APPROVED BY: Pharmacy and Theraeutics Committee Page 1 of 5 Purose: To rovide safe and effective anticoagulation theray for UH atients Policy: Uon order of a hysician, hearin low molecular weight hearin (LMWH) and/or oral warfarin theray will be administered according to the following rotocol. Procedure: I. Hearin Theray a. Indication for use will be documented in the chart. Indications include: i. Dee vein thrombosis iv. Atrial fibrillation with embolism v. Unstable angina vi. Periheral arterial embolism vii. Aortic and/or mitral valve relacement b. Patients with the following contraindications should not receive hearin theray: i. Hyersensitivity to hearin/lmwh ii. Active bleeding iii. Severe thrombocytoenia iv. Hearin-induced thrombocytoenia c. The following clinical information should be documented in the chart rior to initiation of theray: i. Patient age, weight, height, and gender ii. Medical and medication history ertaining to anticoagulation of the atient iii. Indication and duration for hearin theray iv. Laboratory baseline values 1. PT/INR, aptt, CBC, latelet count v. Order for no IM injections while on hearin theray d. Laboratory monitoring and dosing adjustments i. Reeat aptt 6 hours after the start of the hearin infusion and 6 hours after each dose adjustment. ii. Adjust bolus and infusion according to rotocol. iii. After two consecutive theraeutic aptt values, order daily am aptt. e. Physician notification i. The hysician must be notified if atient exeriences any bleeding.
APPROVED BY: Pharmacy and Theraeutics Committee Page 2 of 5 II. ii. The hysician must be notified in the event of significant adverse effect to hearin theray or if aptt is greater than 120. iii. The hysician should also be notified if the theray is not consistent with the duration of theray as documented in the chart. f. Pharmacy is resonsible for reviewing the orders for all hearin theray. g. All hearin rearations shall be of concentrations and volumes aroved by the P&T committee. h. All hearin infusions will be administered via rogrammable infusion ums. i. A rescriber s order is required for the use of all hearin roducts including hearin flush solutions. Low molecular weight hearin a. Indication for use will be documented on the chart. Indications include: i. Dee vein thrombosis iv. Atrial fibrillation with embolism v. Prohylaxis of stroke in ost MI atient vi. Unstable angina vii. Periheral arterial embolism viii. Aortic and/or mitral valve relacement b. Patients with the following contraindications should not receive LMWH theray: i. Hyersensitivity to hearin/lmwh ii. Active bleeding iii. Severe thrombocytoenia iv. Hearin-induced thrombocytoenia c. The following clinical information should be documented in the chart rior to initiation of theray: i. Patient age, weight, height, and gender ii. Medical and medication history ertaining to anticoagulation of the atient iii. Indication and duration for hearin theray iv. Laboratory baseline values 1. PT/INR, aptt, CBC, latelet count v. Order for no IM injections while on hearin theray d. Laboratory monitoring and dosing adjustments
APPROVED BY: Pharmacy and Theraeutics Committee Page 3 of 5 III. i. No routine monitoring is necessary for standard LMWH theray (rohylaxis or treatment doses) ii. For secialized oulations, (renal failure, regnancy, morbidly obese, atients less than 90% of ideal body weight) a single anti-xa level should be measured 3 to 4 hours after the first LMWH dose. e. Physician notification i. The hysician most be notified if atient exeriences any bleeding. ii. The hysician should also be notified if the theray is not consistent with the duration of theray as documented in the chart. f. Pharmacy is resonsible for reviewing the orders for all LMWH theray. g. A rescriber s order is required for the use of all LMWH roducts. Warfarin theray a. Indication for use will be documented in the chart. Indications include: i. Dee vein thrombosis iv. Atrial fibrillation with and without embolism v. Unstable angina vi. Artificial cardiac valve relacement vii. Selected cancer atients viii. Other warranted indications b. Clinical information which must be documented in the chart rior to initiation of theray: i. Indication ii. Duration iii. Theraeutic range iv. Patient age v. Medication history including revious anticoagulation theray vi. Nutritional status vii. Concurrent disease states c. Monitoring i. International Normalized Ration (INR) is used to monitor and modify doses of warfarin. ii. Baseline PT/INR must be obtained for all atients before initial dose or dosing change is ordered
APPROVED BY: Pharmacy and Theraeutics Committee Page 4 of 5 iii. For new atients, INR should be monitored daily until theraeutic for 2 consecutive days. Subsequently, INR should be measured 2-3 times weekly for two weeks, then weekly if stable. d. General information i. Warfarin may be started on the first day of hearin/lmwh theray ii. When converting from hearin/lmwh, warfarin may be overlaed. iii. Warfarin will be disensed one dose at a time and administered at 4PM daily unless secifically indicated otherwise. e. Patient education i. A harmacist will rovide atient education on the safe and effective use of warfarin theray. Each atient will be educated based uon the atient s level of comrehension. Documentation of the education session and comrehension will be documented in the chart. Patient education will include the following: 1. Medication name, strength and descrition 2. Daily dosage and administration times 3. How to handle missed doses 4. Purose of the medication and how it works 5. Dietary and medication interactions 6. Recognition of signs of bleeding and aroriate rocedures to follow 7. Imortance of comliance with medication regimen and clinic aointments 8. Keeing ID indicating warfarin use 9. Imortance of alerting rescriber when regnant, if aroriate ii. Nutritional services may be consulted for additional education f. Outatient anticoagulation theray management i. An anticoagulation service will be rovided within the University Health Shreveort Medicine Clinic. 1. Patients may be referred to this service through the electronic health record 2. Policies and rotocols for this anticoagulation service will be reviewed by the P&T Committee on an annual basis.
APPROVED BY: Pharmacy and Theraeutics Committee Page 5 of 5 IV. ii. Physicians who choose to manage their own atient s anticoagulation theray will be required to submit a clinic-secific olicy to the P&T committee for aroval on an annual basis. Anticoagulation theray outcome measures a. The following criteria will be evaluated for at least 12 randomly selected atients er quarter. A summary will be resented to the P&T committee every 6 months. i. INR is in theraeutic range for atient s condition ii. There are no bleeding eisodes iii. There are no thrombotic comlications iv. Interventions with hysicians regarding atient theray v. Number of atients with INR greater than 6.0 vi. Number of atients with INR less than 1.5