Pharm 6 Thrombi pt0 Anticoag Flowsheet

Question 1

First episode, transient risk factor

Target INR? Duration of Therapy?

Answer 1

2.0-3.0

3 months

Question 2

First episode, idiopathic DVT

Target INR? Duration of Therapy?

Answer 2

2.0-3.0
6-12 months*
*: consider indefinite therapy

Question 3

First episode, patient with cancer

Target INR? Duration of Therapy?

Answer 3

2.0-3.0

LMWH 3-6 months, then warfarin. Tx until cancer is resolved (indefinitely?)

Question 4

First episode and single risk factor

Target INR? Duration of Therapy?

Answer 4

2.0-3.0

6-12 months

Question 5

First episode, antiphospholipid antibodies or at least two risk factors
Target INR? Duration of Therapy?

Answer 5

2.0-3.0
12 months (indefinitely?)

Question 6

Recurrent DVT

Target INR? Duration of Therapy?

Answer 6

2.0-3.0

Indefinitely

Question 7

A fib

Target INR? Duration of Therapy?

Answer 7

2.0-3.0

Indefinitely

Question 8

Rheumatic mitral valve and atrial fibrillation or previous emboli
Target INR? Duration of Therapy?

Answer 8

2.0-3.0

Indefinitely

Question 9

Rheumatic mitral valve disease, normal sinus rhythm, and left atrial
diameter > 5.5 cm
Target INR? Duration of Therapy?

Answer 9

2.0-3.0

Indefinitely

Question 10

Aortic St. Jude Medical bileaflet valve

Target INR? Duration of Therapy?

Answer 10

2.0-3.0

Indefinitely

Question 11

Mitral tilting disk valves and bileaflet mechanical valves

Target INR? Duration of Therapy?

Answer 11

2.5-3.5

Indefinitely

Question 12

Aortic CarboMedics bileaflet or Medtronic Hall tilting disk valves,
normal sinus rhythm, and no LAE
Target INR? Duration of Therapy?

Answer 12

2.0-3.0

Indefinitely

Question 13

Mechanical valves with risk factors (atrial fibrillation, myocardial
infarction, LAE, endocardial damage, low ejection fraction)
Target INR? Duration of Therapy?

Answer 13

2.5-3.5

Indefinitely, low dose aspirin

Question 14

Caged ball or disk valve

Target INR? Duration of Therapy?

Answer 14

2.5-3.5

Indefinitely, low dose aspirin

Question 15

Mechanical valve with breakthrough embolism despite INR 2.0 to 3.0
Target INR? Duration of Therapy?

Answer 15

2.5-3.5

Indefinitely, low dose aspirin

Question 16

Bioprosthetic valve (mitral)
Target INR? Duration of Therapy?

Answer 16

2.0-3.0

3 months after placement

Question 17

Bioprosthetic valve (aortic)
Target INR? Duration of Therapy?

Answer 17

2.0-3.0

3 months of warfarin or aspirin

Question 18

Patient has INR 5.0 to 8.9, no significant bleeding. How do you manage?

Answer 18

Omit 1 to 2 doses; reduce dose 10 to 20 percent; monitor frequently.
Alternatively: Vit K1 PO

Question 19

Patient has INR >9, no significant bleeding. How do you manage?

Answer 19

Hold warfarin therapy; give vitamin K1 5 to 10 mg orally; monitor frequently. Resume at lower dose when INR is therapeutic

Question 20

Patient has serious bleeding (any INR). How do you manage?

Answer 20

Hold warfarin; give vitamin K1 10 mg slow intravenous (IV) plus fresh plasma or prothrombin complex concentrate, depending on urgency; repeat vitamin K1 every 12 hours as needed

Question 21

Life-threatening bleeding, any INR

How do you manage?

Answer 21

Hold warfarin; give prothrombin complex concentrate (or recombinant factor VIIa as an alternate) supplemented
with vitamin K1 (10 mg slow IV); repeat as needed.

Question 22

INR <1.5 (no bleeding)

Dose adjusting, when take next INR?

Answer 22

Adjust: increase dose 10-20%, consider extra dose

Next INR: 4-8 days

Question 23

INR 1.5-1.9 (target is 2.0-3.0 no bleeding)
or INR 1.5-2.4 (target is 2.5-3.5, no bleeding)
Dose adjusting, when take next INR?

Answer 23

Adjust: Increase dose 5-10%

Next INR: 7-14 days

Question 24

INR 2.0-3.0 (target is 2.0-3.0, no bleeding)
or INR 2.5-3.5 (target is 2.5-3.5, no bleeding)
Dose adjusting, when take next INR?

Answer 24

No change
Number of consecutive in-range INRs x 1 week (max 4 weeks)
For example, if a patient has had three consecutive in-range INR values, recheck in 3 weeks.

Question 25

INR 3.1-3.9 (target is 2.0-3.0, no bleeding)

Dose adjusting, when take next INR?

Answer 25

Decrease dose 5-10%

7 to 14 days

Question 26

INR 3.6-4.5 (target is 2.5-3.5, no bleeding)

Dose adjusting, when take next INR?

Answer 26

Decrease dose 5-10% consider holding one dose

7 to 14 days

Question 27

INR 4.0-4.9 (target is 2.0-3.0, no bleeding)

Dose adjusting, when take next INR?

Answer 27

Hold for 0-1 day then decrease dose 10%a

4-8 days

Question 28

INR 4.5-6.0 (target is 2.5-3.5, no bleeding)

Dose adjusting, when take next INR?

Answer 28

Hold for 1-2 days, then decrease dose 5-15%

2-8 days