Drugs Susan Louw Haematology Registrar. 4 Questions to ask: Can I stop? (What is the risk of...
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Transcript of Drugs Susan Louw Haematology Registrar. 4 Questions to ask: Can I stop? (What is the risk of...
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Drugs
Susan Louw
Haematology Registrar
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4 Questions to ask:
Can I stop? (What is the risk of thrombosis?)
Should I stop? (What is the risk of bleeding?)
When should I stop?
Should I bridge?
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Can I stop?
What is the indication for anticoagulation?
How long ago did the event occur?
How serious was the event?
Is life long anticoagulation indicated?
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Should I stop?
Surgery in vulnerable sites
Laparoscopic surgery
Extent of “trauma”
Upper airway
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When should I stop?
Duration of therapeutic effect after discontinuation
Onset of therapeutic effect
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Antiplatelet agents
Aspirin– “No doctor, I am on no medication…” – Commonest cause of post op wound
oozing– No serious bleeding
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Food
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Over the counter medication
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Anticoagulants
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Warfarin therapy and Bleeding Most serious complication of Warfarin Most common sites of serious bleeding
– GIT– Soft tissue including wounds
Highest risk of bleeding:– At initiation of treatment and 1st year thereafter– Age > 65 years– Hypertension– Alcoholism and liver disease– Hx of stroke / GIT bleeding– History of difficulty in controlling the INR– Concomittant therapy
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Incidence of Bleeding in Warfarin therapyFatal bleeding(Bleeding is cause of death)
0.1-1%
Major bleeding
(GIT, retroperitoneal, intracranial or intraoccular bleedingor any bleeding from an orifice + shock / needing transfusion or invasive procedure)
0.5-6.5%
Minor bleeding 6.2 - 21.8%
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Management of Overanticoagulated Patient on Warfarin Look for and correct cause
– dosing, compliance, diet, liver disease, other illnesses
Management depends on– INR level– Severity of bleeding
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Management of Overanticoagulated patient on Warfarin: No or minor Bleeding
INR < 5 Omit 1 Warfarin dose
INR monitoring frequency (2-3 x per wk)
Resume Rx at 10-20% lower dose
INR 5-9 Omit 1-2 doses
INR monitoring frequency (Daily)
Resume Rx at 10-20% lower dose
High risk: ? Vit K 2-3 mg PO
INR >9 Stop Warfarin temporarily
? Vit K 3-5 mg PO
Dly INR + repeat Vit K if INR not at 24 - 48hrs
Resume Rx at 20% lower dose once INR therapeutic
> Frequent INR monitoring
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Management of Overanticoagulated patient on Warfarin: Serious or life-threatening Bleeding
Admit to Hospital (ICU) – urgent referral Stop Warfarin temporarily Local control of bleeding FFP / Other blood products (Recombinant
Factor VIIa & Prothrombin cmplex) Vit K 5 – 10 mg slowly IV Monitor INR 6 hrly and repeat Rx
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Dosage adjustment for patients on Warfarin maintenance
INR Dosage Adjustment< 1.5 wkly dose by 20% & extra dose of 20% wkly dose
1.5 - 1.9 Wkly dose by 10%
2 - 3 No change
3.1-3.9 No change – recheck in 1 week. If persists, wkly dose by 10-20%
4 - 5 Omit 1 dose & wkly dose by 10-20%. Recheck in 2 –5 days
>5 See treatment of Overanticoagulated patients above
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Vitamin K
Safe / Convenient / Effective Route:
– PO: preferred route– Subcut: unpredictable absorption– IM: haemorrhage– IV: SE (e.g. hypotension, chest pain) use only in emergency and
give slowly Effect:
– PO in 24 hrs– IV in 6 – 8 hrs
May be difficult to re-anticoagulate – must give lowest dose orally Oral formulation (tablets) not available any more
– give parenteral preparations orally
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Thrombotic Complications
Complication of under-warfarinisation On arterial or venous side Can occur in any organ
– Brain: cerebrovascular accident (stroke)– Heart: myocardial infarction (heart attack) /
malfunction of artificial heart valves– Limbs: deep vein thrombosis (PE) / gangrene
Can be life-threatening
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Thrombotic Complications: cont
Management – Referral and possible admission– Anticoagulation with Heparin
• LMWH / UFH
– Need quick onset of action– Cannot afford a hypercoagulable state
Close monitoring when re-warfarinised
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Patient Education
Reason for Warfarin and duration of Rx Need to comply: dose, time of administration
and testing Importance of monitoring Importance of diet Caution with all other drugs and alcohol Avoid pregnancy Warfarin side-effects (when to call a doctor) Influence of intercurrent illness