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Table of Contents Table of Contents Section Topic Page I Physiology of coagulation 3 II Hypercoagulable States 4 III Low-Molecular-weight-Heparins Essential Skills: ------------------------- 5 • - Pharmacology, Pharmacokinetics, and Dosing ------------------------- 5 • - Heparin-Induced Thrombocytopenia ------------------------------------ 7 • - 4T scoring system---------------------------------------------------------- 9 • - Creatinine Clearance Calculation ---------------------------------------- 10 IV Warfarin Essential Skills: ---------------------------------------------------- 11 • Warfarin Pharmacology ------------------------------------------------------ 11 • How INR is calculated from the Prothrombin Time (PT)------------------ 13 • Indications -------------------------------------------------------------------- 13 • CHADS/CHADSVASc scoring------------------------------------------------- 14 • Duration of therapy ---------------------------------------------------------- 18 • Warfarin-Drug Interactions ------------------------------------------------- 18 • Warfarin-Disease State Interactions --------------------------------------- 30 • Warfarin-Herbals Interactions---------------------------------------------- 32 • Drug induced Diarrhea--------------------------------------------------------------------------- 32 • Warfarin-Nutrient & Life-Style Interactions ------------------------------- 33 • Vitamin K Content of Selected Foods--------------------------------------- 33 • Warfarin Adverse Effects ---------------------------------------------------- 38 • Warfarin and Inappropriate Aspirin Use----------------------------------- 40 • Warfarin Initiation Guidelines ---------------------------------------------- 42 - Warfarin Maintenance Dosing Algorithm ---------------------------------- 46 - Frequency of Assessment --------------------------------------------------- 47 - Extended INR Decision Flowchart------------------------------------------ 48 V Prevention of Venous Thromboembolism and Postthrombotic Syndrome 49 VI Bridge Therapy --------------------------------------------------------------- 50 Enoxaparin Bridging Algorithm--------------------------------------------- 52 Peri-procedural Bridge Therapy and surgical bleeding risks ------------ 53 HAS-BLED Score for warfarin patients with atrial fibrillation------------ 56 Lovenox(enoxaparin) Dose Rounding Table------------------------------- 57 Outpatient Treatment of Venous Thromboembolism with warfarin & LMWH-- 60 Use of LMWH during spinal anesthesia/injection ------------ 62 Reversal of Lovenox -------------------------------------------- 62 Anticoagulation therapy periprocedural to Watchman procedure-- 63 Anticoagulation therapy Around dental, dermatologic, and cataract extraction procedures ------------------------------------------------- 64 VII Direct Oral Anticoagulants (DOACs)----------------------------------------- 67 Warfarin to DOAC switch Flowchart----------------------------------------- 73 DOAC Prescribing Information Table---------------------------------------- 74 CHILD-PUGH Score------------------------------------------------------------ 79 Peri-procedural Management of DOACs------------------------------------- 80 DOAC Drug Interactions------------------------------------------------------- 82 DOAC Prescribing Checklist for Primary Care Providers------------------- 92 DOAC Monitoring Flowsheets------------------------------------------------- 94 DOAC AT-A-GLANCE drug information sheets------------------------------- 98 DOAC Initial Contact and Follow-up Flowchart----------------------------- 102 Patient Anticoagulation Medication Counseling Basics-------------------- 103 DOAC Reversal Agents-------------------------------------------------------- 104 DOAC Use for Cancer Related VTE------------------------------------------- 105 VTE Prevention in Ambulatory Cancer Patients---------------------------- 106 VIII Patient Education and Phone Interviews------------------------------------ 108 Assessing Compliance--------------------------------------------------------- 115 IX Workflow ---------------------------------------------------------------------- 116 HFMG Ambulatory Anticoagulation Services Training/Resource Manual – 5.2020 Page 1 of 193 • Prioritization of Daily tasks -------------------------------------------------- 116 • Steps for Processing INR Urgent, high, & regular Results --------------- 121 • Call Decision Flowchart------------------------------------------------------ 122 Patient Enrollment ----------------------------------------------------------- 123 Inpatient Admission ---------------------------------------------------------- 124 Hospital Discharge ----------------------------------------------------------- 124 Patient Disenrollment -------------------------------------------------------- 124 Faxed INR results ------------------------------------------------------------ 130 Home INR Testing ------------------------------------------------------------ 130 Procedure for Critical INR Results & Lovenox Renal Dose Adjustments 132 Procedure for Patients with AF undergoing PCI -------------------------- 133 Procedure for Patients who are Pregnant or Breastfeeding------------- 135 Procedure for Managing Patients Discharged on Fondaparinux --------- 137 X References 140 Appendix A Selected warfarin-Herbal Product Interactions 146 Appendix B Anticoagulation Clinic Orientation Checklist 150 Appendix C Job Descriptions 152 Appendix D Quick Reference Guides: ----------------------------------------------------- 161 • - Questions to Ask Lovenox (enoxaparin) Bridge Therapy Patients --- 161 • - Daily Task Reminders ----------------------------------------------------- 162 Appendix E Recommended DOAC Templates--------------------------------------------- 165 Appendix F I’CHECK’D DOAC Initiation Checklist---------------------------------------- 182 Appendix G Routine DOAC Monitoring Checklist----------------------------------------- 183 Appendix H DOAC Education Letters------------------------------------------------------ 186 Appendix I ICD-10 codes for Home INR Monitors--------------------------------------- 190 Anticoagulation Center of Excellence crest---------------------------------- 193 HFMG Ambulatory Anticoagulation Services Training/Resource Manual – 5.2020 Page 2 of 193 I. Physiology of Coagulation: Hemostasis is the body's way of stopping injured blood vessels from bleeding. Hemostasis includes clotting of the blood. Too much clotting can block blood vessels that are not bleeding; consequently, the body has control mechanisms to limit clotting and dissolve clots that are no longer needed. An abnormality in any part of this system that controls bleeding can lead to excessive bleeding or excessive clotting, both of which can be dangerous. When clotting is poor, even a slight injury to a blood vessel may lead to major blood loss. When clotting is uncontrolled, small blood vessels in critical places can become clogged with clots. Clogged vessels in the brain can cause strokes; clogged vessels leading to the heart can cause heart attacks; and pieces of clots from veins in the legs, pelvis, or abdomen can travel through the bloodstream to the lungs and block major arteries there (pulmonary embolism). Hemostasis involves three major processes: narrowing (constriction) of blood vessels, activity of platelets, and activity of blood clotting factors. An injured blood vessel constricts so that blood flows out more slowly and clotting can start. At the same time, the accumulating pool of blood outside the blood vessel (a hematoma) presses against the vessel, helping prevent further bleeding. As soon as a blood vessel wall is damaged, a series of reactions activates platelets so that they stick to the injured area. The "glue" that holds platelets to the blood vessel wall is von Willebrand factor, a protein produced by the cells of the vessel wall. The proteins collagen and thrombin act at the site of the injury to induce platelets to stick together. As platelets accumulate at the site, they form a mesh that plugs the injury. The platelets change shape from round to spiny, and they release proteins and other substances that entrap more platelets and clotting proteins in the enlarging plug that becomes a blood clot. HFMG Ambulatory Anticoagulation Services Training/Resource Manual – 5.2020 Page 3 of 193 Blood Clots: Plugging the Breaks When an injury causes a blood vessel wall to break, platelets are activated. They change shape from round to spiny, stick to the broken vessel wall and each other, and begin to plug the break. They also interact with other blood proteins to form fibrin. Fibrin strands form a net that entraps more platelets and blood cells, producing a clot that plugs the break. Formation of a clot also involves activation of a sequence of blood clotting factors that generate thrombin. Thrombin converts fibrinogen, a blood clotting factor that is normally dissolved in blood, into long strands of fibrin that radiate from the clumped platelets and form a net that entraps more platelets and blood cells. The fibrin strands add bulk to the developing clot and help hold it in place to keep the vessel wall plugged. The reactions that result in the formation of a blood clot are balanced by other reactions that stop the clotting process and dissolve clots after the blood vessel has healed. Without this control system, minor blood vessel injuries could trigger widespread clotting throughout the body—which actually happens in some diseases. II. Hypercoagulable
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