Patient handout

Anticoagulation management

PRODUCTION

1. Your condition

This handout is for anticoagulation management. Your care team identified this based on: new vte (dvt or pe) requiring anticoagulation initiation — ash 2020; accp at10 kearon chest 2016.

Other reasons your team may use this plan: non-valvular atrial fibrillation with cha2ds2-vasc indication for anticoagulation — ash 2020; mechanical heart valve requiring lifelong warfarin anticoagulation — accp at10 kearon chest 2016; perioperative anticoagulation management — interruption, bridging, or continuation — pause douketis nejm 2019; bridge douketis nejm 2015.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
apixaban	5 mg BID	PO	BID	ARISTOTLE showed apixaban superior to warfarin for stroke prevention with significantly less major bleeding and lower GI bleeding than other DOACs — Granger NEJM 2011

Plan: DOAC vs warfarin selection for anticoagulation — ASH 2020; ACCP AT10 Kearon Chest 2016

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable on anticoagulation — no bleeding, therapeutic range — ASH 2020

If you have:

INR 2.0-3.0 (warfarin) at last check — ACCP AT10 Kearon Chest 2016
Taking DOAC as prescribed without missed doses — ASH 2020
No bleeding symptoms — ASH 2020

Do this:

Take medication at the same time(s) every day — ASH 2020
Rivaroxaban: always take with food — Patel NEJM 2011
Warfarin: maintain consistent vitamin K intake (do not eliminate green vegetables, keep intake steady) — ACCP AT10 Kearon Chest 2016
Carry medical alert card/bracelet at all times — ASH 2020
Inform all healthcare providers (including dentist) of anticoagulation — ASH 2020
Avoid NSAIDs and aspirin unless prescribed — ASH 2020
Keep follow-up appointments for INR checks (warfarin) or labs (DOACs) — ASH 2020

YELLOW — Caution — minor bleeding or missed doses — ASH 2020

If you have:

Unusual bruising, prolonged bleeding from cuts — ASH 2020
Nosebleeds lasting >10 min — ASH 2020
Pink or dark urine — ASH 2020
Missed one dose of DOAC or uncertain if took dose — ASH 2020
INR 3.5-5.0 above target (warfarin) — ACCP AT10 Kearon Chest 2016

Do this:

Contact anticoagulation clinic or provider within 24 h — ASH 2020
Missed DOAC dose: take if <6 h late (BID) or <12 h late (daily); otherwise skip and resume normal schedule — ASH 2020
Apply direct pressure for 15 min to bleeding sites — ASH 2020
Do not double up doses — ASH 2020

RED — Emergency — major bleeding or thrombotic event — ASH 2020

If you have:

Vomiting blood or coffee-ground emesis — ASH 2020
Black tarry stools or bright red blood per rectum — ASH 2020
Sudden severe headache, vision change, or weakness (ICH or stroke) — ASH 2020
Coughing up blood — ASH 2020
Sudden leg swelling, chest pain, or shortness of breath (new clot despite anticoagulation) — ASH 2020

Do this:

Call 911 immediately — ASH 2020
Tell EMS which anticoagulant you take, dose, and last dose time — ASH 2020
Bring medication bottles or list to the ED — ASH 2020
Do NOT take additional anticoagulant doses until medically evaluated — ASH 2020

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Major bleeding on anticoagulation: intracranial hemorrhage, GI hemorrhage with hemodynamic instability, retroperitoneal bleed — ASH 2020(life-threatening)
Warfarin INR >9 without bleeding — ACCP AT10 Kearon Chest 2016
Heparin-induced thrombocytopenia confirmed (positive PF4/heparin ELISA + SRA or high clinical probability 4T >=6) — ASH 2018(life-threatening)
New DVT/PE documented while on therapeutic anticoagulation with confirmed compliance — ASH 2020

5. Follow-up

Duration decision: provoked VTE 3-6 months; unprovoked VTE consider indefinite (D-dimer guided cessation — ACCP AT10 Kearon Chest 2016); AF indefinite if CHA2DS2-VASc >=2 males / >=3 females; mechanical valve lifelong; annual reassessment of indication, bleeding risk, renal function; patient self-management education for warfarin if appropriate — ASH 2020; ACCP AT10 Kearon Chest 2016

6. Sources

Guideline: ASH 2020 VTE management guidelines + ACCP AT10 Kearon Chest 2016 antithrombotic therapy for VTE + BRIDGE trial Douketis NEJM 2015 + PAUSE trial Douketis NEJM 2019 + ANNEXA-4 trial Connolly NEJM 2019