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SIGN 129 • Antithrombotics: Indications and Management Help us to improve SIGN guidelines - click here to complete our survey SIGN 129 • Antithrombotics: indications and management A national clinical guideline Updated June 2013 Evidence KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1 - Meta-analyses, systematic reviews, or RCTs with a high risk of bias High quality systematic reviews of case control or cohort studies ++ 2 High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the 2+ relationship is causal 2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results A body of evidence including studies rated as 2++, B directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ A body of evidence including studies rated as 2+, C directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ Evidence level 3 or 4; or D Extrapolated evidence from studies rated as 2+ GOOD PRACTICE POINTS Recommended best practice based on the clinical experience of the guideline development group NHS Evidence has accredited the process used by Scottish Intercollegiate Guidelines Network to produce guidelines. Accreditation is valid for three years from 2009 and is applicable to guidance produced using the processes described in SIGN 50: a guideline developer’s handbook, 2008 edition (www.sign.ac.uk/guidelines/fulltext/50/index. html). More information on accreditation can be viewed at www.evidence.nhs.uk Healthcare Improvement Scotland (HIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. SIGN guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline. This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at www.sign.ac.uk/guidelines/fulltext/50/index.html. The EQIA assessment of the manual can be seen at www.sign. ac.uk/pdf/sign50eqia.pdf. The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www.sign.ac.uk. This document is produced from elemental chlorine-free material and is sourced from sustainable forests. Scottish Intercollegiate Guidelines Network Antithrombotics: indications and management A national clinical guideline August 2012 Updated June 2013 Antithrombotics: indications and management Scottish Intercollegiate Guidelines Network Gyle Square, 1 South Gyle Crescent Edinburgh EH12 9EB www.sign.ac.uk First published August 2012 Updated June 2013 ISBN 978 1 905813 91 9 Citation text Scottish Intercollegiate Guidelines Network (SIGN). Antithrombotics: indications and management. Edinburgh: SIGN; 2012. (SIGN publication no. 129). [August 2012]. Available from URL: http://www.sign.ac.uk SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland. Antithrombotics: indications and management Contents Contents 1 Introduction ......................................................................................................................................................................1 1.1 The need for a guideline ...................................................................................................................................................................... 1 1.2 Remit of the guideline .......................................................................................................................................................................... 1 1.3 Statement of intent ................................................................................................................................................................................ 2 2 Key recommendations ....................................................................................................................................................4 2.1 Antiplatelet agents ................................................................................................................................................................................. 4 2.2 Atrial fibrillation: prophylaxis of systemic embolism ................................................................................................................. 4 2.3 Primary prophylaxis of vascular disease ......................................................................................................................................... 4 2.4 Cerebrovascular disease ....................................................................................................................................................................... 4 3 Antiplatelet agents ..........................................................................................................................................................5 3.1 Aspirin ......................................................................................................................................................................................................... 5 3.2 Dipyridamole ............................................................................................................................................................................................ 6 3.3 Clopidogrel................................................................................................................................................................................................ 6 4 Parenteral anticoagulation ............................................................................................................................................9 4.1 Unfractionated heparin ........................................................................................................................................................................ 9 4.2 Low molecular weight heparins ........................................................................................................................................................ 10 4.3 Fondaparinux ........................................................................................................................................................................................... 12 4.4 Danaparoid ............................................................................................................................................................................................... 12 5 Oral anticoagulation with vitamin K antagonists ......................................................................................................13 5.1 Introduction .............................................................................................................................................................................................. 13 5.2 Initiation, dosage and monitoring of oral anticoagulants ....................................................................................................... 14 5.3 Reversal of oral anticoagulant therapy in patients with bleeding or high INR ................................................................ 15 5.4 Management of VKA therapy for invasive procedures ............................................................................................................. 16 5.5 Recommencing VKA therapy following a major bleeding event .......................................................................................... 17 5.6 Pharmacogenomics and warfarin ..................................................................................................................................................... 18 5.7 Interactions ............................................................................................................................................................................................... 18 5.8 The role of the pharmacist or nurse specialist in anticoagulation clinics ..........................................................................
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