approved by the P & T committee to be implemented by pharmacists. These orders are not used to treat patients with serious hemorrhagic complications. WARFARIN TARGET INR (Ventricular Assist Device Only) PATIENT NAME: DIAGNOSIS: WEIGHT: kg HEIGHT: cm ALLERGIES: INR Range Target INR Indications: Ventricular Assist Device Hematology Consult: Notify LIP Patient is receiving other medications that can affect warfarin. Patient has liver disease, protein C deficiency or Fontan. Patient is an infant Other Concerns for bleeding: guaiac positive, drop in platelet count or HgB, headache or change in neuro exam Laboratory Patient starting therapy: Tests: Prior to first dose obtain: PT/INR Dosing: CBC Beta HCG for females greater than or equal to 12 years of age or post-menarche. INR every morning. CBC every 3 days. Patient is on maintenance therapy: INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week. INR weekly if patient is stabilized at goal INR: most recent INR Date RPh will refer to the dosing nomogram below to calculate and document warfarin dose on Patient Order Form each day for administration at Continue patient s therapeutic home dose of mg PO daily at Loading dose Initial loading dose: mg (0.2 mg/kg) warfarin (max dose 10 mg) PO daily at Liver disease or protein C deficiency: Initial loading dose: mg (0.1 mg/kg) warfarin (max dose 5 mg) PO daily at Other initial loading dose: mg warfarin (max dose 10 mg) PO daily at Warfarin anticoagulation therapy to be managed and orders written by patient s physician/lip according to the Anticoagulation Policy and warfarin guideline. Ongoing dosing and labs to be ordered by pharmacy according to nomogram. INITIAL DOSING (days 2-4) for goal INR MAINTENANCE DOSING (5 days or more ) for goal INR INR Dosing INR Dosing Repeat initial dose and (consider bridge therapy) Consider bridging with LMWH or UFH Give 50% of initial dose Increase daily dose by 20% Give 25% of initial dose Increase daily dose by 10% Give 10% of initial dose Continue current dose Greater than 4.6 Hold dose until INR less than 4, then restart at 20% less than previous dose Decrease daily dose by 10% One dose at 50% less/decrease daily dose by 20% Contact LIP for INR greater than 4 for longer than two days Hold 1 dose. Restart at 20% less than previous daily dose Greater than 5 Hold dose until INR < 3.5, and contact Hematology service Signature: (MD/LIP) Date: Time: Print Name: Signature: (RN) Date: Time: Signature: (HUC) Date: Time: WARFARIN GUIDELINE TARGET INR (Page 1 of 2) PHAXXX (12/2017)

6 TREATMENT OR PROPHYLAXIS FOR Ventricular Assist Device CONTRAINDICATIONS (Consider Hematology Consult) Active bleeding or significant bleeding within the last 24 hours INR greater than 2 Received thrombolytic therapy within the last 12 hours Known or suspected hemorrhagic stroke Monotherapy with recently diagnosed HIT Hematuria NOTIFY LIP if the patient develops any of the following: Bleeding or positive stool guaiac INR greater than 4 for two days Platelet count less than 100,000/cumm or 2-gram drop in Hgb Unusual headache or change in neurological exam Interacting Medications Hemorrhagic disorders Epidural anesthesia Active TB (use with caution) Pregnancy (teratogenic) Hypersensitivity to warfarin Risk for intracranial/intraocular hemorrhage DAILY CARE Consider discontinuing aspirin containing products and anti-inflammatory medications (NSAIDS). No intramuscular injections. Avoid unnecessary venous or arterial punctures. Guaiac stools that appear black, tarry, or contain frank blood. No vitamin K supplements or foods rich in vitamin K (dietary to be alerted of patients on warfarin). BRIDGING GUIDELINE WARFARIN GUIDELINE TARGET INR PEDIATRIC Medication Enoxaparin Warfarin Aspirin Heparin Clopidogrel Rivaroxaban When last dose should be given prior to procedure (Minimium) 24 hours 2 days (dental) 5 days (all other) Goal INR less than days 4-6 hours Goal Anti Xa less than days 24 hours LABS Prior to first dose draw (if not within last 24 hours) PTT, PT/INR, fibrinogen and CBC. Draw a Beta HCG for females older than 12 yr or post-menarche. Draw an INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week. Draw an INR every morning until stable for 2 days and then weekly. Draw a CBC every three days for two weeks then weekly. Increase frequency of monitoring with evidence of bleeding Dosage and Administration of Warfarin If initial labs are appropriate, order a 0.2 mg/kg dose of warfarin (max dose 10 mg) to be given at Consider hematology consult for possible dose adjustments if: o Patient is receiving other medications that interact with warfarin. o Patient has underlying liver dysfunction consider 0.1mg/kg (max dose 5 mg). o If unable to achieve therapeutic levels consider switching to low molecular weight heparin. Once INR is therapeutic, calculate the average daily dose by summing the total loading dose (up to 7 days) and dividing by the number of days needed to load CONVERSION TO ORAL ANTICOAGULANT THERAPY: Continue enoxaparin/heparin for at least five days in combination with warfarin therapy. Ensure INR is therapeutic for at least two days prior to stopping Enoxaparin/heparin. These are intended to be a guide to common clinical circumstances, and may not apply to certain patients and situations. The treating clinician must use judgment in application of guidelines to the care of individual patients. WARFARIN GUIDELINE TARGET INR (Page 2 of 2) PHAXXX (12/2017)

7 Pediatric Supratherapeutic INR Guidelines Bleeding Evaluation Inquire if any signs and symptoms of bleeding are present. o If symptoms of serious bleeding are present, hold warfarin and refer for immediate emergency evaluation. Management in The Bleeding Patient (1) Any INR Action Comment Serious or Life- Threatening Bleeding Hold warfarin Give vitamin K 5 mg IV by slow IV infusion o May be repeated Administer 3-factor prothrombin complex concentrate (PCC) units/kg + Fresh Frozen Plasma (FFP) 10-15mL/kg. Monitor INR every 12 hours. PCC/FFP may be repeated after 6 hours for persistent INR elevation if necessary If PCC unavailable, FFP 10-15mL/kg is an alternative Recombinant Factor VIIa can be considered in highly urgent situations. If no signs or symptoms of serious bleeding are present, the following guideline may be used: INR Management in the non-bleeding patient (2) INR Action Comment Between 4.5 and 10 Greater than 10 Omit one or two doses of warfarin Monitor INR more frequently Resume warfarin at adjusted dose when INR returns to therapeutic range Hold warfarin Give vitamin K mg PO o May be repeated Monitor INR more frequently (e.g. 1-3 days) (give additional vitamin K if necessary) Resume warfarin at an adjusted dose when INR returns to therapeutic range Vitamin K decreases INR faster, but reduced bleeding remains unproven. The decision regarding whether to resume anticoagulation (and if so the timing) must be individualized based upon the patient s clinical circumstances. 1. Streiff MB. The National Comprehensive Cancer Center Network (NCCN) guidelines on the management of venous thromboembolism in cancer patients. Thromb Res 2010 Apr;125 Suppl 2:S Holbrook A, Schulman S, Witt DM, et al. Evidence-Based Management of Anticoagulant Therapy. Chest 2012 February 1, 2012;141(2 suppl):e152s-e84s. Developed by Anticoagulation Task Force Approved by P&T on Oct 17, 2012 Last updated Oct 22, 2012