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Anticoagulation - Coggle Diagram
Anticoagulation
Apixaban
Adverse effects: bleeding - common, seek immediate medical advise in spontaneous bleeding occurs and does not stop or recurs. Common - anaemia, bruising, nausea, skin reactions.
Key drug interactions: NSAIDs, other anticoagulants, antiplatelets, St John's wart, SSRI inhibitors
Caution: Elderly, body weight of 60kg or less, severe renal impairment (dose reductions). Concurrent drug treatment with other drugs that cause bleeding such as NSAIDs.
Further information on CKS on switching between preparations of anticoagulation
Contraindications: creatinine clearance < 15mL/minute, liver disease associated with coagulopathy and clinically relevant bleeding risk, prosthetic heart valve, antiphospholipid syndrome and active bleeding, people with a significant major risk of bleeding and women who are pregnant/breastfeeding.
If surgery or any other invasive procedure is required, they may need to temporarily stop taking apixaban. The decision to stop and when will depend of each the person's risk of thromboembolic event and bleeding risk with procedure.
Used for the prophylaxis of stroke and systemic embolism, treatment of DVT and PE, prophylaxis of recurrent DVT and PE in adults, prophylaxis of VTE in people who have undergone hip replacement surgery and prophylaxis of VTE in people who have undergone knee replacement surgery.
Monitoring - there is no need to monitor INR however regular follow up monitoring recommended. At the start of treatment baseline clotting screen, renal and liver tests and FBC - once treatment started follow up between 1-3 months there after intervals dependent on individual (age, comorbidities, renal function.
During review- adherence to treatment, signs of bleeding or anaemia, adverse effects, features of thromboembolic events, use of other medications including OTC, assess and minimize modifiable risk factors, give appropriate advise and information. Repeat renal and liver function tests yearly for most.
Advise on regular dosing schedule, seek immediate medical advise in spontaneous bleeding which does not stop or recurs or in any dosing error, may have to stop treatment in surgical/dental treatments, read patient information leaflet, and carry and alert card.
Warfarin
Adverse effects: bleeding common in all anticoagulants. See BNF for further side effects.
Key drug interactions: Alcohol, amiodarone, antibiotics, antidepressants, aspirin, azoles, cranberry juice/products, direct-acting antiviral medications, glucosamine, NSAIDs, Tamoxifen and thyroxine.
Weight gain, diarrhoea and vomiting may reduce the effects of warfarin.
Dose reduction may be required in weight loss, acute illness, smoking cessation as warfarin effects may be exaggerated.
If a person need to have surgery or any other invasive procedure they may need to temporarily stop taking warfarin, dependent on the procedure and bleeding risk.
Caution: Elderly people, increased risk of bleeding, risk factors for bleeding, thrombophillia, thyroid disorders, risk factors for over coagulation (severe hypertension, severe renal impairment, or hepatic impairment) or mild/moderate hepatic/renal impairment.
Monitoring - INR - starting daily/alternate days then twice weekly, then monitoring intervals are dependent on the stability of the INR. All results should be in Yellow book with their dose instructions and next appointment time.
Contraindications: Haemorrhagic stroke, clinically significant bleeding, severe hepatic impairment, within 72 hours of major surgery with risk of severe bleeding, within 48 hours of postpartum, pregnant women, drugs where interactions lead to a significantly increased risk of bleeding.
Target INR usually between 2.5 - 3.5 dependent on condition.
Baseline prothrombin measurements are taken before starting warfarin treatment. Doses are tailored to the individual person's requirements and should be taken at the same time each day. Duration of treatment is dependent on the indications and individual factors.
Mode of action: Main use is to prevent thrombus formation or extension of an existing thrombus in the slower-moving venous side of the circulation. There are two main types of oral anticoagulants: Vitamin K antagonists (VKAs) (Warfarin) and direct oral anticoagulants (DOACs) (Apixiban, dagatran, edoxaban, rivaroxaban). Each formulation has different lixensed indications for use.
See BNF/CKS for information about other oral anticoagulation drugs.