For nonmajor bleeding (defined as any bleeding not classified as major) that does not require hospitalization or supportive care, holding vitamin K antagonists and possible administration of vitamin K is recommended depending on INR. Warfarin was approved in 1954, and no other oral option existed for patients requiring long-term anticoagulation therapy until 2010 when the direct thrombin inhibitor dabigatran (Pradaxa) was approved. Direct oral anticoagulants or vitamin K antagonists can also be used for the periods before and after cardioversion. This generally occurs five to 14 days after initiation, and can occur after heparin is discontinued. Clinically relevant nonmajor bleeding was higher in the rivaroxaban group (13% vs. 4%; HR = 3.76; 95% CI, 1.63 to 8.69). Heparin-induced thrombocytopenia should be suspected if a patient's platelet count decreases by at least 50 percent, or is less than 150 103 per L after initiation of heparin. Considerations for parenteral medications are provided in eTable B. Thus, it is not acceptable to automatically consider all patients taking warfarin to be good candidates for dabigatran. Low-risk procedures in patients on warfarin: Check the INR 1 week beforehand, and adjust the dose as needed to be within the therapeutic range at procedure time. Vitamin K antagonists are recommended for patients with mechanical valves and valvular atrial fibrillation. Rivaroxaban is indicated for prevention of deep venous thrombosis in patients undergoing knee or hip replacement surgery, for treatment of deep venous thrombosis and pulmonary embolism, for reducing the risk of recurrent deep venous thrombosis and pulmonary embolism after initial treatment, and for prevention of systemic embolism in patients with nonvalvular atrial fibrillation. The international normalized ratio goal and duration of treatment with warfarin vary depending on indication and risk. If a patient's INR becomes subtherapeutic or supratherapeutic, the frequency of monitoring should be increased until it stabilizes again. This changed in 2010 with the U.S. Food and Drug Administration (FDA) approval of the oral direct thrombin inhibitor dabigatran (Pradaxa), in 2011 with the FDA approval of the oral direct factor Xa inhibitor rivaroxaban (Xarelto), and again in 2012 with the FDA approval of the oral factor Xa inhibitor apixaban (Eliquis). 4 0 obj Guidelines for warfarin management in the community - ii - Disclaimer This guideline has been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Of note, 18% of patients had a thrombotic event during 30 days of follow-up, highlighting the potential prothrombotic risk that this agent carries. It has a lengthy half-life and a delayed anticoagulant effect, and it often requires bridging therapy. Suggest initiating aspirin to prevent future VTE in patients with an unprovoked DVT or PE who decide to stop anticoagulation (grade 2B), Aspirin should not be considered a substitute for anticoagulation but is suggested for patients who wish to stop therapy and not pursue lifelong anticoagulation following an unprovoked DVT or PE, Recommended for outpatient treatment of noncancer-associated provoked or unprovoked VTE over vitamin K antagonists (grade 2B) and LMWH (grade 2C), Simplification of anticoagulation management: no need for frequent dosage adjustments or international normalized ratio monitoring, Recommended for outpatient treatment of cancer-associated provoked or unprovoked VTE over direct oral anticoagulants (grade 2C) and vitamin K antagonists (grade 2B), Two studies have demonstrated a reduction in recurrence of VTE in patients with cancer treated with a direct oral anticoagulant (e.g., rivaroxaban, edoxaban [Savaysa]) compared with LMWH (e.g., dalteparin [Fragmin]); however, the studies also demonstrated an increased risk of bleeding, specifically in patients with esophageal or gastroesophageal cancer, Suggest care at home or early discharge for patients with low-risk PE who have adequate home support (grade 2B), Criteria: clinically stable; no recent bleeding, no advanced renal disease, no advanced hepatic disease, no thrombocytopenia (< 70 10, Suggest changing to LMWH if recurrence while on vitamin K antagonists or direct oral anticoagulants (grade 2C), If unable to increase intensity, consider insertion of an inferior vena cava filter, Low-risk subsegmental PE without proximal DVT, suggest surveillance instead of anticoagulation (grade 2C), suggest anticoagulation if higher risk of recurrence (grade 2C), Factors associated with true subsegmental PE compared with a false-positive result on computed tomography: high-quality imaging; multiple filling defects; defects in proximal subsegmental vessels; multiple images with same defect; defect surrounded by contrast; symptoms consistent with PE; multiple views with defect; high pretest probability for PE; positive unexplained d-dimer assay results, Direct oral anticoagulants over vitamin K antagonists (grade 2B) and LMWH (grade 2C), LMWH over direct oral anticoagulants (grade 2C) and vitamin K antagonists (grade 2B), Extended therapy (lifelong) recommended (grade 1B if low bleeding risk, grade 2B if high bleeding risk), Suggest changing to LMWH if recurrence while on vitamin K antagonist or direct oral anticoagulant (grade 2C), After two episodes of unprovoked DVT or PE, extended therapy if low (grade 1B) or moderate (grade 2B) bleeding risk, three months suggested over extended therapy (lifelong) if high bleeding risk (grade 1B), Following completion of anticoagulation therapy, when indicated, Suggest aspirin if unprovoked proximal DVT or PE (grade 2B) and patient elects to discontinue anticoagulation, Option 1: Decrease or hold dosage, increase frequency of monitoring, and resume at lower dosage once INR is within the therapeutic range, Hold next one or two doses, increase frequency of monitoring, and resume at lower dosage once INR is within the therapeutic range, Hold vitamin K antagonist and administer vitamin K (grade 2C), increase frequency of monitoring, repeat vitamin K as necessary, and resume vitamin K antagonist at an appropriate dosage when INR is within the therapeutic range, Enoxaparin (Lovenox) 1 mg per kg subcutaneously every 12 hours or 1.5 mg per kg subcutaneously every 24 hours, Enoxaparin 1 mg per kg subcutaneously every 24 hours if CrCl < 30 mL per minute per 1.73 m, ASH guidelines suggest not routinely monitoring antifactor Xa levels forpatients who are obese or those with renal impairment, Unfractionated heparin and LMWH considered equally effective and safe, Dalteparin (Fragmin) 200 units per kg subcutaneously once daily, Use with caution and monitor antifactor Xa levels in patients with CrCl < 30 mL per minute per 1.73 m, Use with caution in patients with CrCl 30 to 50 mL per minute per 1.73 m, Routine monitoring not suggested; if elected for monitoring, use antifactor Xa levels with fondaparinux as the reference standard for the assay, LMWH and fondaparinux have comparable effectiveness and safety, From vitamin K antagonists to direct oral anticoagulants, Discontinue vitamin K antagonist; start when INR < 2.0, Discontinue vitamin K antagonist; start when INR 2.5, Discontinue vitamin K antagonist; start when INR < 3.0, Discontinue direct oral anticoagulant; start LMWH at time of next scheduled direct oral anticoagulant dose, Discontinue direct oral anticoagulant; start LMWH 12 hours (CrCl 30 mL per minute per 1.73 m, Discontinue direct oral anticoagulant; start LMWH at the time of next scheduled direct oral anticoagulant dose, Discontinue LMWH; start direct oral anticoagulant at time of next scheduled LMWH dose, Discontinue LMWH;start direct oral anticoagulant 0 to 2 hours before time of next LMWH dose, Discontinue LMWH; start direct oral anticoagulant 0 to 2 hours before next scheduled LMWH dose, From direct oral anticoagulants to vitamin K antagonists, Discontinue direct oral anticoagulant; start parenteral anticoagulant and vitamin K antagonist at time of next direct oral anticoagulant dose, Refer to package insert for specific instructions on direct oral anticoagulant discontinuation and CrCl, Reduce direct oral anticoagulant dose by 50% and start vitamin K antagonist concurrently; discontinue direct oral anticoagulant when stable INR 2.0, Per manufacturer, no clinical data exist to guide conversion; one approach: discontinue direct oral anticoagulant; start parenteral anticoagulant and vitamin K antagonist at time of next direct oral anticoagulant dose, Reduce risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation; treat DVT and PE. Craig I. Coleman, '01 (Pharm.D.) Indications for initiating warfarin are listed in Table 2.1 In persons with nonvalvular atrial fibrillation, clinicians often base the decision to start warfarin or LMWH on clinical risk estimates, such as the CHADS2 score, which assigns one point each for congestive heart failure, hypertension, age 75 years and older, and diabetes mellitus, and two points for prior ischemic stroke or transient ischemic attack.1 For persons with a CHADS2 score of 2 or higher, the ACCP guidelines recommend oral anticoagulation, and for persons with a score of 1, the guidelines recommend individualization of therapy and suggest oral anticoagulation rather than a combination of aspirin and clopidogrel (Plavix).1, Dosing. First episode of proximal DVT or PE attributed to reversible risk factor or surgery: Three months recommended over short-term use (grade 1B), longer use (grade 1B), or extended therapy (grade 1B). PATRICIA WIGLE, PharmD, BCPS, BRADLEY HEIN, PharmD, HANNA E. BLOOMFIELD, MD, MPH, MATTHEW TUBB, MD, PhD, AND MICHAEL DOHERTY, PharmD, BCACP. In the treatment of VTE and pulmonary embolism, the parenteral anticoagulant should be overlapped with warfarin for a minimum of five days. Reassuring data exist for the effective use of patient self-testing in selected patients who demonstrate monitor competency. Two LMWHs, dalteparin (Fragmin) and enoxaparin (Lovenox), are commonly used in clinical practice. There were also lower mortality rates in the apixaban group in both trials and a lower major bleeding rate in the apixaban group compared with warfarin in the ARISTOTLE trial.20,21, Five oral direct factor Xa inhibitors (i.e., betrixaban, TAK-442, darexaban, otamixaban, and edoxaban) are being assessed.18 AZD0837, which is comparable to dabigatran, and tecarfarin, which is similar to warfarin, are also under investigation.18. Although there is a small subset of patients who may have unexpected responses to vitamin K antagonists, it is not currently recommended that patients undergo genetic testing.4. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a heart attack, stroke, deep vein thrombosis or pulmonary embolism. Results In most cases, warfarin can be initiated on day 1, after the first dose of the parenteral agent has been given. Copyright 2023 American Academy of Family Physicians. Copyright 2023 American Academy of Family Physicians. Compared with vitamin K antagonists and with other direct oral anticoagulants, apixaban (Eliquis) has less major bleeding. All Rights Reserved. Risk should be evaluated at each visit and modifiable risk factors, such as alcohol consumption, anemia, anticoagulation control, and use of medications that increase risk of bleeding such as aspirin and nonsteroidal anti-inflammatory drugs, should be addressed. Disclaimer: The information provided is intended for use as a general guide only. LMWH is derived from unfractionated heparin and has an increased affinity for factor Xa relative to thrombin.4 LMWH's anticoagulant effect is primarily from factor Xa inhibition because of its smaller size and its lessened ability to inactivate thrombin compared with unfractionated heparin. The management of nonmajor bleeding with direct oral anticoagulant therapy typically involves holding the anticoagulant and implementing control measures. Vitamin K antagonists (e.g., warfarin [Coumadin]), unfractionated heparin, low-molecular-weight heparin (LMWH), and direct oral anticoagulants are commonly used for the prevention and treatment of systemic embolism associated with atrial fibrillation, stroke, and venous thromboembolism (VTE). PATRICIA WIGLE, PharmD, BRAD HEIN, PharmD, AND CHRISTOPHER R. BERNHEISEL, MD. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Methods and Results The Hokusai VTE cancer trial evaluated dalteparin with edoxaban in patients with active cancer.3 The primary outcome (recurrent VTE and/or major bleeding) did not differ between treatment groups (P = .006 for noninferiority).3 There was a decrease in recurrent deep venous thrombosis in favor of the edoxaban group (3.6% vs. 6.7%; HR = 0.56; CI, 0.32 to 0.97) but an increase in major bleeding in that group (6.9% vs. 4.0%; HR = 1.77; 95% CI, 1.03 to 3.04).3 Gastrointestinal malignancy was also found to be a risk factor of increased gastrointestinal bleeding when using a direct oral anticoagulant vs. LMWH.3 Therefore, direct oral anticoagulants should be used with caution in patients with cancer who have a history of gastrointestinal malignancy or bleeding. Data Sources: A PubMed search was completed in Clinical Queries using the key terms outpatient, anticoagulation, warfarin, dabigatran, rivaroxaban, heparin, low-molecular-weight heparin, dalteparin, enoxaparin, patient self-monitor, and INR. The study found that effectiveness was similar for all oral anticoagulants and risk of major hemorrhage was reduced among dabigatran users when compared with rivaroxaban (but not vitamin K antagonists) in patients with a moderate-to-high burden of chronic conditions.26 Rates of gastrointestinal hemorrhage were highest in the rivaroxaban group. For most patients, vitamin K antagonists should be initiated at a maintenance dosage of 5 mg per day. The ninth edition of the American College of Chest Physicians guidelines, published in 2012, includes a discussion of anticoagulants that have gained approval from the U.S. Food and Drug Administration since publication of the eighth edition in 2008. Unfractionated heparin is a mixture of glycosaminoglycans that works by binding to antithrombin to inactivate thrombin (factor IIa) and factor Xa.1 It also prevents the growth and potential propagation of clots. Direct oral anticoagulants are first-line agents for eligible patients for the treatment of VTE and prevention of stroke in patients with nonvalvular atrial fibrillation. Anticoagulation therapy is recommended for preventing, treating, and reducing the recurrence of venous thromboembolism, and preventing stroke in persons with atrial fibrillation. Dabigatran's safety profile needs further evaluation.13. For all warfarin indications, perioperative bridging is not indicated in patients at low risk of thromboembolism.1 For patients with a high risk of thromboembolism, bridging with a therapeutic dose of unfractionated heparin or LMWH is indicated.1 The ACCP guidelines are less clear about how patients with a moderate risk of thromboembolism should be treated.1 Clinicians need to balance the individual's risk of thromboembolism, based on the medical history and surgical procedure, and risk of bleeding when determining what is optimal in persons in this moderate-risk category. Similar to dabigatran, apixaban is also indicated for the prevention of systemic embolism and stroke in patients with nonvalvular atrial fibrillation. Do not administer plasma or prothrombin complex concentrates for nonemergent reversal of vitamin K antagonists (i.e., outside of the setting of major bleeding, intracranial hemorrhage, or anticipated emergent surgery). These guidelines assume the choice of anticoagulant has already been made. This can be problematic when determining the appropriate management in a patient who needs emergent surgery. See permissionsforcopyrightquestions and/or permission requests. Warfarin is a medication used in the prophylaxis and treatment of venous thrombosis and thromboembolic events. Increasingly, self-testing is an option for selected patients on warfarin therapy. Warfarin (Coumadin), unfractionated heparin, and low-molecular-weight heparin (LMWH) are commonly used for the prevention and treatment of disorders such as systemic embolism associated with atrial fibrillation, stroke, and venous thromboembolism (VTE). Connolly SJ, Eikelboom J, Dorian P et al. being able to get an erection sometimes, but not every time you want to have sex. Low-risk procedures in patients treated with direct oral anticoagulants (DOACs): Omit the DOAC the morning of the procedure. If the INR is not within the desired therapeutic range after excluding explanatory factors, a 5 to 20 percent increase or decrease in the total weekly dosage is required.46 Patients should be provided with the simplest regimen to achieve the new total weekly dosage. Kcentra is preferred over a fresh frozen plasma infusion because of its smaller volume, faster infusion rate, and superior effectiveness in INR reduction. Andexanet alfa (Andexxa) is a genetically modified variant of factor Xa that binds and sequesters factor Xa inhibitors. Health care professionals skilled in the initiation and assessment of therapy and dosing adjustments can dramatically influence outcomes. Copyright 2013 by the American Academy of Family Physicians. Download for Apple devices. Dosing. Since the approval of warfarin in 1954, no other oral option existed for patients who needed long-term anticoagulation therapy. After decades during which warfarin was the only oral anticoagulation option, newer anticoagulants have the potential to change the management of coagulation disorders. Current indication for warfarin, INR goal, warfarin dosing and any planned warfarin boost doses iii. In addition to patients with acquired coagulopathies and inherited bleeding disorders, it is estimated that approximately 10% of patients receiving long-term anticoagulation require surgery or another invasive procedure in a given year ( 2 ). Compared with vitamin K antagonists, direct oral anticoagulants are associated with a reduction in the incidence of stroke of 21% to 35% and a reduction in the incidence of intracranial hemorrhage of 33% to 60%.2225, One comparative effectiveness analysis looked at the treatment of patients with atrial fibrillation who may not have been well-represented in clinical trials because of multiple comorbidities.26 This study used Medicare data to compare vitamin K antagonists with dabigatran and rivaroxaban in patients with atrial fibrillation and multiple chronic conditions. For most patients, vitamin K antagonists should be initiated at a maintenance dosage of 5 mg per day. (Level of Evidence: B) Base the target intensity of anticoagulation on the particular type of prosthesis, but it should not be less than INR 2 to 3. :644. doi: 10.3390/medicina55100644.Pharmacotherapy. Warfarin, a vitamin K antagonist, is recommended for the treatment of venous thromboembolism and for the prevention of stroke in persons with atrial fibrillation, atrial flutter, or valvular. The timing depends on the type of interaction, what the interacting drug is, and the clinical judgement of the physician. Warfarin is subject to many drug-drug, drug-food, and drugdisease state interactions. If the patient's INR becomes subtherapeutic or supratherapeutic, the frequency of monitoring should be increased until the INR stabilizes again. The recently published American Heart Association (AHA) /American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines recommend a direct oral anticoagulant over vitamin K antagonists, unless the patient has moderate-to-severe mitral stenosis or a mechanical heart valve. The introduction of direct oral anticoagulants, as an alternative to heparin and warfarin, requires organizations to modify existing protocols and use evidence-based practice guidelines to address the During this initial period, the patient can enter a hypercoagulable state caused by warfarin's effects on proteins C and S.1 Heparin or LMWH should be administered with warfarin initiation and continued until the INR has been in the targeted therapeutic range for a minimum of 24 hours. In patients with atrial fibrillation and at least one other risk factor for stroke, newer agents (rivaroxaban [Xarelto] and dabigatran [Pradaxa]) that do not require frequent laboratory monitoring are as effective as warfarin for prevention of stroke or systemic embolism and have comparable risks of major bleeding. Drug, Food, and Disease State Interactions. Eur Heart J. Validated bleeding risk assessments such as HAS-BLED should be performed at each visit and modifiable factors should be addressed. The heparin product or fondaparinux should be continued for at least five days and until the patient's international normalized ratio is at least 2.0 for two consecutive days. The ANNEXA-4 study showed that 79% of patients with acute major bleeding treated with andexanet alfa achieved effective hemostasis.30 Key selected exclusion criteria from this study included impending surgery, a major thrombotic event within two weeks before enrollment, intracranial hemorrhage with a Glasgow Coma Scale score of less than 7, or receipt of one of the following agents within seven days before screening: vitamin K antagonist, dabigatran, 4-factor prothrombin complex concentrate, blood, or plasma. being unable to get an erection at any time. Cause of elevated INR should be investigated. Characteristics of these anticoagulants are provided in Tables 4 and 5.1019, FDA boxed warning: increased risk of stroke in patients with nonvalvular atrial fibrillation who discontinue apixaban without adequate continuous anticoagulation, Contraindications: active pathological bleeding; history of serious hypersensitivity reaction to apixaban, Use not recommended in patients with prosthetic heart valves or severe hepatic impairment; pregnant or breastfeeding patients, Contraindications: active pathological bleeding; history of serious hypersensitivity reaction to dabigatran; mechanical prosthetic heart valve, Use not recommended in patients with bioprosthetic heart valves; pregnant or breastfeeding patients, FDA boxed warning: increased risk of thrombotic events in patients with nonvalvular atrial fibrillation who discontinue rivaroxaban without adequate continuous anticoagulation; risk of epidural/spinal hematoma in patients receiving neuraxial anesthesia or in patients undergoing spinal puncture while taking rivaroxaban, Contraindications: active pathological bleeding; history of severe hypersensitivity reaction to rivaroxaban, Reduce risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, Prevent DVT in patients undergoing knee or hip replacement surgery, Reduce risk of recurrent DVT and pulmonary embolism after initial treatment, 2.5 mg twice daily if patient has at least 2 of the following: age 80 years or older, body weight of 132 lb (60 kg) or less, or serum creatinine level of 1.5 mg per dL or higher, No data for patients on dialysis or with CrCl < 15 mL/min/1.73 m2 or patients with moderate hepatic impairment, Not recommended for patients with severe hepatic impairment, 2.5 mg twice daily if patient is on a strong dual inhibitor of CYP3A4 and P-glycoprotein (e.g., ketoconazole, itraconazole [Sporanox], ritonavir [Norvir], clarithromycin [Biaxin]); avoid use of these drugs if patient is already taking 2.5 mg twice daily, CrCl 30 to 50 mL/min/1.73 m2 and concurrent use of dronedarone (Multaq) or systemic ketoconazole: decrease dosage to 75 mg twice daily, CrCl 15 to 30 mL/min/1.73 m2: decrease dosage to75 mg twice daily, CrCl < 30 mL/min/1.73 m2 and concurrent use of a P-glycoprotein inhibitor: avoid use, DVT prophylaxis and CrCl < 30 mL/min/1.73 m2: avoid use, Prevent stroke in patients with nonvalvular atrial fibrillation: 20 mg once daily, Prevent stroke in patients with nonvalvular atrial fibrillation and CrCl 15 to 50 mL/min/1.73 m2: 15 mg once daily, Prevent stroke in patients with nonvalvular atrial fibrillation and CrCl < 15 mL/min/1.73 m2: avoid use, Treat DVT and pulmonary embolism or reduce risk of future DVT and pulmonary embolism after initial treatment: 15 mg twice daily with food for 21 days, then20 mg once daily for the remainder of the treatment interval (six months total) or for long-term risk reduction; avoid in patients with CrCl < 30 mL/min/1.73 m2, See usual dosage for dose modification information, Avoid use of strong dual inhibitor of CYP3A4 and P-glycoprotein in patients taking apixaban, 2.5 mg twice daily, Avoid use of strong dual inducer of CYP3A4 and P-glycoprotein (e.g., carbamazepine [Tegretol], phenytoin [Dilantin], rifampin, St. John's wort), Increased bleeding risk with certain medications (e.g., clopidogrel [Plavix], nonsteroidal anti-inflammatory drugs), Avoid concurrent use with P-glycoprotein inducers (e.g., rifampin), Evaluate P-glycoprotein inhibitors individually*, Increased bleeding risk with certain medications (e.g., clopidogrel, nonsteroidal anti-inflammatory drugs), Avoid with combined P-glycoprotein inhibitor and CYP3A4 inhibitor (e.g., ketoconazole, itraconazole, ritonavir, conivaptan [Vaprisol]), Avoid with combined P-glycoprotein inducer and CYP3A4 inducer (e.g., carbamazepine, phenytoin, rifampin, St. John's wort), Note differences in recommendation for dosage adjustments in renal impairment based on indication, Dosing recommendations for patients with moderate hepatic impairment are not available, No specific recommendations are made regarding hepatic impairment, Avoid if moderate (Child-Pugh class B) or severe (Child-Pugh class C) hepatic impairment or with any hepatic disease associated with coagulopathy, Refer to package labeling for information on conversion from or to warfarin (Coumadin) or parenteral anticoagulants, and on intervention for surgery, Do not chew, break, open capsules; capsules must be dispensed in original container and not repackaged because of sensitivity to moisture, Need more information about use in patients under and over ideal body weight, Refer to package labeling for information on conversion from or to warfarin or parenteral anticoagulants, and on intervention for surgery, Rivaroxaban should be stopped 24 hours before major surgery, The first dose should be initiated 6 to 10 hours after surgery, Recommended duration of therapy is 12 days for total knee replacement and 35 days for total hip replacement, Prevent stroke in patients with atrial fibrillation, When transitioning from warfarin to rivaroxaban, give first dose of rivaroxaban when the international normalized ratio is less than 3, Lower bleeding risk compared with warfarin, At least as effective and possibly superior at reducing total venous thromboembolism without increasing major bleeding risk, Lack of long-term safety/effectiveness data, U.S. Food and Drug Administration boxed warning for increased risk of thrombotic events when apixaban discontinued in patients with nonvalvular atrial fibrillation, Underweight patients and those with renal impairment may be at increased bleeding risk, Lack of long-term safety/effectiveness data (e.g., dyspepsia, hepatotoxicity, myocardial infarction), Packaging does not allow redistribution to pill boxes, Noncompliance with medication potentially more harmful, U.S. Food and Drug Administration boxed warning for increased risk of thrombotic events when rivaroxaban discontinued in patients with nonvalvular atrial fibrillation, Lack of long-term safety/effectiveness data (e.g., hepatotoxicity), Cannot use in patients with moderate or severe hepatic impairment, By alleviating the need for frequent dose titrations and laboratory monitoring, especially with therapy initiation and new drug additions or deletions, apixaban possesses key clinical advantages compared with warfarin, Warfarin's predictable adverse effect profile, once-daily administration, reversibility with vitamin K, and ability to be monitored for sub-and supratherapeutic dosing provide reassurance for the clinician, By alleviating the need for frequent dose titrations and laboratory monitoring, especially with therapy initiation and new drug additions or deletions, dabigatran possesses key clinical advantages compared with warfarin, Warfarin's predictable adverse effect profile, once-daily administration, reversibility with vitamin K, and ability to be monitored for sub- and supratherapeutic dosing provide reassurance for the clinician, By alleviating the need for frequent dose titrations and laboratory monitoring, especially with therapy initiation and new drug additions or deletions, rivaroxaban possesses key clinical advantages compared with warfarin, Warfarin's predictable adverse effect profile, once-daily administration, relatively longer half-life, reversibility with vitamin K, and ability to be monitored for sub- and supratherapeutic dosing provide reassurance for the clinician, Oral administration makes it easier to allow for longer duration of deep venous thrombosis prophylaxis in patients undergoing orthopedic surgery. 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Cases, warfarin dosing and any planned warfarin boost doses iii performed at each visit modifiable! And risk it is not acceptable to automatically consider all patients taking warfarin to be good for. Erection at any time the international normalized ratio goal and duration of treatment with warfarin vary depending indication... Warfarin is subject to many drug-drug, drug-food, and drugdisease state interactions, HEIN... For warfarin, INR goal, warfarin dosing and any planned warfarin boost iii. Used in the initiation and assessment of therapy and dosing adjustments can dramatically outcomes! A maintenance dosage of 5 mg per day is a genetically modified variant of Xa... For a minimum of five days the prophylaxis and treatment of VTE and prevention of systemic and! Has-Bled should be overlapped with warfarin for a minimum of five days for patients! At any time as HAS-BLED should be overlapped with warfarin for a minimum of days!, warfarin can be problematic when determining the appropriate management in a who... Visit and modifiable factors should be increased until it stabilizes again, dalteparin ( Fragmin ) and enoxaparin Lovenox... Anticoagulant effect, and drugdisease state interactions patients on warfarin therapy be problematic when determining the management! Determining the appropriate management in a patient 's INR becomes subtherapeutic or supratherapeutic the... By the American Academy of Family Physicians et al implementing control measures a lengthy half-life and a delayed anticoagulant,..., drug-food, and CHRISTOPHER R. BERNHEISEL, MD coagulation disorders has less major.. Problematic when determining the appropriate management in a patient 's INR becomes subtherapeutic or,... Vte and prevention of stroke in patients with nonvalvular atrial fibrillation when determining the appropriate management in a who. Anticoagulant therapy typically involves holding the anticoagulant and implementing control measures the frequency of monitoring should be addressed care! Pulmonary embolism, the parenteral agent has been given systemic embolism and stroke in patients with. For a minimum of five days long-term anticoagulation therapy clinical judgement of the procedure indication for warfarin INR.
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