Side Effects
How to REVERSE bleeding due to Pradaxa or Xarelto
As a hospital pharmacist, the new oral anticoagulants are bringing up questions about how to reverse bleeding due to Pradaxa or Xarelto . Antidotes for Pradaxa (dabigatran) or Xarelto (rivaroxaban) are NOT available in many hospitals, like vitamin K for warfarin . But there are things you can do. Stopping the anticoagulant and w…
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Warfarin
When to Rely on WARFARIN Instead of a DOAC
As a clinical pharmacist, you will need to know when and why warfarin is sometimes preferred over a direct oral anticoagulant (DOAC). We’ve seen DOACs ( Eliquis , etc) take the lead for most uses, such as for atrial fibrillation or venous thromboembolism (VTE). But sometimes warfarin is still the go-to. Continue to rely on warfarin for patien…
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DOACs
Ensure appropriate DOAC dosing
As a clinical pharmacist, you are in a key position to prevent direct oral anticoagulant (DOAC) dosing errors. Advocate for a pharmacist-to-dose protocol, recent evidence suggests this can reduce DOAC errors by almost half. Require an indication for DOAC orders and when documenting home DOACs to verify appropriate dosing. And include other key factors within your pr…
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Warfarin
DIET may interfere with warfarin therapy
As a nutrition support pharmacist, you should discuss with your patients who take warfarin ( Marevan ) about the interaction with food. Many patients are caught by surprise when fad diets or special foods interfere with their warfarin therapy . Most patients know that green leafy vegetables and other foods with high vitamin K can decrease warfarin's efficacy, (s…
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Stroke
Clinical pharmacology of DOACs
Mechanism of action ㅡ Direct Oral Anticoagulants (DOACs) or Non-Vitamin K Antagonist Oral Anticoagulant (NOACs) are Direct Thrombin Inhibitors (e.g., Dabigatran) and Factor Xa Inhibitors (e.g. Rivaroxaban, Apixaban, Edoxaban) with prothrombinase activity, thus inhibiting the conversion of prothrombin to thrombin, see figure 1 . Thrombin c…
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Dual Antiplatelet Therapy
Limit bleeding risk in patients on triple antithrombotic therapy
How to manage patients on an anticoagulant (warfarin, etc) who also need antiplatelet medications ( aspirin , etc)? ㅡ Many patients end up on " triple antithrombotic therapy " such as warfarin for atrial fibrillation PLUS clopidogrel ( Plavix ) and aspirin after a stent. But bleeding risk is high. One in 50 patients will have a serious bleed in the first…
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Surgery
How to manage direct oral anticoagulants (DOACs) around surgery?!
As a clinical pharmacist, you'll face questions about how to manage direct oral anticoagulants ( Eliquis , etc) around an elective procedure or surgery. Direct oral anticoagulants (DOACs) kick in and wear off faster than warfarin, so they need to be managed differently around procedures. Explain it's okay to continue DOACs for many low-bleeding-risk proced…
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Surgery
Management of minor bleeding from antithrombotics
Patients using an antithrombotic may be alarmed by "nuisance bleeding" OR nosebleeds, prolonged bleeding from a small cut, etc. This isn't typically serious or a reason to stop therapy. Share tips to prevent bleeding, such as using a saline spray to keep the nasal passages moist, an electric razor to avoid nicks while shaving and a soft toothbrush to pr…
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Warfarin
Drug interactions between WARFARIN and many antimicrobials
Questions often come up about how to handle alerts for drug interactions between warfarin and many antimicrobials. The risk of an interaction varies, but it can be significant, especially when the antimicrobial affects warfarin metabolism. For more details, see Table (1) below . Follow these rules of thumb... TMP/SMX ( Septazole, Septrin…
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Obesity
How to dose low-molecular-weight heparin (Clexane, etc) in very obese patients
There's still controversy about how to dose low-molecular-weight heparin (Clexane, etc) in very obese patients. Some physicians worry that doses based on total body weight will be too high for patients over 150 kg. This leads them to cap the dose to try to prevent overdosing. In fact, dalteparin labeling recommends a maximum treatment dose, the other low-molecula…
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GIT and Liver
Safety of using anticoagulants in patients with cirrhosis
As a hospital pharmacist, you'll see anticoagulants used more often to treat thrombosis in patients with cirrhosis . We're used to thinking of these patients as having an increased bleeding risk due to impaired clotting factor production and thrombocytopenia. But don't consider them "auto-antico…
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