Pharm 6 Thrombi pt0 Anticoag Flowsheet Flashcards
First episode, transient risk factor
Target INR? Duration of Therapy?
2.0-3.0
3 months
First episode, idiopathic DVT
Target INR? Duration of Therapy?
2.0-3.0
6-12 months*
*: consider indefinite therapy
First episode, patient with cancer
Target INR? Duration of Therapy?
2.0-3.0
LMWH 3-6 months, then warfarin. Tx until cancer is resolved (indefinitely?)
First episode and single risk factor
Target INR? Duration of Therapy?
2.0-3.0
6-12 months
First episode, antiphospholipid antibodies or at least two risk factors
Target INR? Duration of Therapy?
2.0-3.0 12 months (indefinitely?)
Recurrent DVT
Target INR? Duration of Therapy?
2.0-3.0
Indefinitely
A fib
Target INR? Duration of Therapy?
2.0-3.0
Indefinitely
Rheumatic mitral valve and atrial fibrillation or previous emboli
Target INR? Duration of Therapy?
2.0-3.0
Indefinitely
Rheumatic mitral valve disease, normal sinus rhythm, and left atrial
diameter > 5.5 cm
Target INR? Duration of Therapy?
2.0-3.0
Indefinitely
Aortic St. Jude Medical bileaflet valve
Target INR? Duration of Therapy?
2.0-3.0
Indefinitely
Mitral tilting disk valves and bileaflet mechanical valves
Target INR? Duration of Therapy?
2.5-3.5
Indefinitely
Aortic CarboMedics bileaflet or Medtronic Hall tilting disk valves,
normal sinus rhythm, and no LAE
Target INR? Duration of Therapy?
2.0-3.0
Indefinitely
Mechanical valves with risk factors (atrial fibrillation, myocardial
infarction, LAE, endocardial damage, low ejection fraction)
Target INR? Duration of Therapy?
2.5-3.5
Indefinitely, low dose aspirin
Caged ball or disk valve
Target INR? Duration of Therapy?
2.5-3.5
Indefinitely, low dose aspirin
Mechanical valve with breakthrough embolism despite INR 2.0 to 3.0
Target INR? Duration of Therapy?
2.5-3.5
Indefinitely, low dose aspirin
Bioprosthetic valve (mitral) Target INR? Duration of Therapy?
2.0-3.0
3 months after placement
Bioprosthetic valve (aortic) Target INR? Duration of Therapy?
2.0-3.0
3 months of warfarin or aspirin
Patient has INR 5.0 to 8.9, no significant bleeding. How do you manage?
Omit 1 to 2 doses; reduce dose 10 to 20 percent; monitor frequently.
Alternatively: Vit K1 PO
Patient has INR >9, no significant bleeding. How do you manage?
Hold warfarin therapy; give vitamin K1 5 to 10 mg orally; monitor frequently. Resume at lower dose when INR is therapeutic
Patient has serious bleeding (any INR). How do you manage?
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
Life-threatening bleeding, any INR
How do you manage?
Hold warfarin; give prothrombin complex concentrate (or recombinant factor VIIa as an alternate) supplemented
with vitamin K1 (10 mg slow IV); repeat as needed.
INR <1.5 (no bleeding)
Dose adjusting, when take next INR?
Adjust: increase dose 10-20%, consider extra dose
Next INR: 4-8 days
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?
Adjust: Increase dose 5-10%
Next INR: 7-14 days
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?
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.
INR 3.1-3.9 (target is 2.0-3.0, no bleeding)
Dose adjusting, when take next INR?
Decrease dose 5-10%
7 to 14 days
INR 3.6-4.5 (target is 2.5-3.5, no bleeding)
Dose adjusting, when take next INR?
Decrease dose 5-10% consider holding one dose
7 to 14 days
INR 4.0-4.9 (target is 2.0-3.0, no bleeding)
Dose adjusting, when take next INR?
Hold for 0-1 day then decrease dose 10%a
4-8 days
INR 4.5-6.0 (target is 2.5-3.5, no bleeding)
Dose adjusting, when take next INR?
Hold for 1-2 days, then decrease dose 5-15%
2-8 days
