D.1 Anticoagulation Program .pdf

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

VISN 19

ANTICOAGULATION PROGRAM

I. PURPOSE: To outline the proper management of patients receiving therapeutic anticoagulation therapy in the outpatient area.

II. POLICY:

a. The provision of warfarin to primary care patients requires that the provider monitor the patient’s anticoagulation therapy or make appropriate plans for monitoring.

Delegation of responsibility for the monitoring does not absolve the healthcare provider from issues relating to that patient’s anticoagulation therapy.

b. Monitoring of anti-coagulated Home-Based Primary Care (HBPC) patients is the responsibility of the HBPC treatment team via POC or venipuncture in accordance with Appendix A: Initiating, Monitoring, & Use of Anticoagulant Therapy.

c. Non-VA labs can be accepted providing the Eastern Oklahoma VA Health Care System (EOVAHCS) lab has a CLIA certification for the non-VA lab. All NON-VA labs will be scanned into the patient’s CPRS file. Warfarin and Direct Oral Anticoagulants (DOACs) will only be filled at EOVAHCS if the patient’s PT/INR, CBC, and CHEM 12 are being managed by the Primary Care Team or Clinical Pharmacy Specialist.

d. Patient self-testing results are not accepted at EOVAHCS due to the inability to confirm Quality Control (QC) on patient-owned machines. EOVAHCS does not prescribe point-of-care testing machines for patients.

e. Patients who exhibit repeated non-compliance and/or otherwise uncooperative behavior will be re-educated on their diagnosis, the place in therapy for anticoagulation, and risks vs benefits of anticoagulation. The Primary Care Provider will make the final decision on continuing or discontinuing anticoagulation. Primary Care and the Clinical Pharmacy Specialist (CPS) will follow MCM 11-52, the no-show policy for primary and specialty clinics at EOVAHCS and Community Based Outpatient Clinics (CBOC).

III. RESPONSIBILITY:

a. The Chief of Staff: Is responsible for ensuring that this medical center places, supports and coordinates activities and resources to ensure that anticoagulation therapy

▪ EASTERN OKLAHOMA VA HEALTH CARE SYSTEM MUSKOGEE, OKLAHOMA

▪ MEDICAL CENTER MEMORANDUM 119-06 August 25, 2020

D.1 ANTICOGULATION PROGRAM

36C25923R0040

EOVAHCS Primary Care Anticoagulation Program 08-25-2020 Medical Center Memorandum 119-06

▪ 2 is assessed and managed appropriately and in accordance with the care, treatment and serviced provided.

b. Chief of Pharmacy:

(1) Ensures that the Anticoagulation Clinic is properly staffed and trained.

(2) Ensures adequate resources are available to provide anticoagulation monitoring for eligible patients.

(3) Ensure the anticoagulation program follows all required guidelines set by national guidelines for the Veterans Healthcare Administration (VHA).

c. Chief, Nutrition and Food Service:

(1) Ensures patients on warfarin are educated about food/drug interactions.

(2) Ensures meal planning is focused on steady Vitamin K intake, individualized to meet overall health needs and supplies an adequate dietary reference intake for Vitamin K.

d. Clinical Pharmacy Specialist Responsibilities:

(1) Review appropriateness of anticoagulation therapy for patients being consulted to them.

(2) Provide medication education about the various anticoagulants available including but not limited to: their mechanism of action, reversal agents available, and food and drug interactions. Provide literature/education materials for Warfarin and each DOAC.

(3) Monitor patient response and compliance with anticoagulant therapy.

(4) Adjust doses of warfarin and DOACs based upon recent American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

(5) Initiation or renewal of anticoagulation prescription orders as permitted by individual scope of practice.

(6) Initiation of orders for laboratory tests necessary to monitor anticoagulation or complications to therapy as permitted by individual scope of practice.

(7) The Clinical Pharmacy Specialist and the physician Co-Chief of Primary Care will be the co-champions for the anticoagulation program. *

e. Pathology and Laboratory Medicine Service Responsibilities:

(1) The Chief of Pathology and Laboratory Service will support the Anticoagulation Program from the laboratory collection area. The Chief of Pathology and Laboratory will also serve as the point of care (POC) director with the Ancillary Testing Coordinator as

▪ 3 the technical supervisor. The Chief of Pathology and Laboratory will be responsible for approving all procedures.

(2) Initial POC training and competency assessment of operators will be performed by lab Ancillary staff upon hiring. The lab Ancillary Testing Coordinator will be responsible for keeping records of validated POC users competency testing. After the initial training and assessment all new operators will be certified six months later then annually on their anniversary date.

(3) Proficiency testing of operators will be performed by lab Ancillary Staff three times a year using a CAP approved proficiency survey for PT/INR POC testing. Participation is rotated among testing personnel.

(4) Verification of the performance of each POC analyzer is a completed by Lab Ancillary Staff

f. Clinical Pharmacy Technician Responsibilities:

(1) Appropriate and prompt scheduling or rescheduling of new or return appointments and consults, as ordered by program professional staff.

(2) Referral of all telephone requests for cancellation/change of appointments (when change exceeds 7-day period) to program professional staff.

(3) Maintaining contact with all Home Health agencies to ensure current PT/INR, CBC, and CHEM 12 lab work for all home health patients and scanning the completed lab work into the patients CPRS file.

(4) Follow up contact with patients who cannot be reached by Clinical Pharmacy Specialist (CPS) through use of usual and customary methods. This may include “after-hours” telephone search and/or written communication requesting that patients call back during regular work hours to review laboratory results with a program professional staff member.

(5) Contacts home health with CPS recommendations.

(6) Using the I-STAT machine to check patient’s PT/INR and maintaining proper documentation of visit and CPS recommendations into CPRS.

IV. PROCEDURE:

a. Patients must have Primary Care enrollment at the EOVAHCS or facility where they are being monitored (e.g. VA Community-Based outpatient Clinics). The VA will only supply Warfarin or DOAC if monitored and managed by a VA provider. Warfarin will only be available for a 30 day supply with 1 refill or a 60 day supply with zero refills utilizing only 2mg and 5mg tablets to decrease errors. DOACs will be limited based on the next scheduled appointment to ensure that labs are monitored.

▪ 4

b. All referrals to the Clinical Pharmacy Specialist (CPS) will be in the form of an electronic consult. At a minimum, the consult should state the reason(s) for anticoagulation, the intensity of anticoagulation (if the range differs from recommended ranges/established guidelines), current PT/INR, and time frame to schedule, as well as current Warfarin or DOAC dose. All consult requests for scheduling within 72 hours require a personal communication from the healthcare provider to the CPS to discuss the circumstances and to ensure that the consult has been received. Patients must have a working telephone number for the CPS to manage their care.

c. Patients previously scheduled with the CPS who have been admitted to inpatient care should be re-consulted to the CPS or a comment added to the original consult to generate an alert to the Outpatient Clinical Pharmacy Staff at the time of discharge if warfarin or a DOAC is included among their discharge medications. The responsibility of placing the consult is with the attending inpatient physician or inpatient CPS unless arranged independently with the Primary Care physician.

d. The Anticoagulation Program will follow the American College of Chest Physicians Consensus Conference on Antithrombotic Therapy as outlined in Appendix A, unless otherwise specified by the provider.

e. Before initiating therapy a baseline INR must be obtained for all patients receiving warfarin therapy as well as a baseline CBC including but not limited to platelet function.

This will be the responsibility of the primary care provider, inpatient provider, or the CPS. The first INR measurement will be within 5-7 days of warfarin initiation. Initiation and adjustment of warfarin therapy is available in Appendix A. Initiating, Monitoring, and use of Anticoagulant Therapy section II. Point of Care (POC) testing is available for use by the CPS and primary care. If a POC PT/INR result is greater than 4 then the patient is asked to report to lab for a confirmation venipuncture PT/INR test.

f. Warfarin or DOAC dosage recommendations and return to clinic instructions are always given to the patient verbally and in writing when possible. Patients are mailed notices for each appointment; they may also be given telephone reminders. Special emphasis on the storage and handling of Dabigatran will be provided in verbal and written instructions to the patient or caregiver, if the patient is to use this medication. *

g. Patients taking warfarin will be scheduled for PT/INR every 4 weeks (or less) and every 6 weeks for extenuating circumstances, i.e.: weather, and/or distance traveled to clinic. Warfarin dosing adjustments will be made as necessary to achieve therapeutic range anticoagulation for a particular patient’s indication. Patients receiving warfarin and presenting with INR values outside their therapeutic range, previously maintained with good control will be assessed in an attempt to identify precipitating factors, which may require a loading dose, holding a dose or may eliminate dose adjustment.

h. The person managing Warfarin or DOAC (provider or clinical pharmacy specialist) is to be contacted, by phone or page, for all critical labs regarding anticoagulation during normal business hours. Management of these critical labs after hours will be conducted by the Emergency Room provider.

▪ 5

i. Patient education is the responsibility of all professional staff who provide care of patients receiving anticoagulation therapy. The patient, patient's family, and/or caregiver will be educated and provided information on the following: warfarin or DOAC tablet identification, indication for therapy, interactions (diet/drug/disease), daily dosage, monitoring requirement, medication adherence, dangers of using warfarin from different sources, management of missed doses, signs/symptoms of bleeding and thromboembolic event, fall and trauma precautions (Appendix B). Inpatients are evaluated for educational needs by the Registered Dietitian when they are identified on the Patient on Specific Drug Report. For outpatient dietary services, the provider will need to place a consult for education. The outpatient Registered Dietitian will evaluate the patient’s educational needs on food/warfarin interactions.

j. Bridge therapy during warfarin interruption will be considered on an individual basis.

(See Appendix C) Low molecular-weight heparin (LMWH), (Lovenox) and Fondaparinux (Arixtra) are available for inpatient and outpatient clinic or provider use in warfarin “bridging” during surgery (Appendix C) Enoxaparin (Lovenox) Prophylactic Therapy Handout.

k. Time and therapeutic range report and all anticoagulation program monitoring data and concerns will be reported to Pharmacy and Therapeutic Committee quarterly, for action needed. *

V. REFERENCES:

a. Guyatt G., Akl E., Crowther M., et al. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines. CHEST 2012; 141(2) (suppl): 7S-47S

VI. FOLLOW-UP RESPONSIBILITY: The Chief, Pharmacy Service, is responsible for the contents.

VII. RESCISSONS: MCM 119-06, same subject, dated June 6, 2014.

/s/

MARK MORGAN, MHA, FACHE

Medical Center Director

Attachments: Appendices A, B

Dist: C *Pen and Ink change dated 8-23-17 incorporated into MCM – blue font

EOVAHCS Primary Care Anticoagulation Program Medical Center Memorandum 119-06 Appendix A

INITIATING, MONITORING, & USE OF ANTICOAGULANT THERAPY

Information for the use of warfarin contained below was obtained from a review of current literature.

The information is intended to optimize therapeutic anticoagulation by minimizing patient bleeding risks, decreasing the time required for titration to achieve a desired level of anticoagulation, and promoting efficient use of laboratory tests.

I. USE OF ORAL ANTICOAGULATION

Recommendations for Patient with AF Considered for Chronic Oral Anticoagulant Therapy

Recommendation for

Age Major Risk Factors* Long-term Therapy

<65 No major risk factors Aspirin

<65 Major risk factors Warfarin**

65-75 No major risk factors Aspirin or Warfarin**

65-75 Major risk factors Warfarin**

>75 All patients Warfarin**

*previous TIA, stroke, or systemic embolism; poor left ventricular function (moderate to severe left ventricular dysfunction on echocardiography or recent CHF); hypertension

**Goal INR 2.5; range, 2 to 3

Recommended Therapeutic Goals for Oral Anticoagulation

Indication INR Duration

Prophylaxis of venous thrombosis 2-3 Clinical Judgment for high-risk surgery

Treatment of venous thrombosis

First episode 2-3 3-6 months

High risk of recurrent thrombosis 2-3 Lifelong

Thrombosis associated with 2.5-3.5 Lifelong antiphospholipid antibody

Treatment of pulmonary embolism

First episode 2-3 3-6 months

High risk of recurrent embolism 2-3 Lifelong

Prevention of systemic embolism

Tissue heart valves 2-3 3 months

Acute myocardial infarction 2-3 Clinical Judgment

(to prevent systemic embolism)

Valvular heart disease (after 2-3 Lifelong thrombotic event or if the left atrium is greater than 5.5cm)

Atrial fibrillation

Chronic or intermittent 2-3 Lifelong

Cardioversion 2-3 3 weeks before and 4 weeks after cardioversion if

NSR is maintained

Recommended Therapeutic Goals for Oral Anticoagulation (cont'd)

Indication INR Duration

Antiphospholipid syndrome

No risk factors 2-3 Lifelong

No lack of response to therapy 2-3 Lifelong

Recurrent thromboembolic events 2.5-3.5 Lifelong with a therapeutic INR

Additional risk factors for 2.5-3.5 Lifelong thromboembolic events

Prosthetic heart valves

Bileaflet mechanical valve 2-3 Lifelong in the aortic position, left atrium of normal size, NSR, normal ejection fraction

Other mechanical valves in the aortic 2.5-3.5 Lifelong or mitral position

Bioprosthetic 2-3 Clinical Judgment

II. INITIATION OF ANTICOAGULATION THERAPY

5 MG Warfarin Nomogram

Day INR Dosage (mg)

1 baseline 5.0

2 <1.5 5.0

1.5 - 1.9 2.5

2.0 - 2.5 1.0 - 2.5

>2.5 0.0

3 <1.5 5.0 - 10.0

1.5 - 1.9 2.5 - 5.0

2.0 - 2.5 0.0 - 2.5

2.5 - 3.0 0.0 - 2.5

>3.0 0.0

4 <1.5 10.0

1.5 - 1.9 5.0 - 7.5

2.0 - 3.0 0.0 - 5.0

5 <1.5 10.0

1.5 - 1.9 7.5 - 10.0

2.0 - 3.0 0.0 - 5.0

6 <1.5 7.5 - 12.5

1.5 - 1.9 5.0 - 10.0

2.0 - 3.0 0.0 - 7.5

III. ALTERATION OF ANTICOAGULATION THERAPY

INR Goal of 2.0 - 3.0

INR Dosage Adjustment

<2.0 Increase weekly dose by 5-20%

2.0 - 3.0 No dosage adjustment

3 - 3.5 Decrease weekly dose by 5-15%

3.6 - 4.0 Withhold no dose to one dose; decrease weekly dose by 10-15%

>4.0 Withhold no dose or one dose; decrease weekly dose by 10-20%

INR Goal of 2.5 - 3.5

INR Dosage Adjustment

<2.0 Give additional dose; increase weekly dose by 10-20%

2.0 - 2.4 Increase weekly dose by 5 - 15%

2.5 - 3.5 No dosage adjustment

3.6 - 4.6 Decrease weekly dose by 5-15%

4.7 - 5.2 Withhold no dose to one dose; decrease weekly dose by 10-20%

>5.2 Withhold no dose to one dose; decrease weekly dose by 10-20%

Therapy

Age greater than 65 years

Age greater than 75 years with concomitant atrial fibrillation (intracranial hemorrhage)

History of gastrointestinal bleeding

Comorbid disease states:

Hypertension

Cerebrovascular disease

Serious Heart Disease

Renal Insufficiency

Liver Disease

Clinical Situation Guidelines

INR> therapeutic range but Lower the dose or omit a dose; resume warfarin therapy at a

<5.0, no clinically significant lower dose when the INR approaches desired range; If the INR bleeding, rapid reversal not is only minimally above therapeutic range, dose reduction may indicated for reasons of surgical not be required.

intervention

INR>5.0 but <9.0 no clinically Patients with no additional risk factors for bleeding; omit the significant bleeding. next dose or two of warfarin, monitor INR more frequently, and resume therapy at a lower dose when the INR is in therapeutic range

Patients at increased risk of bleeding; omit the next dose of warfarin, and give vitamin K 1 (1 to 2.5 mg orally)

Clinical Situation Guidelines

INR>5.0 but <9.0 no clinically Patients requiring more rapid reversal before urgent surgery or significant bleeding. (cont'd) dental extraction; vitamin K 1 (2 to 4mg orally); if the INR remains high at 24 h; an additional dose of 1 to 2 mg.

INR>9.0, no clinically Vitamin K 1 (3 to 5 mg orally); closely monitor the INR; if the INR significant bleeding is not substantially reduced by 24 to 48 h, the vitamin K 1 dose can be repeated; Resume therapy at a lower dose when the INR reaches the therapeutic range.

Serious bleeding, or major Vitamin K1 (10mg by slow IV infusion), supplemented with fresh warfarin overdose (e.g.INR>20.0) plasma transfusion, prothrombin complex concentrate, or requiring very rapid reversal of recombinant factor VIIa depending upon urgency, vitamin K 1 anticoagulant effect injections may be needed q 12h

Life-threatening bleeding or Fresh frozen plasma, Prothrombin complex concentrate, or serious warfarin overdose recombinant factor VIIa with vitamin K 1 (10mg by slow IV infusion); repeat if necessary, depending upon the INR

Continuing warfarin therapy Heparin until the effects of vitamin K 1 have been reversed, and indicated after high doses of patient is responsive to warfarin vitamin K 1

References:

1. Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Evidence –Based Clinical Practice Guidelines. CHEST 2012.

Medical Center Memorandum 119-06 Appendix B-1

ANTITHROMBOTIC THERAPY – GUIDELINES FOR

PERI-PROCEDURE MANAGEMENT

This appendix establishes a policy pertaining to guidelines for the safe and effective management of antithrombotic therapy before and after invasive procedures. This policy applies to all organizational elements.

Patients who take antithrombotic drugs due to an increased risk for arterial or venous thromboembolic disease require special consideration in the peri-procedure period due to the relative risk of a thromboembolic event (if therapy is withheld) versus the risk of hemorrhage (if anticoagulant therapy is continued).

RESPONSIBILITIES

The patient’s primary care or specialty medical provider is responsible for providing guidance to

VA (and non-VA) dentists/oral surgeons, when requested, regarding whether and how to withhold warfarin anticoagulation for elective dental procedures.

VA dentists/oral surgeons are responsible for contacting the patient’s primary care provider in the event that a procedure is planned that might require discontinuation of warfarin anticoagulation.

Other medical/surgical providers who are planning an invasive procedure requiring alteration of warfarin therapy may opt to follow these recommendations or contact the primary care or specialty medicine provider for guidance.

DEFINITIONS

Invasive Procedure. For the purpose of this guideline, an “invasive procedure” is a medical, dental, or surgical procedure that may result in some degree of hemorrhage in patients who undergo the process.

Peri-procedure Bridging. This term describes the use of standard (UFH) and/or low molecular weight (LMWH) heparins before and/or after an invasive procedure. Peri-procedure bridging is designed to narrow the window of risk for thromboembolic events during a period when warfarin anticoagulation is withheld. NOTE: Refer to Appendix A for a flowchart.

INR. An abbreviation for International Normalized Ratio, an expression of the intensity of warfarin anticoagulation. INR 1 is a normal (non-anticoagulated) value, whereas 2 – 3 or 2.5 –

3.5 are standard or high-intensity levels of anticoagulation, respectively.

Antiplatelet Agents. Drugs such as aspirin, clopidogrel, prasugrel, ticagrelor, ticlopidine that prevent thrombosis through inhibition of platelet function.

Medical Center Memorandum 119-06 Appendix B-2

INFORMATION:

(1) Warfarin

(a) Most invasive procedures can be performed with no greater than usual hemorrhagic risk when the INR is 1.5.

(b) An INR 1.5 can usually be obtained by withholding standard or high intensity warfarin anticoagulation for 2 to 5 days. This period may be shortened by the oral or parenteral administration of low dose (2.5 mg) vitamin K. Excessive use of vitamin K can markedly prolong the period of time required to restore a therapeutic-range INR post-procedure.

(c) Withholding warfarin for a procedure may result in subtherapeutic range INRs for up to a week (considering time off warfarin pre-procedure and time to achieve adequate anticoagulation post-procedure). Subtherapeutic range anticoagulation may offer a markedly reduced level of antithrombotic protection to patients, especially those with chronic atrial fibrillation or mechanical heart valves. (For example, in atrial fibrillation the risk of stroke doubles as the INR falls from 2.0 to 1.7 and it more than doubles again when the INR is reduced to 1.4.)

(2) Heparins

(a) Weight-based heparin protocols (bolus injection of UFH followed by continuous intravenous (IV) infusion) can result in immediate therapeutic anticoagulation. Discontinuation of continuous IV UFH results in dissipation of anticoagulant effect to the extent that most procedures can be performed after 5 to 6 hours.

(b) The onset of effect for LMWH (enoxaparin) is 3 to 5 hours and significant anticoagulant activity exists for up to 12 hours. Discontinuation of full-dose enoxaparin (1 mg/kg q 12 hours) results in dissipation of anticoagulant effect to the extent that most procedures can be performed after 18 to 24 hours.

(c) Administration of fondaparinux results in a peak effect within 2 to 3 hours. Its elimination half-life ranges from 17 to 21 hours and is prolonged in patients with renal impairment. Cautious use is recommended when the creatinine clearance is 30-50 ml/min;

fondaparinux is contra-indicated when creatinine clearance is < 30 ml/min.

(d) Pre- and post-procedural bridging may be accomplished through use of a weight-based heparin protocol administered in a hospital setting. In a hospital or ambulatory setting adjusted-dose UFH may be used (administered SQ to achieve a PTT 1.5 to 2.0 x control) or LMWH can be utilized at a dose of 1 mg/kq SQ q 12 hours (maximum = 150 mg) or 1 mg/kg SQ q 24 hours when creatinine clearance < 30 mL/min.

(e) Fondaparinux is best utilized only for post-procedural bridging (due to its prolonged half-life) and is dosed every 24 hours according to patient weight in kilograms (<50 kg: 5 mg

SQ; 50 – 100 kg: 7.5 mg SQ; > 100 kg: 10 mg SQ).

Medical Center Memorandum 119-06 Appendix B-3

(f) LMWH (enoxaparin) is suggested for patients with creatinine clearance < 30 mL/min or bacterial endocarditis, and is also preferred in patients < 50 kg undergoing hip fracture, hip replacement or knee replacement. Fondaparinux is suggested for venous thromboembolic prophylaxis in hip fracture/replacement, knee replacement or abdominal surgery in patients weighing > 50 kg.

(3) Antiplatelet Agents

(a) The antiplatelet effects of aspirin, clopidogrel, prasugrel, ticagrelor, ticlopidine are irreversible for the life of the platelet. The average lifespan of a platelet is 7 to 10 days and approximately 10 percent of circulating platelets are replaced every 24 hours.

(b) The antiplatelet activity of aspirin is almost immediate (1 hour). At least 50 percent of platelet function is restored 5 days after the last ingestion of drug.

(c) The full antiplatelet effect of ticlopidine is exerted 8 to 11 days after initiation of the drug and platelet function is normalized approximately 14 days after its discontinuation.

(d) Standard dosing of clopidogrel (75 mg daily) results in steady state drug effects (50 to

60 percent platelet inhibition) after 4 to 7 days. Steady state effects can be obtained within

2 hours when a 300 mg loading dose is utilized. Discontinuation of clopidogrel results in baseline platelet function after 5 days.

(e) Platelet function screening can be performed by use of the Platelet Function Analysis test, or PFA.

(4) Thromboembolic (TE) Risk Stratification

(a) TE risk with atrial fibrillation + valvular heart disease > that with lone atrial fibrillation.

(b) TE risk with mitral valve replacement > that with aortic valve replacement.

(c) TE risk with multiple valve replacements > single valve replacement.

(d) TE risk with valve replacements is increased in patients with decreased left ventricular systolic function, patients > 70 years of age, or patients who also have atrial fibrillation.

(e) TE risk with mechanical valves (i.e., Caged ball (Starr Edwards) valve replacement, single-tilting disk (Bjork-Shiley, and others), bileaflet tilting disk (St. Jude, Carbomedics)) is significantly greater than that associated with bioprosthetic valves (Carpenter Edwards, Hancock).

(f) Arterial or venous TE risk is greater in patients who have had a previous TE episode compared to those who have not, especially if the TE event has been recent.

(5) Peri-Procedural Bridging Guideline http://qio.ipro.org/wp-content/uploads/2015/10/AQIN_MAP_5-1-2014.pdf http://qio.ipro.org/wp-content/uploads/2015/10/AQIN_MAP_5-1-2014.pdf

Medical Center Memorandum 119-06 Appendix C-1

Enoxaparin (Lovenox®) Prophylactic Therapy Handout

Name: __________________________________ ID: ____________________________

Weight: _________________________________ Estimated CrCl: ___________________

This handout is provided to help you understand your “blood thinning” medications. The medications covered in this handout are enoxaparin (Lovenox®) and warfarin (Coumadin®). This combination is used in preparation for certain surgeries or procedures when you have to stop warfarin for a period of time. The reason you have to take two blood thinners is because warfarin has a very slow onset of action and elimination; therefore, you need a quick acting blood thinner during this period of stopping and restarting warfarin.

Date of last CBC: _____________ Baseline platelet count: _____________

Surgery/Procedure Date: ___________________

1) Hold warfarin (Coumadin) for _____________ days. Take your last dose of warfarin on

2) Start enoxaparin injections on ________________. Inject _______________mg SQ

_____________daily (40 mg SQ daily or if BMI >30 kg m2 use 0.5 mg/kg SQ daily or if CrC1

<30 mi/mm: 30 mg SQ daily).

3) Skip the dose of enoxaparin 24 hours before and the evening of your procedure/surgery.

4) On the evening of your surgery day, resume your usual warfarin dose.

5) On the day after surgery _______________, resume your enoxaparin injections

6) Overlap enoxaparin with warfarin for a minimum of ___ days.

7) Recheck your INR on __________________.

We reviewed and discussed the following:

✓ Purpose of medication

✓ Side effects of medication including bruising and bleeding

✓ Precautions/warnings/drug interactions

✓ Storage of medication

✓ Proper aseptic technique for administration of medication

✓ Appropriate SQ injection technique

✓ Proper disposal of used needles

Recommendations regarding antiplatelets: ________________________________

Additional comments:

Medical Center Memorandum 119-06 Appendix C-2

If you have any questions or concerns regarding your enoxaparin dosing or procedure, feel free to call a provider with the EOVAHCS at (918) 577-3000.

/S/

MARK E. MORGAN, MHA, FACHE

Medical Center Director Dist: C