Health Care Team Contact Information Please bring this booklet with you to each visit, since it has been designed to allow you and your TEAM to follow your progress. Name Doctor/Nurse Phone Number / Address Pharmacy Laboratory Other Please read this first Take all medications as prescribed by your Health Care Team (TEAM), and keep all medicines out of the reach of children. Go to the laboratory for blood work as prescribed by your TEAM. Record the results of these tests on page 22 of this guide. Call a member of your TEAM if you have any concerns or questions. Additional Instructions: 2
What are blood clots? Blood flows through the body to deliver oxygen and nutrients to the tissues, and to remove waste products from the tissues. The flow of blood is controlled by the heart, and the functioning of the blood is controlled by substances in the blood itself. Blood clots can form as a defense by the body when tissues are damaged or when changes take place with blood flow or its makeup. Risk factors for blood clots include: a trauma or injury surgery (such as hip or knee replacement) prolonged bed rest or immobilization family history of blood disorders heart or lung disease obesity some drugs (such as hormone therapy, or birth control pill) cancer and cancer medications pregnancy advanced age Having more than one of these risk factors further increases your risk for blood clots. Also see section starting on page 16. 3
What are blood clots? Tissue damage causes blood cells to move to the site and make repairs. Excessive clotting can slow or block blood flow to the heart or tissues. Part of the clot can break off and travel to the lungs. A blood clot may form in an artery or vein and cause a disruption in blood flow. If a clot forms in an artery, it can prevent the flow of fresh blood to that part of the body supplied by the blood vessel. If a clot forms in a vein, it can inhibit blood flow back to the heart. Usually clots start in the veins of the lower legs and are called a deep vein thrombosis. Pain, redness, tenderness and swelling may occur around the site of the clot. More severe deep vein thrombosis can lead to varicose veins, circulatory problems in the legs (post thrombotic syndrome) and, occasionally, leg ulcers (see inside back cover illustration). Sometimes clots can dislodge and travel to the lungs. This is called a pulmonary embolism. If this occurs, it can cause symptoms such as lightheadedness, sharp chest pain and shortness of breath. If the clot is large enough, the consequences can be very severe, including death. Certain tests will be performed to determine the likelihood of your having a blood clot. These can involve blood tests, sound waves or X-rays. 4
How does this medication help? The medication you are now, or will be taking, helps prevent the formation of blood clots, or prevents existing blood clots from growing larger. This medication is sometimes referred to as a blood thinner or an anticoagulant. The medication does not actually thin the blood and will not cause you to feel cold. It works by changing the body s blood clotting system to reduce the amount of clotting taking place, thus allowing the blood to flow more freely. The main risk from this type of medicine is a possible increase in bleeding complications. However, the products are generally very effective and safe when used properly. What drugs am I likely to be receiving? Your drug therapy will be modified by your TEAM to specifically treat your condition. However, it is likely that you will be taking one or both of the following two medications: Warfarin * (Coumadin, Apo-warfarin, Taro-warfarin ) This medication is a pill and comes in a variety of colours which indicate various strengths. 1 mg 2 mg 2 1 /2 mg 3 mg 4 mg 5 mg 6 mg 10 mg Each person can respond differently to this medication, so the dosage may need to be changed on occasion to suit your specific needs. In order to determine the exact dose required for you, your TEAM will take regular blood samples (blood work). If you are on this medication for a long period of time, some of the blood tests may be performed at a laboratory away from the hospital. If you have just undergone surgery, you may only be required to use this medication for a few weeks. If you are being treated for an existing blood clot, it is likely that you will use this medication for three to six months, and in some cases, even longer. 5
There is some concern when using warfarin during pregnancy. Also, warfarin is among the top medications for drug interactions (see page 20). However it is relatively safe and effective when used properly. Make sure you inform your pharmacist and TEAM of all other medications and herbal remedies you are taking, and do not radically change your diet or drink alcohol to excess while receiving warfarin. You must record the dose of warfarin taken each day along with the results of your blood tests (INR), so your TEAM can adjust your dosage accurately. This information should be recorded on page 22 of this guide. Low Molecular Weight Heparin (innohep, tinzaparin) This medication comes as a liquid in a vial or syringe, and is given as an injection just under the skin once a day. Your TEAM will determine the amount of medication you require, and discuss how you can give yourself the injections. The dosage is usually determined by your weight and medical condition. Refer to the section that begins on page 10 for detailed self injection information and the safe disposal of used needles. Low molecular weight heparin should be stored at normal room temperature and be protected from light and freezing. Go to the following website for more information: http://www.leo-pharma.com/canada Both warfarin and low molecular weight heparin work together to provide fast acting and long lasting benefits and there may be some instances when you are receiving both medications on the same day. It is important that you take both medications as prescribed. 6
What precautions should I take? If you take your medication as instructed by your TEAM, it is unlikely that you will experience problems. However, you can help avoid potential problems by following these recommendations: Take your medication and go for blood tests exactly as instructed by your TEAM. If you miss a dose, do not double your next dose continue with your usual dosing schedule and inform your team Advise your TEAM of all other medications that you may be taking, and notify them if any dosing changes occur. Do not take any new prescription medications or over-thecounter (non-prescription) medicines (including aspirin and herbal or naturopathic remedies) without checking first with your TEAM. Try to take your medication at the same time each day, as suggested by your TEAM. Inform your TEAM of any upcoming medical or dental appointments, especially those that may involve surgical procedures. If you see any other health care providers (doctors, dentists, pharmacists), tell them that you are using an anticoagulant. Avoid activities, such as contact sports, that could cause you to bruise or cut yourself, and use caution in activities that can not be avoided, ie., brushing teeth, shaving. Cut out the Medical Alert Card at the front of this booklet and carry it with you in case of an emergency. 7
Limit alcohol consumption (no more than one or two drinks per day). Do not alter your normal diet substantially while on warfarin. Notify your TEAM of any anticipated activities that could temporarily disrupt your therapy (vacations, extended travel). Advise your TEAM if you are pregnant or plan to become pregnant, since this can effect the type of medicine you receive. Keep all medicine in its original container, and safely out of the reach of children. Exercise caution while using needles and dispose of them safely (see page 13). What are the potential problems or side effects associated with taking this medication? Once again, if you take your medicine as recommended by your TEAM, it is unlikely that you will have any problems. However, if you notice or sustain any of the following, please contact your TEAM as soon as possible: Excessive bruising around the injection site Excessive bruising, especially black or brown spots on the skin if you have not sustained an injury. An abnormal amount of bleeding after a cut, nose bleeds or bleeding gums. Report if heavy bleeding (twice the normal amount) occurs during menstrual cycles. Vomiting and/or coughing up blood or material that resembles coffee grounds. Changes in the colour of your urine or bowel movements to red or dark brown/black. 8
Major trauma especially to the head, eyes or joints. Any major changes to your health, such as increased nausea, dizziness, headaches, or skin rashes. Excessive or unusual swelling of extremities or eyelids. Any signs that you may have a (new) deep vein thrombosis or pulmonary embolism: leg pain / warmth / redness; chest pain / lightheadedness / difficulty breathing. Warfarin dosage and INR record In the space provided on page 22, please record your daily dose of warfarin and the results of your blood tests. Your blood tests, which are performed in the hospital or laboratory, will be related to you using the term INR value or level. In most cases your INR (International Normalized Ratio) value should be between 2.0 and 3.0. If it is not, your TEAM will likely adjust your dose of warfarin. It is important that you take your medication exactly as prescribed by your TEAM. If you miss a dose for any reason, just continue with your regular schedule. Do not take additional medication if you miss a dose unless advised to do so by your TEAM. Always inform your TEAM of any missed doses, or extra doses you may have taken by mistake. 1 mg 2 mg 2 1 /2 mg 3 mg 4 mg 5 mg 6 mg 10 mg 9
Low Molecular Weight Heparin Injection Information How do I perform injections? A member of your TEAM will show you how to give yourself an injection. It is easier than you may think. If you are unable to self-administer the injection, discuss this with your TEAM as they may be able to make special arrangements for you. You may be using prefilled syringes, or you may be preparing syringes from a multi-dose vial Preparing the Injection from a Multi-dose Vial (go to step 7 if using a prefilled syringe) 1. With clean hands, flip off the plastic top from the vial. Wipe the rubber top with an alcohol swab. 2. Remove the syringe needle cap and pull air into the syringe by pulling back on the plunger to the mark of 0.9 F 3. Push the needle through the rubber top of the vial, and inject the air from the syringe into the vial. The vial can be punctured several times until all the medication has been used. 10
Preparing the Injection 4. Keep the syringe inserted into the vial, turn them both upside down and pull back on the plunger to the same mark as in step #2. If you see air bubbles in the syringe, you should remove a little extra amount of medicine from the vial. 5. Air bubbles can be removed by gently tapping the syringe. Ensure that you have the right dose of medicine in the syringe (same mark as in step #2). 6. Pull the syringe out of the vial and place the prepared syringe on a clean surface. Preparing the Injection site 7. Select a site for an injection. Rotate sites between injections. Avoid injection around the navel or bony areas. Avoid injection around any scars, bruised, reddish, or hardened areas. If required, the thigh or back of the arm can also be used as injection sites (discuss with your Health Care Team). 11
8. With clean hands, wipe your injection site with an alcohol swab. Allow the area to dry. Giving the Injection 9. Get an innohep safety syringe. (If you have already prepared your syringe from a vial, go to step 12) Needle cap Needle Syringe barrel Plunger rod 10. Grip the syringe barrel with your writing hand. Remove the needle cap by pulling it straight off the needle with the other hand. 11. If dose adjustment is not required, simply proceed to step 12; there is no need to remove the air bubble. If a dose adjustment is required, push in the plunger rod to the appropriate spot. 12. Hold the syringe barrel like a pencil in your writing hand. With your other hand, gently gather a fold of skin. Gently but firmly push the needle into this fold of skin at a 90 o angle, or a 45 o angle if you are thin. 12
13. Once the full length of the needle is under the skin, push in the plunger and inject ALL the medication. (Some health care providers may suggest that you release the fold of skin as you inject). 14. Remove the syringe from your skin at the same angle it entered, keeping your finger on the end of the plunger rod. 15. If using a prefilled safety syringe, face the needle away from you and others. Now give a firm push on the plunger rod an inner syringe barrel will automatically move forward to cover the needle. You should hear a click to confirm this is locked in place. Do NOT test locking by pushing your finger against needle tip end. 16. Dispose of used syringes in a safe manner. For home use: Keep medications out of the reach of children. 17. Hold a cotton swab on the injection site for a few minutes. Do not rub or massage the area or wear tight clothing over the injection site as it may increase bruising. Write down this injection site location to guide future injections. 13
Rotate Injection Sites Date Injection Site Date Injection Site Date Injection Site 14
Other Sites The stomach/belly is the preferred location for injections since it has few nerves and blood vessels close to the surface. However, in some cases it may be necessary to choose sites other than the stomach for injection: long term use (may also require additional blood work) following abdominal surgery or when scars are present when bruising has occurred in the abdomen due to previous injections in pregnancy, when the abdomen skin becomes taut and it is difficult to pinch an inch. In such cases, alternative sites such as the middle of the thigh may be chosen. Inject at least 10cm away from the knee or groin. The technique for injection remains the same; ensuring that you inject into the fat under the skin and not into the muscle. The back of the arm or the buttocks are also options (least preferred) as injection sites. However, to inject in these locations you will require help from another person. 15
Ongoing risks for Blood Clots The previous section of this booklet described the initial use of anticoagulant medicine ("blood thinners") to prevent or treat blood clots in your veins. This section describes diseases or conditions that may put you at an increased risk of developing another blood clot in the future. Although you may stop taking anticoagulation medicine soon, it is important to know that you may be at an increased risk for developing more blood clots in the future. Your health is your responsibility. Tell your doctor if you have had a blood clot in the past. Please review the following pages and contact your doctor if any of these situations apply to you. Your doctor may put you on another course of anticoagulation medicine or provide additional information or approaches to treatment. It is much simpler, safer, and cheaper to prevent the development of a blood clot than to treat it once it has formed. If you experience any of the following symptoms, be sure to see your doctor immediately to determine if you have another blood clot: leg pain redness, warmth or swelling in the calf muscle of the leg chest pain or difficulty breathing lightheadedness coughing up blood 16
Situations of Immobilization can Increase your Future Risk for Blood Clots Blood clots can form when the blood does not flow freely. It is important to avoid such situations in which you are inactive for long periods of time. Keep as active as possible and flex the calf muscles often to make sure the blood does not pool in the legs. Some specific high risk examples include: Surgery The immobilization time during the surgery and the recovery after the surgery can interfere with the normal movement of blood. If you are at a high risk for blood clots due to your surgery (a hip or knee replacement, a major abdominal surgery), your surgeon will likely place you on a course of anticoagulation medicine which reduces your risk significantly. Hospital Stay Over half of blood clots occur in non surgical patients: people who are in the hospital for illnesses not related to surgery such as heart failure, stroke, trauma and other diseases in which one is in a hospital bed for a long period of time. Tell your doctor if you have had a previous clot as this increases your risk of having another one. Plaster Casts Plaster casts on the legs following a fracture can interfere with walking and the normal return of blood to the heart since the calf muscle is held tight in the cast. Make an effort to flex the calf muscles often to make sure blood does not pool in the legs. Don't forget to tell your doctor if you have had a blood clot in the past. 17
Extended Airplane or Car Travel (Economy Class Syndrome or Travelers' Thrombosis) Sitting for long periods of time in an airplane or car can cause the blood to pool in the legs and lead to blood clots. This can be further complicated by cabin pressure and dehydration in the airplane and seats which push on the back of the knees. Although the link between long travel and subsequent blood clots is controversial it is suggested that you should: Take breaks often, get out of your seat and walk around to get the blood moving, and stretch the calf muscles Drink plenty of water or non-alcoholic beverages Avoid constrictive clothing around the waist, legs or feet If you are planning a long trip, speak to your doctor. If you are at a high risk for blood clots, your doctor may place you on a short course of anticoagulation medicine or prescribe specially fitted graduated compression stockings. Some Medical Conditions can Increase your Future Risk for Blood Clots There are some conditions that can place you at a higher risk of developing blood clots. Having Had a Previous Blood Clot (Venous Thromboembolism, Deep Vein Thrombosis, or Pulmonary Embolism) Be sure to mention to your doctor or health care team if you have had a previous blood clot(s) or have a family history of blood clotting problems. This can put you at an increased risk for developing another blood clot and can affect which medicines you need and for how long they should be taken. 18
Pregnancy or Planned Pregnancy Due to changes in hormone levels, changes in the blood, weight gain and pressure of the fetus on the veins in the groin, pregnant women can be at a 5 to10-fold increased risk of developing blood clots compared to non pregnant women. Women who have had prior blood clotting related miscarriages, have a diagnosed blood disorder (thrombophilia) or who are on hormone therapy may be at an increased risk, and you may receive an anticoagulant to reduce the risk of a blood clot to you and your fetus. If you have a blood clot you will receive an anticoagulant medicine that is best suited to your condition. Warfarin is usually avoided during pregnancy as it can have effects on the fetus, so it is important that you advise health care providers if you are, or plan to become pregnant. In contrast, there is no evidence that low molecular weight heparin or heparin effects cross the placenta. However, warfarin may be prescribed in special cases during pregnancy, especially if you have artificial heart valves. It may seem scary to inject into your belly with low molecular weight heparin during advanced pregnancy, but please know that the needle length is short, will be in the fat layer just below the skin, and there is no risk of the needle entering the womb. Follow the injection instructions described in the booklet and given to you by your TEAM. Your medication may be adjusted just prior to delivery. You may also continue on anticoagulant medicine for several weeks after delivery, as blood clots risks can continue even once your child is born. After delivery the risks associated with warfarin are greatly reduced. Both warfarin and low molecular weight heparin are generally considered safe if you are breast feeding. Make sure you discuss any concerns with your TEAM. 19
Cancer Patients with cancer have a 6-fold increased risk of developing blood clots due to changes in the makeup of the blood, reduced activity, and the toxic effect cancer has on cells. Chemotherapy medications can increase the risk of blood clots even further. Chemotherapy can also interact with warfarin, requiring you to go for more frequent blood tests, to adjust the dose or to change to low molecular weight heparin instead. If you are at a high risk for a blood clot, your doctor may prescribe anticoagulants; make sure you tell your cancer doctor if you have had a blood clot in the past, or have a family history of blood clots. If you have a blood clot, it is likely that you will be receiving an anticoagulant medicine for 3-6 months or longer. As blood clots are more difficult to manage in people with cancer, make sure you follow the instructions of your TEAM carefully. Other Medicines Some medicines can increase the risks of developing blood clots; most notably, estrogen (as replacement therapy or in birth control medication) and cancer chemotherapy. Many medications, herbal remedies and some foods (in high amounts) can interact with warfarin. Be sure to tell your doctors that you have had a blood clot in the past, or are taking any other medications. Going for Surgery (and still taking an anticoagulant) Some patients may require long term anticoagulation medicine due to an underlying risk of blood clots. If surgery is also planned, it is important that warfarin anticoagulation medicine is "shut-off" before the surgery, since it takes about 5 days to reverse its effects and about 5 days to start the effects up again. 20
If you are going for surgery, you may be asked to stop your warfarin and start on a shorter acting anticoagulant medicine like innohep which is effective but has shorter duration of action. If you are going for surgery or an intervention your doctor may fill in this chart to adjust your medication: 21
Record of Oral Warfarin Treatment Date Dose INR Date Dose INR 22
Please use this space to record any notes, problems or questions that you wish to discuss with your TEAM. Date Note/Problem/Question 23
Date Note/Problem/Question 24
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