INTRODUCTION

This module of the UConn Anticoagulation Certificate Program discusses laboratory monitoring of various anticoagulants. It builds on previous modules and repeats some information. Repetition will help consolidate learning and perhaps stimulate thought.

 

Coagulation Cascade

To monitor anticoagulation therapy effectively, it’s essential to first understand the coagulation cascade. This process begins with two distinct pathways—the intrinsic and extrinsic pathways—which ultimately converge at a critical step.¹ At that step,  Factor X is activated to Factor Xa. Factor Xa, along with Factor Va and calcium (Ca²⁺), then catalyzes the conversion of prothrombin (Factor II) into thrombin (Factor IIa). Thrombin plays a pivotal role by converting fibrinogen into fibrin, the key structural protein that crosslinks with platelets to form a stable clot.¹

 

Two of the most widely used laboratory tests for assessing coagulation function are²

• activated partial thromboplastin time (aPTT) – primarily monitors the intrinsic pathway.
• prothrombin time (PT) – primarily monitors the extrinsic pathway.

By evaluating these tests, clinicians can assess both pathways’ functionality, making them valuable tools for screening coagulation disorders. These tests are particularly useful when investigating unexplained bleeding, as they help determine whether one or both pathways are impaired.

 

Prothrombin Time

PT measures the time it takes for plasma to clot after exposure to a tissue factor reagent. This test assesses both the extrinsic and common coagulation pathways. Laboratory and point-of-care machines detect clots using various methods, such as visual, optical, or electromechanical techniques, depending on the device. A normal PT range typically falls between nine and 13 seconds³; however, this range can vary significantly based on the laboratory equipment and reagents employed. Therefore, it is crucial to verify the normal range for a specific laboratory’s setup regularly to ensure accurate interpretation of results.^4,5

 

PT and INR Standardization

The therapeutic level of vitamin K antagonists (VKA) is measured by PT and international normalized ratio (INR). The INR is a standardized ratio the World Health Organization (WHO) developed in the 1980s specifically for VKA monitoring, as PT varies greatly between laboratories.⁶ WHO’s goal was to allay the discrepancy in tissue factor (TF) activity between PT reagents to create a common scale that would display PT results consistently. The INR uses data and processes from the International Sensitivity Index (ISI), a WHO project that quantifies analyzers and individual PT reagents’ reactivity. In addition, each laboratory has its own geometric mean PT (MNPT), which laboratory staff calculate using is the average PT calculated from at least 20 normal donors of both sexes, tested on the same local analyzer and under the same test conditions as the patient’s PT. The formula for INR is INR = (patient’s PT/MNPT). A normal INR is usually in the range of 0.8 to 1.2.^7,8

 

Clinical Uses of PT/INR

When patients present with unexplained bleeding, measuring the PT/INR can provide valuable insights. An elevated PT/INR suggests a potential issue within the patient’s coagulation system, indicating that something may be wrong.^4,5 Conversely, if the PT is normal, healthcare providers may need to investigate alternative causes for the bleeding, as the coagulation factors may not be the source of the problem. Table 1 describes several important clinical applications for the PT and INR.^4,5

 

 

Factors That Prolong the PT/INR

Several factors can influence PT/INR, complicating the monitoring of patients on warfarin therapy^4,5,9:

• Warfarin: The primary medication affecting PT/INR, warfarin requires careful monitoring to ensure that patients remain within the therapeutic range.
• Other anticoagulant drugs: Direct oral anticoagulants (DOACs) and argatroban can impact PT/INR readings. For instance, transitioning a patient from argatroban to warfarin requires caution, as argatroban significantly increases INR measurements, potentially leading to misleading results.
• Heparin and low molecular weight heparins (LMWH): Although traditional references indicate that these medications affect PT measurements, modern reagents, and laboratory techniques typically correct for this interference, making it less of a clinical concern.
• Liver disease: The PT is a reliable indicator of both anticoagulation status and liver function. Patients with severe liver disease often present with elevated PT values due to impaired clotting factor synthesis.
• Vitamin K deficiency: Poor dietary intake or nutritional issues can lead to vitamin K deficiency, resulting in elevated PT levels.
• Coagulation factor deficiencies: Genetic disorders that reduce the production of specific coagulation factors can also manifest as elevated PT, even if they are not related to liver disease.
• Antiphospholipid antibodies: The presence of these antibodies can influence PT measurements, adding another layer of complexity in monitoring anticoagulation.

It is crucial to consider these factors when monitoring patients on warfarin therapy, as they can significantly affect PT/INR results beyond the effects of the medication itself.

 

Understanding Warfarin Monitoring and Its Mechanism

Warfarin inhibits the production of vitamin K-dependent coagulation factors, specifically Factors II, VII, IX, and X, along with proteins C and S. The INR is particularly effective for monitoring warfarin therapy because it directly measures Factors II, VII, and X.¹⁰

 

Anticoagulation does not occur immediately upon achieving adequate warfarin serum levels. Instead, anticoagulation begins when the serum levels of affected coagulation factors decrease. Warfarin reduces the production of these factors rather than directly affecting them. The half-lives of these factors vary significantly^11,12:

• Factor VII has a short half-life of approximately three to six hours, causing it to decrease quickly.
• Factor II (prothrombin) has a long half-life of about 24 to 48 hours (and up to 60 hours), making it the most significant factor in determining the time it takes for warfarin to become effective.

This long half-life is why it takes a couple of days for warfarin to exert its full anticoagulant effect; the therapy is essentially waiting for Factor II levels to decrease adequately.

 

Monitoring Warfarin Therapy: When and How Often?

The frequency of monitoring may vary depending on whether the patient is treated in an inpatient or outpatient setting. In 2018, The Joint Commission published National Patient Safety Goals for anticoagulant therapy, highlighted below.¹³

 

Baseline PT/INR Testing

Before initiating warfarin therapy, obtaining a baseline PT/INR level is crucial. The Joint Commission mandates this step to ensure no underlying deficiencies in coagulation factors could affect future monitoring.¹³ Clinicians can order baseline testing on the day therapy starts or use a previous test, if the results are relevant. For stable patients, a result from a month or two ago may suffice. However, if the patient has fluctuating liver function or other issues, the baseline should be determined from a more recent test.¹³

 

Monitoring Schedule After Initiating Warfarin

After establishing the baseline, the timing for subsequent INR testing is essential. Testing the INR the day after the first dose of warfarin may not provide significant insights since coagulation factors usually take at least two days to decrease.^11,13 In rare cases, if a higher-than-expected dose is administered, especially in elderly patients with comorbidities and drug interactions, a noticeable increase in INR might occur within the first day or two. However, routine daily testing is typically unnecessary.

 

Generally, clinicians don't see significant changes until day three after starting therapy.¹² Warfarin’s full effects are usually evident within five to seven days.¹²

 

For stable patients, there’s some debate regarding the frequency of testing. Typically, unstable patients may need testing every few days to once a week.¹² Clinicians can monitor stable patients less frequently, often every four weeks or, in some cases, even every 12 weeks. Other modules will discuss lengthening the testing interval.¹²

 

PAUSE AND PONDER: What alternative methods can we use to monitor warfarin therapy without relying on PT/INR?

 

The alternative method for monitoring warfarin therapy in patients with antiphospholipid antibody syndrome is to measure Factor II or Factor X activity levels.¹⁴ (In other patients, measuring these indices may confirm pharmcodynamic issues.) While the PT/INR tests provide a broad assessment of coagulation factors affected by warfarin, monitoring just one of these factors can be sufficient.¹⁴ Ordering a factor level test is typically straightforward, similar to any other blood test. However, it’s important for clinicians to ensure that the lab understands that a Factor X activity level, not an anti-Factor Xa level, is needed. These are different tests altogether.

 

Factor activity levels are reported as a percentage of normal, indicating how much the factor has decreased compared to a healthy individual. For instance, a Factor X level between 24% and 45% of normal correlates with an INR of 2-3.^15-17 This approach allows continuous monitoring of these patients without relying on INR, which may be unreliable due to the interference caused by their condition. The module on challenging topics covers this subject in more depth.¹⁸

 

Activated Partial Thromboplastin Time

The aPTT, or simply PTT, is a test that measures the time it takes for plasma to clot after exposure to a reagent, but importantly, it does not use tissue factor. The aPTT specifically assesses the intrinsic pathway down to the common pathway.^4,5

 

Normal Ranges and Variability

The normal range for aPTT is highly dependent on the laboratory equipment and reagents used, similar to PT testing. However, unlike PT, there is no standardization mechanism like the INR to correct aPTT results. Each laboratory, along with its reagents and testing equipment, will have its own normal values, generally falling between 25 to 35 seconds.¹⁹

 

Additionally, the behavior of aPTT results can vary significantly; for example, as heparin is administered, the aPTT will increase over time.¹⁹ This response can differ between labs and within the same lab if they change reagent companies or reagent lot numbers. Therefore, continuous testing and calibration are essential to ensure accuracy in aPTT results.

 

Establishing aPTT Therapeutic Range for Heparin Monitoring

Given the variability in aPTT testing, it is crucial to ensure that the therapeutic range for heparin is accurately established based on the specific reagents and tests being used. Each laboratory must perform a correlation whenever it introduces new equipment or switches reagent lot numbers.

 

Guidelines for Establishing PTT Range

Laboratories must adapt the PTT range based on the responsiveness of the reagent and the coagulometer in use.^20,21 The recommended approach is as follows:

• Select a therapeutic PTT range: This range should correlate with a heparin level of 0.3 to 0.7 units.
• Sample collection: Collect blood samples from patients receiving heparin therapy.
• Testing with anti-Factor Xa: Measure the heparin levels in the blood using an anti-Factor Xa test.
• Regression analysis: Conduct a regression analysis to determine the appropriate PTT range that corresponds to the established therapeutic range for your heparin protocol.

This process ensures that the PTT monitoring accurately reflects heparin’s therapeutic effect, thereby enhancing patient safety and treatment efficacy.

 

Interpreting Regression Analysis for Heparin Monitoring

Figure 1. Regression Analysis for Heparin Monitoring²²

Figure 1 illustrates a regression analysis used to establish the therapeutic range for heparin monitoring. In this analysis, researchers evaluated a cohort of patients to determine their PTT values in relation to their anti-Factor Xa heparin levels. By plotting this data on a graph and drawing reference lines, the laboratory defined the appropriate PTT therapeutic range for its heparin protocols. In this cohort, the therapeutic PTT range appeared to be approximately 60 to 120 seconds, represented by the horizontal lines that correspond to heparin levels of 0.3 to 0.7 units.²²

 

However, as highlighted in the circled areas, clusters of patients experienced significant variability ²²:

• Supra-therapeutic patients: The group in the upper right corner appeared to have PTT values within the therapeutic range but were actually supra-therapeutic with respect to their heparin levels.
• Sub-therapeutic patients: Conversely, the circled group in the middle had PTT values indicating they were slightly sub-therapeutic, even though their actual heparin levels were adequate.

This variability can lead to unnecessary dose adjustments, as some patients may be treated for perceived under-dosing although their anticoagulation therapy is effective.

 

The take-home message is clear: interpatient variability and the differences in testing methods necessitate continuous adjustments to the therapeutic range for heparin protocols. Each time a laboratory receives a new reagent lot or changes equipment it must re-evaluate and adjust the therapeutic range accordingly to ensure optimal patient care.²²

 

Clinical Uses of aPTT

Table 3 demonstrates how the aPTT test serves several important clinical functions.

 

Factors That Prolong aPTT

Several factors can lead to an elevated aPTT²³:

• Heparin and DTIs are well-known for prolonging the aPTT due to their mechanisms of action within the coagulation cascade.
• DOACs can prolong the aPTT, but this test is not reliable for monitoring these agents.
• Liver disease can serve as a general marker for coagulation status and may prolong the aPTT.
• Specific factor deficiencies, such as hemophilia A or B, where specific coagulation factors are deficient, will result in prolonged aPTT.
• Antiphospholipid antibodies can interfere with coagulation testing, leading to aPTT prolongation. Although the impact on aPTT is not as significant as on INR, patients with antiphospholipid syndrome may still experience coagulation issues.

Understanding these factors is crucial for interpreting aPTT results accurately and making informed decisions regarding patient management.

 

THROMBIN TIME OVERVIEW

Thrombin time (TT) is a laboratory test that measures the time it takes for fibrinogen to convert to fibrin,²⁴ marking the final step in the coagulation cascade. Unlike other coagulation tests, TT specifically focuses on this critical transition, which results in clot formation. The normal range for TT typically falls between 14 to 19 seconds. However, this can vary depending on the specific laboratory equipment and reagents used. As with the other tests, the TT is highly dependent on the specific methods and instruments employed in the laboratory.²⁴

 

Clinical Uses of TT

TT is not commonly used as a broad screening tool due to its specificity to the final step of coagulation. However, Table 4 lists the clinical situations in which it is invaluable.

 

 

Although TT is a valuable test for specific conditions, it is not typically used as a general screening test for coagulation disorders.²⁴ Since it measures only the final step of the coagulation process, it does not provide comprehensive insight into earlier steps in the cascade. Therefore, its use is generally reserved for diagnosing issues directly related to fibrinogen conversion, such as inherited fibrinogen disorders, heparin contamination, or DIC.²⁴

 

ACTIVATED WHOLE BLOOD CLOTTING TIME

The activated whole blood clotting time (ACT) is a laboratory test used to assess the time it takes for whole blood to clot when exposed to a reagent that activates the intrinsic pathway of coagulation.²⁵ Unlike other coagulation tests that use plasma samples, ACT measures the clotting time of whole blood, making it unique in this regard. The normal range for ACT typically falls between 70 and 120 seconds, although the time can vary depending on the specific laboratory equipment, reagents, and protocols used. As with other coagulation tests, the normal range is highly dependent on the testing environment.²⁵

 

Clinical Uses of ACT

ACT is primarily used in clinical settings where large doses of heparin are administered, such as during procedures in a cardiac catheterization lab (Cath Lab) or during cardiopulmonary bypass. Table 5 explains these uses in more detail. It is a quicker, more reliable alternative to other coagulation tests, particularly when measuring the effects of high doses of heparin.

 

 

While ACT is an essential test in certain high-risk procedures, it is not routinely used for general anticoagulation monitoring.²⁵ It is most valuable in settings where high doses of heparin are required, and where quick, real-time results are crucial. Additionally, the normal therapeutic ranges for ACT vary based on the specific procedure being conducted, and so results must be interpreted within the context of the clinical setting.²⁵

 

PRACTICE PATIENT CASE

A 41-year-old pregnant woman carrying twins is admitted for a DVT. She begins treatment with a heparin drip at 80 units/kg bolus, followed by an 18 units/kg/hour infusion. Over time, her infusion rate is adjusted to approximately 2000 units/hour, which equates to 25.7 units/kg/hour, a relatively high heparin dose. Despite seeming to be in a therapeutic range, she develops gross hematuria, and her hemoglobin drops from 10.4 to 7.9 over four days. Given these complications, the medical team is concerned about why she requires such a large heparin infusion and whether the rate should be reduced.

 

Key Questions to Ask

1. Is the patient's weight correct? The first thing to check is whether the patient’s weight was accurately recorded on the scale and entered into the infusion pump. This ensures the proper amount of heparin is being delivered based on her body mass. If the weight was incorrect, it could explain why she is receiving an excessive amount of heparin.
2. Was the infusion rate correctly calculated? It's crucial to verify that the infusion rate calculation was accurate. Errors in dosage calculations can lead to the patient receiving more heparin than intended, potentially contributing to bleeding complications like the one seen in this case.
3. Is the patient’s lab work accurate and correctly matched? Mislabeling or mixing up lab work can lead to incorrect patient data being used, which could explain why the infusion rate appears to be appropriate when it is actually too high. Checking that the lab results are from the correct patient is essential.

 

Testing for Heparin Levels

If the above factors are ruled out and the patient's weight, infusion calculations, and lab results all appear correct, testing the anti-factor Xa level is the next logical step. This test measures the level of heparin activity in the blood and provides a more reliable measure of anticoagulation than other tests like the PTT, which can be influenced by various patient-specific factors.

• Anti-factor Xa level: This test would reveal the true extent of heparin activity in the bloodstream. The patient's remarkably elevated anti-Xa levels indicate that she has a high amount of heparin in her system, far beyond what would be expected based on the current infusion rate. This suggests heparin resistance.

 

Management and Resolution

Upon discovering the elevated anti-Xa levels, the infusion rate was adjusted down to 1500 units/hour, which is closer to typical dosing for patients of this clinical presentation. Following this adjustment, the patient's symptoms resolved, and she was no longer experiencing the bleeding complications associated with excessive heparin.

 

This case illustrates the importance of monitoring heparin therapy and being aware of heparin resistance. Even though the patient was receiving what seemed to be a therapeutic dose of heparin, the excessive infusion led to bleeding complications. By testing anti-factor Xa levels, the underlying issue was identified and treated. This highlights the need for accurate dosing calculations, laboratory testing to monitor heparin levels, and consideration of heparin resistance in patients who require unusually high doses of the drug to achieve anticoagulation.

 

HEPARIN RESISTANCE AND APPARENT HEPARIN RESISTANCE

Heparin resistance can be categorized into two types: true resistance and apparent resistance.²⁰ Understanding the differences between these is crucial for diagnosing and managing patients who require unusually high doses of heparin, as was the case with the 41-year-old pregnant patient.

 

True Heparin Resistance

In true heparin resistance, the patient does not respond to heparin despite receiving therapeutic or even higher-than-expected doses.²⁶ This can happen due to several pharmacokinetic or pharmacodynamic factors, including²⁶

• Increased heparin clearance: The patient's body may metabolize heparin faster than expected, requiring higher doses to maintain therapeutic anticoagulation.
• Increased heparin-binding proteins: Some patients have elevated levels of plasma proteins that bind to heparin, effectively reducing the amount of free, active heparin available to exert its anticoagulant effect.
• Altered volume of distribution: Changes in the patient's body composition, such as a higher volume of distribution, can affect how heparin is distributed throughout the body, requiring higher doses to achieve the desired effect.

These factors contribute to the need for much higher doses of heparin to achieve the expected anticoagulant effect, making it a true form of resistance to the drug.

 

Apparent Heparin Resistance

In contrast, apparent heparin resistance refers to a situation where the patient appears to require more heparin than expected, but the issue is not due to pharmacokinetic resistance.²⁶ In the case of apparent heparin resistance, the PTT does not accurately reflect the patient's anticoagulant status. For example, elevated levels of coagulation factors like Factor VIII can lead to a falsely short PTT, suggesting that the patient is adequately anticoagulated when, in reality, they may require higher doses of heparin to achieve the correct therapeutic effect. This condition can make it difficult to assess the patient's true anticoagulation status, which can lead to the overuse of heparin and the risk of bleeding complications.²⁶

 

ANTI-FACTOR Xa TEST

The anti-factor Xa test is an important when using drugs like heparin, enoxaparin, and dalteparin. Unlike clotting tests like the PTT, the anti-factor Xa test does not measure clotting time. It is a functional test that quantifies the enzymatic activity involved in coagulation. The test is often referred to as chromogenic anti-factor Xa because it involves a color change as a result of the chemical reaction between the reagent and the substance being tested.^4,5

 

The chromogenic test measures the activity level of Factor Xa, which is essential for blood clotting. In the presence of a specific anticoagulant (such as heparin), the test measures the inhibition of Factor Xa activity. ^4,5 The results are reported in units/mL (e.g., units of heparin per mL), which indicates the concentration of the anticoagulant drug in the patient’s blood. The normal range for this test is 0, meaning if there's no drug present, there’s no activity detected, and the test result is zero.^4,5

 

Clinical Uses of Anti-Factor Xa Testing

A primary uses of anti-factor Xa is to monitor heparin therapy, especially in institutions where heparin infusions are used for anticoagulation.²⁰ This test has become more commonly used than PTT for monitoring heparin therapy due to its simplicity and lack of interference from factors like factor XIII levels or warfarin. Anti-factor Xa can also be used to monitor LMWHs (e.g., enoxaparin and dalteparin) and fondaparinux, although the calibration curves for these drugs are different. Each drug may have its own specific calibration and the lab will need to adjust accordingly. Some oral anticoagulants, such as direct factor Xa inhibitors (e.g., apixaban, rivaroxaban), can affect coagulation assays. To quantify their activity rapidly and accurately, anti-factor Xa testing must be calibrated specifically to the DOAC being assessed.²⁷

 

Advantages of anti-factor Xa for monitoring heparin include²⁸

• Less interference: Unlike the PTT test, which can be influenced by many factors (e.g., factor XIII levels, warfarin therapy), the anti-factor Xa test is more specific and free from interference, providing a more reliable result.
• No calibration issues: Since anti-factor Xa directly measures drug concentration, there’s no need for recalibration each time new reagent lots are used, unlike with PTT testing. The therapeutic range for heparin is consistently set at 0.3 to 0.7 units per mL, which simplifies monitoring.
• Improved accuracy: The anti-factor Xa test provides a more accurate assessment of heparin levels, reducing the chance of over- or under-dosing, which can lead to complications like bleeding or thrombosis. This accuracy reduces the frequency of dosage adjustments and the associated risk of error.
• Less frequent retesting: Because there’s less need for frequent adjustments in dosing, patients may require fewer tests, which reduces laboratory workload and improves overall patient care.

 

Anti-factor Xa Testing for LMWHs and Fondaparinux

The use of anti-factor Xa testing for LMWHs like enoxaparin and dalteparin, and fondaparinux, has been an area of ongoing discussion. While it is not universally required for all patients on these medications, testing can provide valuable information and improve patient safety in specific situations.²⁹

 

In patients who are extremely obese or very small (i.e., children), the pharmacokinetics of LMWHs can be unpredictable.³⁰ These patients may have altered drug clearance or distribution, meaning they may handle the drug differently than expected based on weight alone. In these cases, testing can ensure that the drug is working effectively and that the patient is within a therapeutic range.²⁹

 

Renal dysfunction is another consideration.²⁹ Patients with impaired renal function may not clear LMWH or fondaparinux as efficiently, leading to drug accumulation and potentially dangerous levels in the bloodstream. Testing anti-factor Xa levels in these patients helps assess if their drug concentrations are within a safe therapeutic window.²⁹

 

Pregnancy introduces significant pharmacokinetic changes that can affect how LMWH are metabolized.²⁹ These changes are especially pronounced in the third trimester, as women experience substantial physiological shifts, including weight gain, blood volume changes, and increased renal clearance. Regular anti-factor Xa testing during pregnancy, especially in the third trimester, ensures that dosing adjustments are appropriate to maintain effective venous thrombosis prevention without putting the patient at risk of bleeding.²⁹

 

Prior to surgery, particularly when patients have been on LMWH or fondaparinux, there is a concern about the drug's clearance from the system.³² While guidelines generally recommend holding the dose for about 24 hours before surgery, anti-factor Xa testing can be particularly useful in emergent situations or when there is uncertainty about the drug's clearance. In these cases, testing can provide additional reassurance that the anticoagulant effect has sufficiently diminished before surgical intervention.

 

Anti-factor Xa Testing for Direct Factor Xa Inhibitors

Routine monitoring of DOAC concentrations is not necessary in standard clinical practice due to their predictable pharmacokinetics and wide therapeutic windows. However, in emergent situations, such as active bleeding, urgent surgical intervention, suspected overdose, or impaired renal function, assessment of anticoagulant activity may be warranted to guide clinical decision-making and ensure patient safety.

 

In these cases, chromogenic anti-factor Xa assays can be used to measure the anticoagulant effect of factor Xa inhibitors (e.g., apixaban, rivaroxaban, edoxaban). These assays are available in many hospital and reference laboratory settings and can provide relatively rapid and quantitative estimations of drug levels, provided they are calibrated specifically to the DOAC in question. While not universally available, when accessible and properly calibrated, they serve as a valuable tool for managing complex or high-risk situations involving DOAC therapy.³²

 

COAGULATION FACTOR ACTIVITY TESTING

Coagulation factor activity testing is a straightforward, valuable method for evaluating various factors involved in the coagulation cascade.^4,5 This test is especially useful in diagnosing factor deficiencies or other coagulation abnormalities. The most common reason for performing coagulation factor activity testing is to diagnose hereditary bleeding disorders caused by deficiencies in one or more coagulation factors. These include hemophilia A (a Factor VIII deficiency) and hemophilia B (a Factor IX deficiency). This testing may identify other rarer factor deficiencies that could result in bleeding problems.^4,5

 

While INR is most commonly used for warfarin monitoring, coagulation factor activity testing can be employed as an alternative method. This might be necessary in cases where INR results are unreliable or not available, or when more specific information about the patient’s coagulation status is needed.

 

D-DIMER TEST

D-dimer is a protein fragment produced when plasmin breaks down fibrin, a major component of blood clots.³³ This process occurs during fibrinolysis. In simple terms, when a blood clot forms and then begins to dissolve, D-dimer is released into the bloodstream. The normal range for D-dimer levels can vary depending on the method of testing (whole-blood agglutination assays, ELISA [enzyme-linked immunosorbent assay], or latex immunoagglutination method) and each test manufacturer establishes the normal range and different assay manufacturers use different units (e.g., ng/mL, mcg/mL). Laboratories frequently report the results in units other than those recommended by the assay manufacturer.^24,34

 

D-dimer testing is most commonly used as a screening tool to help rule out the presence of active thrombotic activity, such as a DVT or a pulmonary embolism (PE).³³ For example, clinicians may order a D-dimer test for a patient presenting with calf pain in the emergency department. If the test comes back with normal D-dimer levels, it essentially rules out an active DVT or PE without needing further, more invasive testing like ultrasound.³³

 

In patients who have experienced a previous thrombotic event (e.g., DVT or PE), D-dimer testing can help determine whether ongoing anticoagulation therapy is needed. Elevated D-dimer levels approximately one month after the acute event might suggest an increased risk of recurrence, and the patient may need to continue anticoagulation therapy for a longer period.^33-36 Conversely, normal D-dimer levels can suggest the risk of recurrence is low, and the patient may be safely transitioned off anticoagulation therapy, depending on other clinical factors.^35,36

 

PRACTICE PATIENT CASE

Joyce has been on warfarin and has maintained a therapeutic INR range for the past six weeks. She comes into your outpatient anticoagulation clinic, and reports no changes to her diet, exercise, or overall health. Her POC test result on your clinic’s machine shows an INR of 4.7. Following clinic policy, you send Joyce to the lab for venipuncture to confirm this critical value. After a couple of hours, the lab result comes back with an INR of 3.2. Now, you're in a bit of a dilemma. You inform Joyce of the new lab result, and she asks why there's a discrepancy, what test she should trust, and why the POC result isn’t aligning.

 

What to Communicate with the Patient

Despite advances, we have been unable to fully standardize INR testing across different methods. The fact that two testing methods yield different results does not automatically mean that one is correct and the other is incorrect; both could be slightly inaccurate. In medical testing, there are distinctions between accuracy, reliability, and repeatability, all of which contribute to overall test validity. Repeatability—how consistently a test produces the same result—is an important factor in assessing reliability.

 

The medical community and laboratory testing guidelines generally accept that a difference of 0.5 INR units between two different testing methods is reasonable. However, in clinical practice, a 0.5 INR difference can be significant.³⁷ When managing warfarin therapy, such a discrepancy might mean the difference between adjusting a patient’s dose or keeping it the same, which adds to the complexity of interpreting INR results.

 

Ultimately, when discussing test discrepancies with patients, it's essential to reassure them that variability is expected and that INR management is based on trends rather than single data points. Clinical judgment, alongside repeat testing when necessary, helps ensure that anticoagulation therapy remains both safe and effective.

 

POINT OF CARE TESTING

Point of care testing (POCT) refers to the use of small, often handheld devices to perform diagnostic tests outside of a traditional laboratory. One of its earliest applications was INR testing, allowing INR measurements to be performed at the bedside or in outpatient settings.

 

POCT’s advantages include³⁸

• Rapid turnaround time: INR results, for example, can be obtained in about a minute, whereas lab testing takes significantly longer.
• Home testing capability: Patients can monitor their INR levels at home, improving convenience and adherence.
• Ease of use: POCT devices are designed for simple operation, making them accessible for both healthcare providers and patients.

 

POCT also has some disadvantages.³⁹ POCT devices tend to be expensive, both in terms of initial purchase and per-test cost compared to traditional lab testing. In addition, each device has specific testing guidelines. These may include temperature sensitivity, hematocrit limitations, and other operational constraints. However, for the majority of patients, these devices function effectively without issues.³⁹

 

Understanding INR Result Discrepancies

Result variability issue has long been recognized, which is why the WHO introduced the INR system to standardize results across different testing methods. However, even with standardization, variation still exists because different thromboplastin reagents are used in different testing systems.

 

One key limitation is that thromboplastins are only standardized for their International Sensitivity Index (ISI) up to an INR of approximately 4.0—4.5. Beyond this range, variability between testing methods increases significantly. This means that INR values above 4.5—whether measured by a POC device or a lab test—become less precise.⁴⁰ For example, all healthcare clinicians should interpret an INR of 5.0, 6.0, or 7.0 with caution, as these values are more of an estimation than an exact measurement.

 

Device Correlation Testing

When comparing INR results from different testing methods, we essentially perform correlation testing. This process assesses how well two testing methods align by analyzing multiple samples side by side and plotting the results on a correlation graph. Studies commonly use this approach, where investigators compare two or more devices by testing the same samples simultaneously and then measuring how closely the results match. A strong correlation, often above 90%, suggests that the methods are generally in agreement. However, these studies rarely explain the inconsistencies visible in the data.

 

Correlation testing does not determine whether one method is "right" or "wrong"; it simply tells us how similar or different the results are between two methods. There is no true gold standard for INR measurement. No single test can definitively provide the "correct" INR. Many assume that the laboratory venipuncture method is the gold standard simply because it has been used the longest and is more complex. Recent studies have generally found that both methods tend to be accurate provided the testing devices are well-maintained and calibrated.^41-43

 

Pre-analytical errors in INR testing occur before the test is even run, affecting both POC and venipuncture testing methods. Pre-analytical errors can introduce variability into the results, making it harder to interpret the patient’s true anticoagulation status. Table 6 explains these errors in more detail.

 

 

Understanding pre-analytical errors highlights how both POC and venipuncture tests are susceptible to variability—even before testing begins. Recognizing these potential issues reinforces the need to interpret INR results cautiously, especially when discrepancies arise between testing methods. Proper sample collection techniques, equipment calibration, and awareness of external factors all play vital roles in producing accurate and reliable test results.

 

Evidence Supporting the Accuracy of POC INR Testing

How do we know that POC INR devices are reliable? The answer lies in extensive clinical evidence. Numerous large-scale clinical trials have demonstrated that these devices provide accurate and effective INR monitoring, leading to positive patient outcomes. In fact, some of the most significant trials in anticoagulation therapy—such as ARISTOTLE (for apixaban)⁴⁵ and ROCKET AF (for rivaroxaban)^30,31—used POC devices to monitor patients taking warfarin. These studies achieved excellent results, showing effective stroke prevention with low bleeding risks, reinforcing confidence in the reliability of POC INR testing.

 

Key Takeaways

POC devices are clinically validated. They have been used in major anticoagulation trials and have consistently produced reliable results. When clinicians receive an unexpected out-of-range INR, they must consider all possible factors:

• Could a pre-analytical error be affecting the test?
• Did the patient take an over-the-counter medication that interacted with warfarin?
• Is there an adherence issue that the patient forgot to mention?

 

Single abnormal results are no reason to panic. If the result seems inconsistent with the patient’s history and condition, a simple retest may be the best approach rather than immediately adjusting therapy.

 

ORAL ANTICOAGULATION

DOACs do not require routine monitoring due to their predictable pharmacokinetics and pharmacodynamics. However, laboratory testing can be useful in urgent situations to determine if the drug is still in the system. Table 7 lists the standard laboratory tests that can be used to monitor these anticoagulation agents.

 

 

Liquid Chromatography-Mass Spectrometry

Liquid chromatography-mass spectrometry (LC-MS) is considered the gold standard for measuring direct oral anticoagulants (DOACs) due to its high specificity, sensitivity, selectivity, and reproducibility.²⁷ However, its use is limited in routine practice because of the complexity and labor-intensive nature of the method. LC-MS requires expensive equipment and highly trained personnel to perform the test correctly. As a result, while not routinely used in clinical practice, LC-MS serves as the reference method against which other testing methods are compared to assess their accuracy.²⁷

 

Laboratory Testing for Dabigatran

Dilute Thrombin Time

Dilute thrombin time (DTT) is a coagulometric method specifically designed to measure the concentration of dabigatran.⁴⁷ It is a modification of the standard TT, which is extremely sensitive to dabigatran and often becomes excessively prolonged. By using a diluted thrombin reagent, DTT establishes a linear relationship between dabigatran concentration and clotting time, allowing for more accurate and quantitative assessment of the drug's anticoagulant activity. LC-MS is extensively used for research and clinical trials, but it cannot be used in routine conditions for rapid testing in laboratories.

 

Ecarin Clotting Time

The Ecarin Clotting Time (ECT) is a highly sensitive qualitative test where clotting time is directly related to dabigatran concentrations.⁴⁸ In this assay, ecarin, a metalloprotease enzyme derived from the venom of Echis carinatus (the saw-scaled viper), is added to the plasma sample. Ecarin converts prothrombin to meizothrombin, an intermediate that promotes clotting. In the presence of dabigatran, however, the conversion of prothrombin is inhibited, resulting in a prolonged clotting time.⁴⁸

 

The ECT has a linear dose-response relationship and can be used to measure dabigatran levels within the therapeutic range. Due to its simplicity, the ECT can be automated for use with modern coagulation analyzers, although performance verification is required for accuracy.⁴⁸

 

While the ECT is primarily a research tool with limited clinical availability in the United States, the development of commercial kits could potentially improve its practicality. However, these kits have not been fully standardized or validated for dabigatran, and thus their use may be problematic.⁴⁸

 

It is important to note that low prothrombin levels or hypofibrinogenemia can lead to falsely elevated clotting times that are disproportionate to dabigatran or other DTI concentrations. For these reasons, the ECT is not recommended for emergency monitoring of anticoagulant effects, despite its inclusion in some prescribing information.

 

Ecarin Chromogenic Assay

The Ecarin Chromogenic Assay (ECA) is a quantitative coagulometric test specifically designed to assess the concentration of dabigatran, a DTI.⁴⁸ Unlike some other coagulation tests, the ECA is not influenced by levels of prothrombin or fibrinogen, which can cause inaccurate results in other assays. This makes the ECA particularly useful in clinical situations where these factors may be variable, such as in patients with coagulopathies or low fibrinogen levels. The linear dose-response relationship between dabigatran concentration and clotting time allows the ECA to provide precise, quantitative measurement across the therapeutic range.⁴⁸

 

Although the ECA is a reliable method for assessing dabigatran activity, it is not widely available due to its complexity and the need for specialized equipment.⁴⁸ The assay requires appropriate calibration and performance verification to ensure accuracy. While it has shown promise for emergency settings, such as in cases of bleeding or urgent surgery, its clinical use is still somewhat limited, primarily due to availability issues and the high cost of the reagents.⁴⁸

 

Despite these limitations, the ECA remains a valuable tool for assessing the anticoagulant effect of dabigatran in specialized clinical scenarios where precise quantification of drug levels is necessary.

 

Anti-Factor IIa Testing for DTIs

The anti-factor IIa assay is a valuable tool for the precise quantification of the anticoagulant effect of DTIs, such as dabigatran.⁴⁷ This assay works by measuring the cleavage of a thrombin substrate in the plasma. Plasma is mixed with the substrate, which is typically cleaved by thrombin to produce a measurable signal. If dabigatran is present, it inhibits thrombin activity, leading to a decrease in substrate cleavage. As a result, the extent of inhibition correlates with the dabigatran concentration. This assay is particularly useful in situations where accurate quantification of dabigatran levels is critical, such as in emergency scenarios or for monitoring patients with renal impairment.⁴⁸

 

CONCLUSION

When it comes to clotting and anticoagulation, pharmacists need expertise. They must consider the reason for the testing, be it screening, diagnosis, or monitoring. Patient factors complicate the decision, and unexpected results need to be researched and mitigated. Laboratory results are the clues that inform the detective work of anticoagultion.

 

 

1. If a patient is undergoing a percutaneous coronary intervention and already taking rivaroxaban daily for atrial fibrillation, what are the recommendations for dual antiplatelet therapy (DAPT) and oral anticoagulant therapy?
2. There is no need for any antiplatelet therapy in this situation because rivaroxaban is sufficient to cover the risks with less bleeding risk
3. DAPT therapy + rivaroxaban for one month and then the P2Y12 inhibitor + rivaroxaban for 5 months and then just rivaroxaban thereafter
4. DAPT therapy + rivaroxaban is needed for 6 months and then rivaroxaban can be stopped with just DAPT therapy continued thereafter

 

 

2. Which of the following agents would be unable to satisfactorily reverse the effects of the anticoagulant to which is was linked when used with in cases of life threatening bleeds such as intercranial hemorrhage?
3. Idarucizumab reverses dabigatran
4. Andexanet alfa reverses apixaban
5. Vitamin K reverses edoxaban

 

3. A 47-year-old patient with recurrent venous thromboembolism has a creatinine clearance of 99 mL/min. Which of the following oral anticoagulants should be avoided?
4. All anticoagulants can be used
5. Edoxaban should not be used
6. Rivaroxaban should not be used

 

4. A 67-year-old patient is currently taking itraconazole, a potent CYP3A4 inhibitor, for a toenail infection and has four months of therapy left. You want to start an oral anticoagulant that is not a substrate for CYP3A4 to avoid an interaction. Which of the following anticoagulants could you use?
5. Rivaroxaban
6. Apixaban
7. Dabigatran

 

 

5. A 49-year-old patient has chronic GERD and takes a proton pump inhibitor daily and occasional antacids for acute heartburn. Which of the following oral anticoagulants is most likely to exacerbate the acid reflux and to have mild drug interactions with the patient’s current medicatio?
6. Rivaroxaban
7. Apixaban
8. Dabigitran

 

 

6. A 77-year-old patient needs to be switched from warfarin to apixaban. When would you counsel the patient to start the apixaban?
7. When the INR falls below 2
8. At the time the next dose of warfarin was scheduled
9. 48 hours after the last dose of warfarin

 

1. What is the primary mechanism by which warfarin exerts its anticoagulant effect?
A. Inhibits thrombin directly
B. Inhibits vitamin K epoxide reductase (VKOR)
C. Inhibits platelet aggregation

2. Which clotting factor is most rapidly affected by warfarin therapy due to its short half-life?
A. Factor II (Prothrombin)
B. Factor X
C. Factor VII

3. A patient on warfarin starts amiodarone. What is the most appropriate clinical action?
A. Stop warfarin for 3 days
B. Increase warfarin dose
C. Monitor INR more frequently and adjust dose as needed

4. What is the INR goal range for a patient with a mechanical mitral valve?
A. 2.0–3.0
B. 2.5–3.5
C. 1.5–2.0

5. Which of the following best explains why warfarin requires an overlap with heparin during initiation?
A. Warfarin causes rapid bleeding initially
B. Protein C is depleted before procoagulant factors
C. Warfarin acts immediately on all clotting factors

6. A consistent intake of which nutrient is essential for patients taking warfarin?
A. Vitamin K
B. Vitamin B
C. Calcium

7. What is the most appropriate INR goal for a patient being treated for a DVT with warfarin?
A. 1.5–2.0
B. 2.0–3.0
C. 3.5–4.0

8. Which patient would most appropriately be started on a lower initial warfarin dose (≤5 mg)?
A. 25-year-old male with no comorbidities
B. 70-year-old female with heart failure and liver disease
C. 35-year-old woman with DVT and no medication interactions

9. What is the main reason INR needs to be monitored frequently during the first few weeks of warfarin therapy?
A. To detect liver toxicity
B. Because INR can fluctuate as factor levels change
C. To determine bone density

10. What is a major advantage of the On-X mechanical aortic valve compared to other mechanical valves?
A. It allows a lower INR goal
B. It requires no anticoagulation
C. It eliminates risk of thromboembolism

Drug Interaction Cases with Anticoagulation Therapy

Post-test

After completing this continuing education activity, the learner will be able to
1) Identify anticoagulation therapy’s clinically significant drug interactions
2) Discuss drug interactions that patients may ask about, but are generally not clinically significant
3) Analyze cases to determine if a drug interaction is clinically significant
4) Diminish the effect of identified drug interactions in simulated cases
5) Describe monitoring parameters for the identified drug interactions in the simulated cases

1. A patient arrives at the clinic with a new prescription for bananamycin. This drug was approved yesterday and the patient is on warfarin. Bananamycin’s prescribing information doesn’t discuss anticoagulants as it was approved based on very small studies. What would be the BEST way to determine if bananamycin is likely to interact with warfarin?
A. Check warfarin’s prescribing information
B. Request information from warfarin’s manufacturer
C. Evaluate bananamycin’s metabolic characteristics

2. Which of the following pairs correctly links the warfarin enantiomer with the CYP enzyme of concern?
A. R enantiomer = CYP1A2
B. R enantiomer = CYP2C19
C. R enantiomer = CYP3A4

3. Which of the following pairs correctly links the warfarin enantiomer with the CYP enzyme of concern?
A. S enantiomer = CYP2C9
B. S enantiomer = CYP2C19
C. S enantiomer = CYP3A4

4. Arlene comes to the clinic to have a PT/INR drawn. You note that she is drinking green tea. You tell her that under certain circumstances, green tea can affect INR, and you ask her how much green tea she drinks. Which of the following answers would be of MOST concern?
A. “I usually drink a 16 ounce bottle every day over six hours or so.”
B. “I don’t know… a gallon a day…maybe more? It’s good for you.”
C. “This is the first time I ever had it.”

5. Bob is a 77-year-old fellow who has been on warfarin for five years. He has stable hypertension and hypercholesteremia but is pretty healthy otherwise. You say, “Tell me anything that has changed regarding your health or diet since we last talked.” He responds that he recently received a diagnosis of osteoarthritis and is now taking acetaminophen. What should your next question be?
A. Is the acetaminophen providing some relief from the pain?
B. How much acetaminophen are you taking and how often?
C. Did your prescriber call your hematologist before prescribing?

6. Patients may experience drug-drug interactions that are unpredictable. Which four factors might vary between patients?
A. Patient susceptibility, response magnitude, time of onset, duration of effect
B. Drug manufacturer, INR testing method, dietary preferences, reason for anticoag
C. Brand, lot number, manufacturer reliability, patient health literacy level

7. Olivia is an 82-year-old who has frequent urinary tract infections. She takes 5 mg of warfarin daily. The culture/sensitivity results indicate that this organism is sensitive to cotrimoxazole. Her gynecologist wants to start cotrimoxazole for 10 days to treat the active infection and then use trimethoprim 100 mg daily as prophylaxis for six months. What should you expect? (You may need a drug interaction checker to answer this question.)
A. Sulfamethoxazole will decrease warfarin levels so you may need to increase the warfarin dose by 10-20%.
B. Trimethoprim will increase warfarin levels so you may need to decrease the warfarin dose by 10-20%.
C. Sulfamethoxazole usually increases warfarin levels, but trimethoprim is not expected to interact with warfarin.

8. Which of the following medications is MOST LIKELY to affect warfarin levels because it affects both warfarin enantiomers?
A. Amiodarone
B. Cimetidine
C. Omeprazole

9. According to the Anticoagulation Forum’s Direct Oral Anticoagulant (DOAC) Drug-Drug Interaction Guidance, which medications are MOST LIKELY to cause clinically significant drugs interactions? (You may pull the Guidance to answer this question.)
A. Drugs that are STRONG modifiers of CYP3A4 and CYP2C19
B. Drugs that modify BOTH p-gp and are STRONG modifiers of CYP3A4
C. The DOACs have few if any drug interactions, which is why they are so popular.

10. Roger is a 76-year-old man who is on apixaban pursuant to a diagnosis of atrial fibrillation. He has contracted an infection that is sensitive to clarithromycin, a combined p-gp and STRONG CYP3A4 inhibitor. The infection control specialist wants to prescribe it as soon as possible. What does the Anticoagulation Forum’s Direct Oral Anticoagulant (DOAC) Drug-Drug Interaction Guidance say about concurrent use of apixaban and clarithromycin?
A. Avoid use of clarithromycin entirely
B. Reduce the apixaban dose by 50% while taking clarithromycin
C. Clarithromycin does not significantly increase apixaban exposure

11. Jerrilyn, age 57, has diagnoses including HTN, hypercholesterolemia, and osteoarthritis. She takes warfarin 7.5 mg Monday and Friday, and 5 mg x 5 days after an atrial valve replacement. She develops a vaginal infection and decides to use OTC miconazole to treat it. What monitoring should you implement?
A. Recheck INR in 3-4 days
B. Recheck INR in 2 weeks
C. Recheck INR in 1 month

12. A patient is taking griseofulvin and his prescriber indicates it’s time to discontinue it. Right now! Today! When should you call the patient in for the next INR?
A. Recheck INR in 5 days
B. Recheck INR in 2 weeks
C. Recheck INR in 1 month

Post-Test Questions:
1. Which of the following factors would more likely indicate an inherited thrombophilia?
a. A relative with a known clotting disorder
b. Active combination oral contraception use
c. Recent travel overseas on a long flight

2. Which of the following conditions is more likely to be an acquired form of thrombophilia?
a. Antiphospholipid antibody
b. Factor V Leiden
c. Prothrombin gene mutation

3. Which of the following are the most appropriate next steps following a ‘normal’ functional assay for AT III deficiency?
a. Administer vitamin K PO 5mg once and discontinue anticoagulation
b. Confirm functional assay results with an antigenic assay
c. Continue anticoagulation and consider alternative diagnosis

4. Which of the following pharmacotherapy is associated with acquired protein s deficiency?
a. Oral contraceptives
b. Unfractionated heparin
c. Vitamin K

5. A patient develops microthrombi in extremities two days after starting warfarin 10mg for 2 doses. His INR is 1.8. Which of the following is the most appropriate initial management?
a. Bridge warfarin with apixaban 5mg
b. Vitamin K administration
c. Warfarin 10mg again to hit goal INR

6. A patient screens positive for prothrombin gene mutation, but has no signs of active thrombosis. What is the best treatment plan?
a. Begin chronic oral anticoagulation with a DOAC to prevent future thrombotic events
b. Consider prophylactic doses of anticoagulation should the patient ever have surgery
c. Start warfarin therapy with a goal INR of 2.5-3.5 given increased risk of VTE

7. Which of the following could result in a false negative result for a factor V leiden functional assay?
a. Current use of apixaban therapy
b. Multivitamins containing vitamin K
c. O negative blood types

8. Which of the following therapies is associated with lowering homocysteine levels in the blood?
a. Apixaban
b. Folic acid
c. Warfarin

9. Following a PE a patient is started on apixaban therapy. She is ultimately found to have positive lupus anticoagulant in the plasma. Why can we not definitively give an antiphospholipid antibody syndrome diagnosis?
a. Her laboratory values need to be confirmed by an additional test in 3 months
b. Her positive lupus anticoagulant is likely secondary to her apixaban use
c. She needs to meet at least 2 clinical criteria to qualify for diagnosis

10. Which of the following options is the most appropriate management strategy for a patient diagnosed with Antiphospholipid Syndrome?
a. Apixaban
b. Dabigatran
c. Warfarin

This module is a scavenger hunt. Attached you will find the

• 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee
• 2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage: A Guideline from the American Heart Association/American Stroke Association.
• ACC’s Considerations For Anticoagulation Reversal/Hemostasis

Your job is to work through the documents and answer all of these multiple-choice questions. Here’s a HINT: The questions are for the most part in the order the answers appear in the referenced documents. If you have trouble finding the answer, use your FIND or SEARCH function and search for the most difficult word in the question’s stem or answer options.

Let’s start with the 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. (go to blue button under download pdf)

1. Why did the American College of Cardiology update this consensus pathway in 2020?
A. To replace clinical practice guidelines and to inform clinicians about areas where evidence may be new and evolving or where sufficient data may be more limited
B. To complement clinical practice guidelines and to inform clinicians about areas where evidence may be new and evolving or where sufficient data may be more limited
C. To provide a single correct answer to bleeding episodes and serve as a single standalone policy for the numerous situations in which bleeding is a concern.

2. A student on your rotation takes a drug information call from a physician who wants to know what reversal and hemostatic agents are commercially available as of June 15, 2025. Which list is correct?
A. Prothrombin complex concentrates, plasma, vitamin K, idarucizumab and andexanet alfa
B. Recombinant complex concentrates, whole blood, vitamin K, idarucizumab and andexanet alfa
C. Prothrombin complex concentrates, plasma, vitamin K, idarucizumab and ciraparantag

3. After confirming the list is correct, the student calls the prescriber. The prescriber asks which of the products are specific reversal agents for DOACs. What should the student say?
A. Andexanet alfa is specific for idarucizumab and dabigatran is specific for apixaban or rivaroxaban
B. Andexanet alfa is specific for dabigatran and idarucizumab is specific for apixaban or rivaroxaban
C. Andexanet alfa is specific for apixaban or rivaroxaban and idarucizumab is specific for dabigatran

4. According to this consensus pathway, what should you ask if a patient has a hemoglobin drop of 3.5 g/dL?
A. Does the bleed require a transfusion?
B. Is the bleed at a critical site or life threatening?
C. Does the bleed require a surgical intervention?

5. A patient in the ICU who is taking a DOAC is experiencing pericardial tamponade. Her stool is black and the hospitalist is concerned that the patient may be developing a bleed. Hemodynamically, she is stable and her hemoglobin has dropped from 11 g/dL to 10 g/dL. According to this consensus pathway what is the next reasonable question to ask?
A. Is the bleed at a critical site, require surgical/procedural intervention or life threatening?
B. Does the bleed require hospitalization, surgical/procedural intervention, or transfusion?
C. How quickly is the patient’s hemoglobin falling and should we draw another level?

6. Under what condition would the anticoagulation team consider continuing an oral anticoagulant in a patient experiencing a bleed?
A. The bleed is considered major, but the team has administered 4 units of RBCs and her hemoglobin has risen significantly.
B. The bleed is considered major, and it is in the process of being controlled with surgical intervention or transfusion.
C. The bleed is considered non-major, and it does not require hospitalization, surgical/procedural intervention, or transfusion.

7. In this consensus pathway, how does Figure 1 differ from Figure 2?
A. Figure 1 provides an overview of the expert consensus decision pathway, whereas Figure 2 summarizes the algorithms on managing bleeding in patients on anticoagulants.
B. Figure 1 summarizes the algorithms on managing bleeding on patients on anticoagulants whereas Figure 2 provides an overview of the expert consensus decision pathway.
C. Figure 1 describes sites where bleeding is considered critical and Figure 2 describes surgical and procedural interventions and transfusion guidelines when patients experience a bleed.

8. A patient arrives at your office and indicates that he tripped going up the stairs and his shin has been bleeding for more than 24 hours. He lifts his pantleg and you see that his bandage is saturated with blood. He said he changed the bandage right before he came to the clinic. When questioned, he says that he feels exhausted and experiences dizziness when getting out of his chair. You use point of care testing and determine that his hemoglobin is now 8. What is the appropriate next step?
A. Ask if he intentionally overdosed on his anticoagulant
B. Determine the bleeding’s exact onset, location, and severity
C. Admit the patient for close monitoring and interventions

9. Which of the following would be considered bleeding at a critical site?
A. Bleeding in the intraluminal gastrointestinal tract
B. Bleeding in the intracranial compartment or CNS
C. Bleeding pursuant to a routine dental extraction

10. The team is monitoring a patient's hemodynamic stability. Which of the following would indicate hemodynamic instability?
A. A decrease in systolic blood pressure greater than 25 mm Hg
B. Orthostatic blood pressure changes leading to syncope
C. A heartbeat of 80 beats per minute

11. Mary Lou is your patient who has been stabilized on warfarin for two years. She fell and broke her hip yesterday, and she needs an urgent hip replacement. What laboratory test(s) should you order immediately?
A. A hematocrit
B. An Anti-FXa
C. A PT and an aPTT

12. What is the minimum DOAC level that may contribute to bleeding or surgical bleeding risk?
A. >30 ng/mL
B. >50 ng/mL
C. That number is unknown

13. At what DOAC level does the International Society on Thrombosis and Haemostasis recommend considering anticoagulant reversal for patients with serious bleeding?
A. >20 ng/mL
B. >50 ng/mL
C. That number is unknown.

14. At what DOAC level does the International Society on Thrombosis and Haemostasis recommend considering anticoagulant reversal for patients requiring an invasive procedure with high bleeding risk?
A. >30 ng/mL
B. >50 ng/mL
C. That number is unknown.

15. Ed is on dabigatran. What test(s) correlate(s) closely with dabigatran levels?
A. A chromogenic anti-FXa assay calibrated with dabigatran
B. Dilute thrombin time, ecarin clotting time, ecarin chromogenic assay
C. PT and aPTT

16. Blanche is taking rivaroxaban. What test(s) correlate(s) closely with rivaroxaban levels?
A. A chromogenic anti-FXa assay calibrated with rivaroxaban
B. Dilute thrombin time, ecarin clotting time, ecarin chromogenic assay
C. PT and aPTT

17. When does the Consensus Decision Pathway recommend aggressive volume resuscitation using intravenous isotonic crystalloids?
A. When patients have 1 or more risk factors for major bleeds
B. When patients are experiencing hypothermia or acidosis
C. When patients have ongoing bleeding and/or hemodynamic instability

18. Rose has renal dysfunction and is taking dabigatran. She has developed an intra-abdominal bleed. The hospitalist suggests starting aggressive fluid resuscitation. What is the BEST response to this suggestion?
A. It’s best to start 0.9% NaCl or Ringer’s lactate immediately
B. Aggressive fluid resuscitation could worsen bleeding
C. We need to schedule hemodialysis before starting IVs

19. What does this consensus pathway say about routine administration of platelets for patients who are bleeding and on antiplatelet agents (e.g., aspirin, P2Y12 inhibitors)?
A. No patient should be taking antiplatelet agents concurrently with anticoagulation
B. It does not support routine administration of platelets in this situation
C. Robust evidence supports routine administration of platelets in this situation

20. John is experiencing a nonmajor bleed. What is the PREFERRED way to proceed?
A. Stop the oral anticoagulant immediately, administer the appropriate reversal medication
B. Consider the possibility that the patient is experiencing a drug-drug or drug-food interaction
C. Use local measures to control bleeding, consider stopping the oral anticoagulant temporarily

21. Leroy is a 42-year-old gardener who is on an anticoagulant. He fell and hit his head. What may be a concern that would prompt you to discontinue the anticoagulant?
A. A slow bleed requiring repeat imaging
B. Leroy’s older age and apparent frailty
C. Asymptomatic anemia

22. Why might the anticoagulation team decide to continue irreversible antiplatelet agents (e.g., aspirin, clopidogrel, prasugrel) when a patient is experiencing bleeding?
A. The risk of a CV event is too great
B. Their half-lives are very short
C. Their duration of action is long

23. Which medication would be reversed using off-label high-dose andexanet alfa?
A. dabigatran
B. edoxaban
C. rivaroxaban

24. What is the appropriate dose of 4F-PCC for Molly, a woman who is experiencing a bleed, takes warfarin, and has a current INR of 5.2?
A. 25 units/kg
B. 35 units/kg
C. 50 units/kg

25. Which medication has the longest half-life in patients who have a creatinine clearance of at least 30 mL/min?
A. Apixaban
B. Betrixaban
C. Rivaroxaban

26. What is the PREFERRED administration for using vitamin K to reverse warfarin’s effects rapidly and predictably?
A. Oral
B. Slow intravenous administration
C. Subcutaneous injection

27. Your hospitalist wants to use plasma to reverse a warfarin-associated bleed rapidly. What do you need to consider as a disadvantage?
A. ABO blood group compatibility
B. Cost and availability
C. Availability of freezer space

28. What is an advantage of using 4F-PCCs in patients who take warfarin and have a major bleed?
A. ABO blood group compatibility is not a concern
B. It costs significantly less than plasma
C. It is refrigerated, not frozen

29. What is idarucizumab’s mechanism of action?
A. It has an affinity for dabigatran that is approximately 350 times that of dabigatran for thrombin.
B. Its structure is similar to endogenous FXa and binds dabigatran without enzymatic activity
C. It binds to direct and indirect FXa and thrombin inhibitors with a noncovalent charge–charge interaction.

30. What is andexanet alfa’s mechanism of action?
A. Its affinity for Factor Xa Inhibitors is approximately 350 times that of dabigatran for thrombin.
B. Its structure is similar to endogenous FXa and binds Factor Xa Inhibitors without enzymatic activity
C. It binds to direct and indirect FXa and thrombin inhibitors with a noncovalent charge–charge interaction.

31. What is ciraparantag’s mechanism of action?
A. This is an investigational agent and its mechanism of action is unknown.
B. Its structure is similar to endogenous FXa and binds dabigatran without enzymatic activity
C. It binds to direct and indirect FXa and thrombin inhibitors with a noncovalent charge–charge interaction.

32. Which of the following is a list of potential adverse effects associated with plasma transfusion?
A. Circulatory volume overload, allergic reactions, and acute lung injury
B. Post-reversal thrombotic complications and nausea and vomiting
C. Shortness of breath, tachypnea, hypotension, paradoxical pulse

33. In general, how quickly will patients treated with dabigatran respond to a dose of two 2.5-gram aliquots of idarucizumab?
A. Within 2 hours
B. In 3.5 to 4.5 hours
C. In 4.5 to 5.5 hours

34. Approximately what percentage of idarucizumab-treated patients may experience postreversal thrombotic complications?
A. <5% B. ~6% C. >10%

35. In idarucizumab-treated patients who experience postreversal thrombotic complications, what is the most significant risk factor?
A. Failure to use hemodialysis to remove dabigatran
B. Failure to re-initiate any antithrombotic therapy
C. No risk factors have been identified to date

36. Harry is a 76-year-old patient who is experiencing a serious bleed pursuant to an intraocular hemorrhage. He has been taking dabigatran. Your facility has no idarucizumab. What would you recommend so Harry can be stabilized as quickly as possible and the ophthalmic surgeon can operate?
A. 50 gm activated charcoal, repeat PRN
B. 2,000 units of 4F-PCC
C. 50 units/kg PCC or aPCC (maximum dose 4,000 units)

37. In the ANNEXA-4 trial, what was noted in the safety analysis?
A. All patients achieved excellent or good hemostasis 6 hours after infusion.
B. At 30-day follow-up, 14% of patients had died (most had not restarted OAC)
C. At 30-day follow-up, 14% of patients had developed a new thrombotic event

38. Gerald is an 82-year-old who has been taking apixaban for several years for AFib. He has developed a bleeding ulcer and needs emergency surgery. In discussions about the need to reverse the anticoagulation, Gerald’s family expresses concerns about its cost and he is under-insured. What should you tell them about using PCC as hemostatic therapy?
A. Evidence of PCC’s efficacy is limited.
B. PCC is a cost-saving and effective choice
C. PCC is a fine alternative in very high doses

39. Gerald does well in surgery and remains hospitalized. It’s time for some shared decision making! The surgeon determined his gastric bleed was the result of liberal use of OTC ibuprofen. He is eating, has no further surgery planned, is not pregnant (LOL! That’s a clue!) and his bleeding risk is back to baseline. He is not taking concomitant antiplatelet therapy or any medications that interact with his oral anticoagulant. Should you suggest restarting anticoagulation?
A. Yes
B. No
C. Maybe next week

40. When you discuss restarting anticoagulation with Gerald, in addition to discussing bleeding risks after resuming anticoagulation, clinical signs of bleeding (e.g., monitoring for melena after GI bleeding), and the likelihood of thrombotic events and death without anticoagulation, what should you be certain to emphasize?
A. The necessity of sticking to a consistent diet
B. Risks associated with OTC analgesic use
C. The need to switch to a different anticoagulant

41. Our 76-year-old patient Harry is very reluctant to restart oral anticoagulation. The team has determined that he is at low thrombotic risk. Considering Harry’s trepidations, what could you suggest?
A. Engage his family to pressure him to restart anticoagulation
B. Tell him he will be discharged AMA if he refuses anticoagulation
C. Delay anticoagulation for a short duration and reassess

42. What complication of anticoagulation do patients fear most?
A. Intracranial hemorrhage
B. Gastrointestinal bleeding
C. Unidentified drug interactions

Now look at the 2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage: A Guideline from the American Heart Association/American Stroke Association.

43. Betty Ann is on an anticoagulant and experiences an intracerebral hemorrhage. She is seen in your clinic. What is the BEST way to ensure the best possible outcome?
A. Ensure early recognition, expedite transport to the most appropriate facility, and notify the hospital BEFORE she arrives to expedite the in-hospital stroke response
B. Differentiate intracerebral hemorrhage from other possible diseases by sending Betty Ann for neuroimaging at a local hospital
C. Have the person who brought Betty Ann to the clinic take Betty Ann to the hospital immediately without calling AMS because it will be considerably faster.

44. What does this guideline recommend when dealing with patients who develop an intracranial hemorrhage while anticoagulated and why?
A. Order an INR if the patient is on warfarin or quantitative levels if the patient is on a DOAC because the team needs data before acting
B. Start by taking steps to lower blood pressure because successful BP lowering also lowers 30-day mortality rates,
C. Start immediate, anticoagulant-appropriate acute reversal because risk of morbidity and mortality is high

45. Al is a 55-year-old man who experienced an ICH yesterday. The team is monitoring and finds he has a hematoma expansion (HE). Compared with patients who are not or have not been on anticoagulation, what has research found about HE in patients with ICH on anticoagulation therapy?
A. The risk of HE, rapid deterioration, and poor outcome is increased.
B. Lowering BP even after six hours improves outcome and reduces HE.
C. Data indicates anticoagulation reversal improves functional outcomes.

46. Lillian, an 83-year-old who resides in a nursing home, experiences a spontaneous ICH. She needs immediate neurosurgery. She is on aspirin and an antiplatelet drug. Which approach may reduce postoperative bleeding?
A. Desmopressin
B. Fluid resuscitation
C. Platelet infusion

47. Louie has a trauma-associated ICH and symptomatic VTE. Based on two retrospective studies, when does it appear that initiation of therapeutic anticoagulation after the onset of ICH would be safe?
A. 1 to 2 weeks
B. 2 to 4 weeks
C. 4 to 6 weeks

48. Louie has resumed his anticoagulant but says he “lacks energy and worries.” His primary care provider (PCP) assesses Louie and determines he has mild depression and anxiety. His PCP is thinking about prescribing an antidepressant. What have several meta-analyses found?
A. SSRIs are the antidepressant class of choice for patients with mild depression.
B. SSRIs should be reserved for patients with moderate to severe depression.
C. Plenty of data indicate that SSRIs or SNRIs are safe and effective after ICH.

49. Which of the following statements is TRUE concerning anticoagulant-related hemorrhages in ICH?
A. They are decreasing in number because clinicians are tending to use DOACs rather than warfarin.
B. They are the most common bleeding event in patients taking DOACs, while GI bleeds are more common with warfarin.
C. They are associated with increased hematoma volume and expansion, and increased morbidity and mortality.

Finally, please pull up the ACC’s Considerations for Anticoagulation Reversal/Hemostasis.

50. What do you need to remember when PCCs are used to reverse VKAs?
A. Use a fixed dose of 35 units/kg
B. Always give concurrent plasma
C. Always give concurrent vitamin K

51. When might the treatment team use activated charcoal for dabigatran, edoxaban, or betrixaban?
A. As a precaution whenever these patients experience a bleed
B. If the last dose was taken two to four hours ago
C. Never; it is only used with apixaban and rivaroxaban

52. What facts do you need to consider when calculating the dose of andexanet alfa to reverse the apixaban or rivaroxiban?
A. Amount and time of last dose
B. Patient’s renal function
C. Documenting off-label use

ABSTRACT

Many different guidelines and clinical studies address how to manage anticoagulation around the time of surgeries or procedures. This module’s goal is to help learners pull dry information together and apply it to real-world anticoagulation situations. It discusses terminology, renal function assessment, recent guideline changes, and how to stratify a patient’s periprocedural risk of thrombosis and bleeding. In addition, the module covers anticoagulation during the periprocedural period, potential interactions with over-the-counter products, and how to communicate the plan with patients and caregivers. It includes practice pearls from an experienced certified anticoagulation provider. Finally, it concludes with a sample case to show learners how to use this information in typical situations in direct patient care.

 

INTRODUCTION

Appropriate perioperative anticoagulation management is essential for patient safety. Guidelines can be valuable tools for identifying a potential course of action when tailoring perioperative plans for individual patients who take anticoagulants. However, significant gray areas remain. Clinicians must consider individual patient characteristics before finalizing any plan. This module familiarizes learners with the most recent guidelines and demonstrates how to optimize perioperative anticoagulation care for patients.

 

Many guidelines about anticoagulation are available. Good clinical practice requires occasional surveillance for changes in the current landscape. Select organizations that periodically release guidelines include the American Society of Hematology (ASH), the American College of Cardiology/American Heart Association (ACC/AHA), and the American College of Chest Physicians (CHEST). This module primarily uses the 2022 Perioperative CHEST Guideline. Please note, guidelines sometimes refer to medications that are used internationally, but this module only discusses medications available in the United States. Additionally, each institution’s protocol or clinician’s opinion may vary from the views presented here.

 

TERMINOLOGY

• "Bridging" refers to using a shorter half-life anticoagulant to act as a "bridge" between pre-procedure and post-procedure maintenance anticoagulation. This action minimizes patients' exposure to subtherapeutic anticoagulation while their maintenance anticoagulation is held for a procedure. Most commonly, this refers to using low molecular weight heparin (LMWH) while warfarin is held.
  • Practice Pearl: Patients or providers sometimes incorrectly refer to simply holding an anticoagulant as "bridging."
• “DOAC” refers to the direct oral anticoagulants (the Factor Xa inhibitors rivaroxaban [Xarelto], apixaban [Eliquis], edoxaban [Savaysa], and the Factor IIa inhibitor dabigatran [Pradaxa]). The old term "NOAC" has fallen out of favor as it implies a negative connotation.
• “Glycoprotein IIb-IIIa inhibitor” refers to the antiplatelet agents eptifibatide (Integrilin) and tirofiban (Aggrastat).
• “Low-molecular weight heparin” refers to enoxaparin (Lovenox) and dalteparin (Fragmin).
• “P2Y₁₂ inhibitor” refers to the antiplatelet drugs clopidogrel (Plavix), prasugrel (Effient), ticagrelor (Brilinta), and cangrelor (Kengreal).
• The terms “surgery” and “procedure” are sometimes used interchangeably.

 

ESTIMATING RENAL FUNCTION

Some anticoagulants are renally cleared, so clinicians must be prepared to make dose adjustments for renal impairment. Directly measuring glomerular filtration rate (GFR) is not practical, so formulas that estimate renal function guide treatment decisions. Commonly used formulas use serum creatinine (SCr), height, age, and some form of body weight (in kg) to estimate renal function (discussed in more detail later). Calculators for these equations are available online.

 

Renal function formulas assume stable renal function and the results are just estimates, so the anticoagulation team must consider the whole patient when making dosing adjustments. Note that neither the CKD-EPI Creatinine Equation (2021) nor the Cockcroft-Gault formula have been validated for use in children, pregnancy, or patients with low creatinine values.

 

The most recent Kidney Disease: Improving Global Outcomes (KDIGO) Guidelines recommend using the CKD-EPI Creatinine Equation (2021) to estimate renal function. This formula takes body habitus (common variations in the shape of the human body, which in turn determines the position of internal viscera) and gender into account and is now widely used.¹

 

CKD-EPI Creatinine Equation (2021)

eGFR_Cr = 142 x min (S_Cr/k,1)^α x max (S_Cr/k,1)^-1.200 x 0.9938^Age x 1.012 [if female]

Female: k = 0.7, α = -0.241; Male: k=0.9, α= -0.302

“min” =minimum of SCr/k or 1; “max” = the maximum of SCr/k or 1

 

Then convert the result to a non-indexed eGFR using BSA as follows:

BSA (m²) = 0.007184 x (weight in kg) ^0.425 x (height in cm) ^0.725

Non-indexed eGFR = indexed eGFR x BSA /1.73 (result expressed as mL/min/1.73 m²)

 

This formula estimates kidney function more accurately than others, is widely regarded as the current standard of care, and reference laboratories use it. However, the pharmacokinetic studies that lead to United States (U.S.) Food and Drug Administration (FDA) approval often use the historical Cockcroft-Gault (CG) formula instead. Therefore, FDA-approved prescribing information often bases renal dosing adjustments on CG creatinine clearance (CrCl).²

 

Cockcroft-Gault Formula (1976)

CrCl = [((140–age) x (weight in kg))/ (72 x SCr)] x 0.85 (for females)

 

The Cockcroft-Gault formula was developed from data collected from white adult males and often yields inaccurate results when applied to the general population. The formula’s developers suggestion for an 85% correction for female gender was not derived from clinical data. They acknowledged its limitations. Its flaws have been extensively discussed.^1,3,4 Common patient characteristics that may yield inaccurate results include:

• Actual body weight (ABW) either below or more than 30% above, ideal body weight (IBW)
• Edema
• Frailty
• Height under 60"
• Hydration status
• Low muscle mass

 

Special Populations

Unfortunately, choosing an appropriate measure of body weight to use in CG is not always as simple as having the patient step on the scale. Table 1 describes how clinicians use different representations of body weights in different circumstances.

 

 

Adjusting Weight for Obesity

The literature suggests adjusting body weight for obesity (body weight greater than 30% over IBW). The adjusted body weight (AdjBW) is calculated using the following formula, and the result is used in the CG formula.⁵

IBW (male) = 50 + (2.3 x (height minus 60 inches))

IBW (female) = 45.5 + (2.3 x (height minus 60 inches))

AdjBW0.4 = IBW + 0.4 (ABW - IBW)

 

Practice Pearl: Note that the rivaroxaban prescribing information specifically calls for using Actual Body Weight when calculating CrCl.⁶

 

Adjusting Weight for Amputations

Currently, no validated method is available to estimate renal function in patients who are amputees. One possible method is to estimate the IBW before the amputation, subtracting an approximation of what that limb might have weighed (see Table 2), then using the AdjBW in the formula. Alternatively, clinicians can use an online calculator such as https://clincalc.com/kinetics/ebwl.aspx.⁷

 

 

Transgender Patients

Hormonal therapy influences lean body mass and should be considered when estimating renal function in transgender patients. For transgender patients who have completed at least six months of hormone therapy, the team should calculate CrCl using their gender identity, not their sex assigned at birth.⁹

 

PAUSE AND PONDER: In what situations should heparin be used to protect the patient from thrombosis while oral anticoagulants are held for surgery?

 

CHEST GUIDELINE

CHEST released an updated Clinical Practice Guideline for the Perioperative Management of Antithrombotic Therapy in 2022.¹⁰ The new more user-friendly guideline replaces the 2012 version.¹¹ It only provides guidance for elective procedures that are not urgent. The 2022 version provides more comprehensive and detailed guidance on the perioperative use of DOACs, antiplatelet medications, and heparin bridging. It also includes more specific guidance on perioperative risk of thrombosis and bleeding.

 

Many CHEST Guideline recommendations are presented as being supported by either "Low" or "Very Low" Certainty of Evidence. For these, individual patient characteristics and clinical judgment become more important when determining a plan of action. The main body of the text sometimes describes specific considerations for different patient populations.

 

The CHEST Guideline only makes two strong recommendations, both regarding warfarin¹⁰:

• Prescribers should not bridge patients using warfarin with LMWH when atrial fibrillation (AF) is the sole indication.
• Warfarin should be continued, not held, for ICD or pacemaker placement if the international normalized ratio (INR) is less than 3.0.

 

It makes several other important recommendations¹⁰:

• Warfarin patients at high risk of venous thromboembolism (VTE) should be bridged with heparin.
• Avoid heparin bridging for patients who take DOACs.
• Avoid heparin bridging for warfarin patients with minimal to moderate risk of VTE with the following:
  1. Mechanical heart valves
  2. VTE as the only risk factor (post-procedure low-dose heparin may be used)
  3. A colonoscopy with polypectomy
• Avoid adjusting
  1. LMWH or DOAC dosing to anti-Xa levels
  2. Antiplatelet medications based on antiplatelet testing
• Discontinue apixaban, dabigatran, edoxaban, and rivaroxaban before procedures.
• Continue aspirin (ASA) for patients having non-cardiac surgery.
• Patients who take ASA and have coronary artery bypass graft (CABG) scheduled should continue ASA.
• Patients who take dual antiplatelet therapy (DAPT) who had a coronary artery stent placed six to 12 weeks ago should either continue both antiplatelet agents or should hold one of them seven to 10 days pre-procedure.
• DAPT patients who had a coronary artery stent placed three to 12 months ago, and patients who are having CABG surgery, should hold their P2Y₁₂ inhibitor (clopidogrel, prasugrel, ticagrelor, or cangrelor).
• Do not use glycoprotein IIb-IIIa inhibitors (eptifibatide, tirofiban) or cangrelor to bridge antiplatelet patients.
• When holding a DOAC, continue holding until at least 24 hours post-procedure, as restarting sooner can increase bleeding risk.
• Patients with an INR above 1.5 up to two days before the procedure should not receive vitamin K as this can delay return to full therapeutic INR post-procedure.
• Continue warfarin for dental procedures.
  1. Exceptions: Hold warfarin if the patient has poor gingival condition or is expected to bleed profusely. Consider patient history.
  2. Tranexamic acid and additional sutures can be used to limit bleeding.
• Continue warfarin for minor dermatologic procedures.
  1. Exceptions: Hold warfarin if the patient is having a skin graft or expected to bleed profusely.
• Continue warfarin for minor ophthalmologic procedures.
  1. Exceptions: Retinal surgery or any time retrobulbar anesthesia is used

 

Practice Pearl: It can be challenging to find information that applies to a highly specific patient population in a dry document like a CHEST Guideline. This is an optional exercise: under what heading in the CHEST Guideline does it describe specific patient characteristics that may make you inclined to hold an anticoagulant or antiplatelet drug for a dental extraction?

1. Assessing Perioperative Risk for Surgery/Procedure Related Bleeding
2. Summary of Key Recommendations
3. Patients Having a Minor Dental, Dermatologic, or Ophthalmologic Procedure

 

Table 3 summarizes CHEST Guideline recommendations for how long to hold an anticoagulant before a procedure and when to resume it after a procedure.¹⁰

 

 

PAUSE AND PONDER; How do clinicians decide who is at high enough risk of thromboembolism to interrupt anticoagulation for a surgery or procedure or to warrant the additional bleeding risk of LMWH during a warfarin bridge?

 

PATIENT-SPECIFIC PERIOPERATIVE ANTICOAGULATION PLAN

Overview

Step 1: Begin by collecting basic information:

• What procedure or surgery is happening, and when?
• Which anticoagulant is the patient using?
• What herbal and vitamin supplements are the patient currently taking?
• What is the patient's medical history and allergies? Are there any recent updates from either inside or outside your healthcare system?
• Does the patient have a history of heparin-induced thrombocytopenia (HIT), severe bleeding such as SDH, thrombosis, or other complications during a historical perioperative period?
• Do you need to update the patient's weight or lab work?

Step 2: Communicate with other healthcare team members involved in this patient's care.

Step 3: Assess risks and prepare the perioperative plan.

• Assess the risk of thrombosis. Is holding the anticoagulant really necessary? How long? Is bridging required?
• Assess the risk of procedure-related bleeding.
• Calculate renal function and Child-Pugh score if applicable.
• Obtain or place orders as necessary following the institution's protocol.
• Review plan for feasibility and accuracy. Examples of potential errors include
  1. Bridging warfarin patients in end stage renal disease (ESRD) with therapeutic-dose LMWH
  2. Bridging DOAC patients with LMWH
  3. Holding warfarin for 5 days without LMWH bridging in mechanical mitral valve replacement (MVR) patient with antiphospholipid syndrome (APS), a history of VTE, with low bleeding risk
  4. Holding warfarin 7 days before a single dental extraction in patients with paroxysmal AF
  5. Holding warfarin 1 day before spinal surgery

Step 4: Educate the patient and/or caregiver.

 

A written plan can facilitate adherence and communication between team members and the patient, especially if the plan is complicated. Clinicians who review the plan verbally with patients can evaluate feedback and clarify questions instantly. If applicable, patient education should cover subcutaneous injection technique and sharps disposal. Confirm that patients and caregivers understand the plan using the teach-back technique and spot-checks. A critical element is how to recognize the signs of bleeding or thrombosis with patients, so the patient knows when to call 911.

 

Practice Pearl: The electronic health record (EHR) often contains errors or omissions. Reviewing medication and problem lists with patients may identify medication that was discontinued (sometimes years ago!). Sometimes, patients do too much yard work and injure a knee; they start ibuprofen without notifying their healthcare provider. Perhaps they visited London and didn’t tell their provider about the pulmonary embolism they developed on the flight, or the fact that they are now using rivaroxaban. They may have been hiking in the Grand Canyon when they had a myocardial infarction and didn’t think to mention they are now using clopidogrel and aspirin. Clinicians will not know unless they ask.

 

OVER-THE-COUNTER PRODUCTS

Many foods and over-the-counter (OTC) products can increase bleeding risk and should be held in the perioperative period. Table 4 shows a sample of interactions between foods/supplements and selected anticoagulants. For example, using cannabidiol (CBD) with apixaban can increase the patient's bleeding risk; if patients who have a high bleeding risk procedure restart apixaban and CBD after the procedure, bleeding risk will be high during that time.

 

Some supplements and foods have intrinsic anticoagulant or antiplatelet properties and can increase the bleeding risk even wihout a CYP450 or P-glycoprotein interaction. St. John’s Wort can increase risk of thrombosis when used with apixaban, dabigatran, rivaroxaban, and warfarin; it induces CYP3A4 and P-glycoprotein. When in doubt, it is generally best to err on the side of caution and hold all patient-initiated supplements in the perioperative period.

 

Practice Pearl: Surgeons often require tobacco cessation before scheduling surgery. This can increase warfarin sensitivity through a CYP1A2 interaction.

 

Cannabis is widely used. It is primarily metabolized by the liver, but about a fifth is renally eliminated. It inhibits CYP450 enzymes, including 3A4, 2D6, 2C9, and 2C19. In addition to its potential interactions with anticoagulants, it can also prolong sedation and increase the risk of myocardial ischemia. Patients with cannabis use disorder can experience increased perioperative morbidity and mortality.^12-14

 

*Ibuprofen and naproxen may block antiplatelet effect of ASA.

 

PERIOPERATIVE RISK ASSESSMENT

The following risk stratification methods are general guides, not absolute rules. Pharmacists must consider the whole patient and use good clinical judgement. Caution and prioritizing patient safety are always prudent.

 

Risk of Thrombosis

Certain patient characteristics increase a patient’s risk of thrombosis during a procedure. The CHEST Guideline presents three main risk categories: AF, VTE, and mechanical heart valves. When a patient has an elevated risk score in multiple categories, the team should use the highest value for stratification purposes. For example, if a patient has a CHA₂DS₂VASc score of 2 and antiphospholipid antibodies, classify the patient as high risk of thrombosis.

 

Atrial Fibrillation

The CHADS₂ and CHA₂DS₂VASc scoring formulas classify patients with AF as having a high, medium, or low risk of stroke as described in Table 5. the CHEST Guideline references both:

• CHADS₂: Add one point for each of the following conditions: congestive heart failure (CHF), hypertension, age at least 75 years, and diabetes; add two points for a history of stroke/TIA.
• CHA₂DS₂VASc: Add one point for each of the following conditions: CHF, hypertension, diabetes, vascular disease (myocardial infarction, peripheral artery disease, aortic plaque), age 65-74 years, and sex category of female; add two points each for age at least 75 years and history of cerebrovascular accident (CVA)/TIA/thromboembolism.

CHA₂DS₂VASc identifies low-risk patients more accurately and classifies fewer patients as moderate risk.²⁰

 

Source: Adapted from reference 10 p.e212.

 

Venous Thromboembolism

 

Mechanical Heart Valves

*Major risk factors for CVA: History of AF, CVA/TIA during previous anticoagulation hold, rheumatic heart disease, valve thrombosis, HTN, diabetes, CHF, age 75 or greater.

 

Bleeding Risk

Some patients develop serious bleeding during or after a procedure, so risk assessment is critical. The literature describes several different bleeding-risk scoring systems, including HAS‐BLED, HEMORR₂HAGES, ORBIT‐AF, ATRIA, and GARFIELD‐AF. In short, while these tools can help identify potentially high-bleeding-risk patients, their accuracy varies depending on the patient population studied.^21,22 The CHEST Guideline includes empiric classification guidance.¹⁰

 

High

Generally, surgeries and procedures performed on highly vascularized organs, that cause extensive tissue damage, or are spinal-invasive are considered high risk. Anticoagulants should be held long enough to reverse their effects. Examples include

• Cancer
• Cardiac
• Colonic polyp or bowel resection
• Epidural injections
• Gastrointestinal (GI)
• Kidney
• Major orthopedic
• Major thoracic
• Neuraxial interventions
• Reconstructive plastic
• TURP
• Urologic

 

Low to Moderate

These surgeries are considered low to moderate bleeding risk surgeries and procedures, regardless of whether biopsies are performed. Anticoagulants can be held for less time during the perioperative period.

• Arthroscopy
• Bronchoscopy
• Colonoscopy
• Coronary angiography, femoral approach
• Foot, hand
• GI endoscopy
• Hemorrhoidal surgery
• Hysterectomy
• Laparoscopic cholecystectomy
• Lymph node biopsies

 

Minimal

Many patients can remain fully anticoagulated for minimal bleeding risk procedures, although it would be reasonable to consider holding a DOAC on the day of the procedure. In certain circumstances, such as a dental extraction in a patient who has poor gingival health, it may be reasonable to hold anticoagulation before a minimal bleed risk procedure.

• Cataract procedures
• Coronary angiography, radial approach
• Minor dental procedures, including extraction(s)
• Minor dermatologic procedures, including excision of skin cancers
• Pacemaker or ICD placement

 

DIRECT ORAL ANTICOAGULANTS

Since heparin bridging is not used for patients who use DOACs, these instructions are simple. Clinicians should provide patients with instructions to hold their DOAC on specific dates. However, they need to know the audience! For some patients, verbal communication suffices. In this case, the best practice would be to ask the patient to repeat the instructions to confirm understanding. Other patients find it more helpful to have written instructions, especially those who have caregivers. For patients who live in assisted living facilities that manage their medications, pharmacists can do two things: (1) review the instructions with the patient for their own knowledge and (2) provide instructions directly to the facility.

 

DOACs only take a few hours to become fully effective. Ask the patient to check with the surgeon after the procedure is complete to make sure it’s safe to restart the DOAC.²³

 

WARFARIN

The inter-patient variability in responses to warfarin cannot be understated. Warfarin’s half-life is 20 to 60 hours and varies significantly from patient to patient. Warfarin ultimately inhibits activation of clotting factors II, VII, IX, and X, and it also affects the natural anticoagulants protein C and S. Table 8 compares these factors’ half-lives and reveals that they are not necessarily pivoting in concert while warfarin doses are being adjusted.

 

Source: Adapted from 24 p. 20.

 

Many factors affect a patient's response to a warfarin dose. These include interactions with diet, pharmacokinetic medication interactions, pharmacodynamic interactions, liver function, edema status, and many more. Surgery and hospitalization commonly cause physical stress and decrease appetite; both increase warfarin sensitivity. The patient's history can be invaluable when determining post-procedure doses but caution is warranted. Even if the patient had a similar warfarin holding situation in the past available for comparison, they may respond differently this time.

 

It can take three to seven days (or more) to see the effect of warfarin dosing changes on the INR. Therefore, patients usually resume warfarin in the evening after a procedure is completed. It can take weeks for INR to stabilize after major surgery. This is when shorter-acting LMWH and unfractionated heparin (UFH) become useful.

 

Heparin Bridging During Warfarin Interruption

Unless otherwise specified, when the CHEST Guideline mentions "heparin bridging," it specifically refers to using a therapeutic-dose LMWH. Examples include enoxaparin 1 mg/kg twice daily or 1.5 mg/kg daily, dalteparin 100 international units/kg BID or 200 international units/kg daily, or full-dose UFH to achieve target aPTT of 1.5-2x the control, or a target anti-Xa level of 0.35 to 0.70 international units/mL. Lower prophylactic or intermediate doses may be used in certain circumstances.¹⁰ Clinicians need to calculate renal function before finalizing a dose. If a patient with ESRD needs to bridge for a procedure, it is best to use IV UFH for inpatient bridging rather than LMWH.

 

Practice Pearl: It may be difficult for patients who are underweight (with little subcutaneous fat) or who have had major surgery (scarring or local trauma) to find suitable sites for subcutaneous injections.

 

Practice Pearl: It can be challenging to determine an appropriate therapeutic dose of LMWH for patients with BMI exceeding 40 kg/m², especially in the outpatient setting, where monitoring anti-Xa levels would be more challenging. Whether or not to cap the dose at some amount lower than 1 mg/kg twice daily is a controversial topic.^14,25

 

Practice Pearl: Procedures that require LMWH bridging and are scheduled without much notice can cause logistical challenges for patients. Questions to consider include

• When does the patient need to start using LMWH?
• Does the pharmacy have it in stock?
• If not, how long will it take them to order it?
• Will the patient be able to afford the copay?

 

Practice Pearl: Significant drops in hemoglobin, hematocrit, or platelets after a surgery or procedure can be the first warning sign of severe post-operative bleeding.

 

Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a potentially life-threatening condition that is a possible reaction to heparin. The ASH Guideline suggests monitoring for drops in platelet count for patients who are considered to have moderate or high risk of HIT, including patients using UFH and patients using LMWH after major surgery or trauma. In these cases, the guideline recommends monitoring platelet count every two to three days until heparin is discontinued.²⁶

 

Example Warfarin Bridge Plan

Oliver is a 52-year-old male patient with a MVR, antiphospholipid antibodies, and a history of CVA. He has a colonoscopy scheduled next month. Lab work done 9 months ago was largely unremarkable, except his platelets were 30 points below the minimum EHR reference range (unknown etiology). His medication list includes warfarin 5 mg daily, lisinopril 20 mg daily, and aspirin 81 mg daily. He said he does not use supplements. His INR has been stable and therapeutic for the past two months. He has had no other procedures in the past year. Repeat bloodwork indicates his platelets are now within normal limits. He will return home the same day as the procedure.

 

Vitals: Weight 174 lb, BP 135/82 mmHg. CrCl 65 mL/min.

 

Your institution's protocol indicates he should bridge with therapeutic dose enoxaparin for this procedure, and you have whatever approvals you need to proceed. You send a prescription for 80 mg enoxaparin syringes #20 to his local pharmacy, to be used twice daily as instructed in Table 9. Since his procedure is still a month away, his pharmacy has time to order the enoxaparin if necessary.

 

 

PAUSE AND PONDER: How would you provide instructions to the patient in a way that they both understand and are willing and able to follow?

 

COMMUNICATION TECHNIQUES

Practice Pearl: Use active listening, reflective statements, and motivational interviewing techniques to ensure patients know you hear their concerns and are comfortable asking questions.

 

In the ambulatory setting, the patient must fully understand and accept the perioperative plan to minimize the risk of harm. Patients may not follow through if they think the team doesn’t care about their concerns.

 

Consider Emma, who has been your patient for several years. She arrives at the clinic irritated and you do not know why. You try to make small talk with her, but she snaps, “Just get on with the visit.” She crosses her arms across her chest and looks away. You do not know this yet, but her mother was just diagnosed with metastatic colon cancer and is considering foregoing treatment and entering hospice care.

 

Emma is here today to review perioperative instructions for her upcoming colonoscopy. She has had precancerous polyps removed in the past and has recently developed a small amount of hematochezia (presence of fresh [bright red] blood in stools). Emma was not expecting to have to bridge for her colonoscopy because she didn’t bridge for the last one. She recently established care with a new provider who is more concerned about her risk of thrombosis than her last one was.

 

She is expecting to hold her warfarin five days prior to her procedure and restart it the same evening, but then you show her a detailed calendar of LMWH bridging instructions and begin reviewing them. She becomes increasingly disengaged and even a little tearful and refuses to follow the plan. She says, “Forget it. I am cancelling the colonoscopy.”

 

The sooner you identify a bad situation developing, the easier it is to avert it. The patient's body language is a signal to address concerns immediately. The moment Emma crossed her arms across her chest and looked away was your cue to stop and attempt to determine the problem. If she shares her concern about her mother’s recent diagnosis and her concerns about her own health, use a reflective statement (summarize and repeat the problem back to her). Don’t judge, contradict, or redirect her. Demonstrate you are really listening to her and trying to understand her concerns. She will probably uncross her arms and make eye contact with you again.

 

At an appropriate time, gently guide the discussion back to the reason she is here. You might say something like, "Thank you for sharing your concerns. I hear that you are feeling very stressed right now. You only want the best for your mother, and this news is devastating. You’re worried about what the doctor will find in your own colonoscopy. I went right into all these details about a complicated, unexpected bridge plan. I would feel anxious myself if I were you. I want you to know that you are always in control of your own healthcare. You get to decide for yourself if you want to proceed, if and when you are ready. If it turned out that you have another polyp, would you want to have the opportunity to have it removed?"

 

While you are having this discussion, it is important to remain attentive and welcome her to interrupt you with new information or questions or concerns as they come up. Emma agrees to proceed, and you review the instructions with her. After presenting the plan, ask her to explain to you what she will be doing at each step of the process to confirm understanding. This is called a “teach-back technique.”

 

Practice Pearl: Use teach-back techniques and spot-checking to ensure understanding.

 

Language Barriers and Hearing Impairment

Practice Pearl: Use only qualified interpreters when communicating complicated instructions to patients who do not share your native language. Use alternate communication methods as needed for deaf or hard-of-hearing patients.

 

Patients may find it more difficult to understand instructions that contain slang or medical jargon. Sometimes, patients nod to indicate they understand what you are saying, even when they do not, to be polite or to avoid social discomfort. When using interpreters, make eye contact with and speak directly to the patient, not the interpreter. Speaking louder will not improve understanding when the obstacle is a language barrier. Patients with hearing impairment may benefit from careful enunciation, especially of consonants. They may also lip-read, even if they do not realize they are doing it. This can be challenging in situations when masking is required.

 

Practice Pearl: In the United States, the format frequently used to describe dates is month-day-year; however, other countries use day-month-year. To minimize confusion, provide written dates with the month shown as a word instead of a number, e.g., “August 3” instead of “8-3.”

 

Cognitive Impairment

Practice Pearl: Be prepared to repeat your instructions as often as needed to ensure understanding.

 

Cognitive impairment occurs across a broad spectrum that can make it challenging for patients to understand and/or follow detailed instructions.²⁷ Some patients may need to review the material with you several times. Other patients may bring a caregiver or friend to help them think of questions to ask and to remember their instructions. Some patients cannot take their medication on their own; in this case, it is essential to provide education to a caregiver who can help them navigate the process. If caregivers accompanies a patient to an appointment, acknowledge their presence and include them in the discussion. They may have relevant questions, concerns, or valuable feedback.²⁷

 

The following resources provide more tips on patient communication:

• https://www.cds.udel.edu/wp-content/uploads/2017/02/effective-communication.pdf
• https://store.jointcommissioninternational.org/assets/3/7/jci-wp-communicating-clearly-final_(1).pdf

 

Vision Impairment and Tremor or Arthritis

Practice Pearl: Round a dose to the nearest commercially available dose instead of strict weight-based dosing.

 

The more complicated or physically challenging the perioperative instructions are, the greater the risk of dosing errors. For example, enoxaparin syringes are graduated but the small markings may be hard for patients with vision impairment to see. Additionally, tasks requiring fine motor skills, such as removing a tiny amount of liquid from a syringe, or even administering an injection, may be difficult or impossible for patients with tremors or arthritis. Dose rounding to the nearest commercially available strength can help with this.

 

Enoxaparin comes in the following prefilled syringe doses: 30, 40, 60, 80, 100, 120, and 150 mg.²⁸

 

Common Patient Misconceptions

Practice Pearl: To prevent patient misunderstandings, explain the independent roles of warfarin and LMWH in the bridge and why both are used simultaneously.

 

Sometimes, patients misunderstand the role of warfarin and LMWH in the bridging process, even when they have detailed written instructions. They may not resume LMWH post-procedure because they think their INR will return to their therapeutic range immediately after restarting warfarin. They may not resume warfarin post-procedure because they believe the LMWH increases their INR. You can prevent these kinds of misunderstandings by providing a basic explanation of the independent roles of warfarin and LMWH in the bridge, and why they will be using both at the same time post-procedure.

 

Practice Pearl: Ask patients to "hold" the anticoagulant on specific dates (and resume it on specific dates). Do not use the term "stop." If you tell patients to stop their warfarin on Tuesday, they might take that to mean you want them to take their last dose of warfarin on Tuesday, not to take the last dose of warfarin on Monday and start holding it on Tuesday. This misunderstanding can result in a patient holding warfarin for only four days before their procedure, instead of five

 

Revisions Due to Unexpected Developments

Clinicians involved in anticoagulation must remain flexible and prepared to adapt to an evolving situation after a patient’s surgery or procedure. Some common examples of periprocedural situations that may warrant closer monitoring post-procedure include

• Bleeding may delay the resumption of anticoagulation post-procedure.
• NSAIDs prescribed for pain control on discharge can increase bleeding risk.
• Vitamin K reversal increases warfarin dosing requirements post-procedure.
• Reduced appetite or food intake post-procedure may reduce rivaroxaban absorption or increased warfarin sensitivity.
• Bariatric surgery can have unpredictable effects on warfarin dosing requirements. Although patients are eating less, they may have initiated supplements that contain more vitamin K than they consumed pre-procedure.
• Dental procedures can temporarily decrease food intake; however, some dentists ask patients to use protein shakes (many of which contain vitamin K) post-procedure.
• Tobacco cessation increases warfarin sensitivity
• Changes in kidney or liver function may affect medication clearance.

 

CONCLUSION

Assembling an appropriate perioperative plan for a patient's anticoagulation can be complicated. The material and pearls provided in this activity can help clinicians devise and implement a plan that is appropriate for each patient.

 

 

 

1. Which of the following patients should be bridged for a hip replacement surgery?
a. A 46-year-old male who uses a DOAC for atrial fibrillation
b. A 38-year-old female who uses warfarin for heterozygous Factor V Leiden mutation
c. A 42-year-old male who uses warfarin for Protein S deficiency

2. Which of the following surgeries carries the highest risk of perioperative bleeding?
a. Colonic polyp resection
b. Hemorrhoidal surgery
c. Hysterectomy

3. Which of the following patients has the highest risk of perioperative thromboembolism, assuming all medical conditions are listed?
a. A 34-year-old female with antiphospholipid antibodies
b. A 75-year-old female with atrial fibrillation and aortic plaque
c. A 65-year-old male with atrial fibrillation, history of stroke, and hypertension

4. A 26-year-old Ukrainian patient who does not speak English comes to your clinic to review perioperative instructions for a laparoscopic cholecystectomy next week. His only other medical condition is asthma. You have arranged for a professional interpreter to attend today’s visit. While using the interpreter, which of the following will help the patient understand your instructions?
a. Increasing your voice’s volume so he can hear what you are saying
b. Making eye contact and speaking directly to the patient
c. Using medical jargon and using highly technical terms

For the next two questions, consider the following patient case:
Evelyn is a 50-year-old female patient with an MVR, diabetes, protein C deficiency, Crohn’s disease, and hypertension. She has a bowel resection scheduled. Her current medications include warfarin, metformin, losartan, aspirin 81 mg, and prednisone. She also uses a daily multivitamin and alpha lipoic acid.

5. Which of the following perioperative plans would be most appropriate?
a. Hold both warfarin and ASA for seven days before the surgery, bridge with therapeutic dose LMWH, with the last pre-surgery LMWH dose, at half the total daily dose, 48 hours before the surgery and restarting LMWH 24 hours after the procedure if hemostasis is achieved. Continue ASA and alpha lipoic acid for the surgery.
b. Hold warfarin for five days before the resection and restart warfarin the evening of the surgery with no LMWH bridging if hemostasis is achieved. Hold the aspirin and alpha lipoic acid starting the week before until at least a week after the surgery.
c. Hold warfarin for five days before the surgery, bridge with therapeutic dose LMWH, at half the total daily dose, with the last pre-surgery LMWH dose 24 hours before the surgery and restarting LMWH 48 hours after the surgery if hemostasis is achieved. Continue ASA but hold alpha lipoic acid starting the week before until at least a week after the surgery.

6. If Evelyn was having a pacemaker placement instead of a bowel resection, which of the following perioperative plans would be most appropriate?
a. Hold warfarin for five days before the surgery, bridge with therapeutic dose LMWH, with the last pre-procedure LMWH dose, at half the total daily dose, 24 hours before the procedure and restarting LMWH 48 hours after the surgery if hemostasis is achieved. Continue ASA but hold alpha lipoic acid starting the week before until at least a week after the surgery.
b. Continue warfarin and ASA for the procedure but hold alpha lipoic acid starting the week before until at least a week after the surgery.
c. Hold both warfarin and ASA for seven days before the surgery, bridge with therapeutic dose LMWH, with the last pre-surgery LMWH dose, at half the total daily dose, 48 hours before the surgery and restarting LMWH 24 hours after the procedure if hemostasis is achieved. Continue ASA and alpha lipoic acid for the surgery.

7. Lily is a 78-year-old female with atrial fibrillation, CHF, and hypertension. She has a Watchman left atrial appendage closure device and a history of hemorrhagic stroke. Her current medications include sacubitril/valsartan and ASA. If she were to have an epidural injection, which of the following supplements would you be most concerned about her using during the perioperative period?
a. Echinacea
b. Gingko biloba
c. Grapefruit

8. John is a 67-year-old male who is scheduling a TURP. His medications include apixaban 5 mg BID, tamsulosin 0.4 mg daily, and metoprolol tartrate 50 mg BID. What is the minimum number of hours John would need to hold apixaban before the surgery?
a. Hold apixaban starting 12 hours before the surgery and restart no sooner than 24 hours after the surgery
b. Apixaban does not need to be held for this surgery
c. Hold apixaban starting 48 hours before the surgery and restart no sooner than 48 hours after the surgery

The following two questions are about the following patient case: Samantha is a 72-year-old female who lives alone and is 5’ 8” and weighs 210 lb. She uses topical diclofenac gel for arthritis. She also uses a daily multivitamin. She had a lab draw last month that was within normal limits. Her serum creatinine was 1.64 mg/dL. She is having hip replacement surgery in two weeks.
9. If she uses warfarin for antithrombin deficiency, what would be the most appropriate enoxaparin dose for her to use as an outpatient?
a. 95 mg
b. 40 mg
c. 100 mg

10. If she used a DOAC, which of the following would need to be held four days before the procedure?
a. Apixaban
b. Rivaroxaban
c. Dabigatran

1. Ty is admitted to your hospital for community-acquired pneumonia. You notice that he is a candidate for VTE prophylaxis. He is a 70-year-old male, 5’5”, and 75 kg (165 lbs). Labs include INR 1.1, BUN 30, and SCr 2.5. What is the most appropriate recommendation?
a. Enoxaparin 40 mg SC daily
b. Heparin IV per thromboembolic protocol
c. Enoxaparin 30 mg SC daily

2. Which of the following is an approved indication for low molecular weight heparin?
a. Treatment of venous thromboembolism
b. Anticoagulation in patients with a history of HIT
c. Prevention in patients with renal insufficiency

3. You are at a lecture on LMWH and fondaparinux and the speaker says that these two medications have three things in common. He says, “First, with both medications, you would not dose adjust or avoid using them in patients with impaired renal function. Second, you must order anti-Xa testing on Days 2 and 4 of therapy. Third, with both, active major bleeding is a contraindication for use.” What should you do?
a. Raise your hand and challenge his statement on patients with impaired renal function
b. Raise your hand and challenge his statement on ordering anti-Xa testing
c. Do nothing; these great clinical pearls will make it easier for you to screen patients.

4. A nurse calls, concerned about a patient on heparin for a new blood clot. The patient is going for hemodialysis today. They are unsure of how dialysis will affect the patient's heparin therapy. What would you recommend?
a. Recommend an additional bolus heparin dose immediately following dialysis
b. Ask the prescriber to change to LMWH because heparin is contraindicated in dialysis
c. Say hemodialysis will not affect heparin levels so continue therapy as prescribed
5. A patient who is on LMWH is experiencing a major bleed and needs surgery. The surgeon wants to give protamine. What should you tell her?
a. Protamine will completely reverse LMWH’s anti-factor IIa and Xa effects
b. Give 1 mg protamine per mg of LMWH and repeat every 8 hours for 4 additional doses
c. Anti-factor IIa and Xa activities may return up to three hours after you give the dose

6. Why should prescribers never use enoxaparin sodium injection from multiple dose vials in neonates, infants or pregnant women?
a. No studies have established the appropriate dose
b. It contains benzyl alcohol preservative
c. It causes gastrointestinal colic-like symptoms

7. Which of the following is a contraindication for fondaparinux?
a. Body weight greater than 150 kg (330 lbs)
b. Bacterial endocarditis
c. Sever hepatic impairment

8. A patient accidentally injects her dalteparin twice and the prescriber is frantic and wants to handle the overdose quickly. What is the appropriate dose of protamine?
a. 1 mg protamine for every 1 mg dalteparin administered
b. 1 mg protamine for every 100 anti-Xa units of dalteparin given
c. 1 mg protamine for every 1 mg dalteparin in excess of the normal dose

9. What are the most serious symptoms of protamine overdose?
a. Severe hypotensive fatal reactions, often resembling anaphylaxis
b. Excessive bleeding unresponsive to further protamine doses
c. Epidural or spinal hematomas causing long-term/permanent paralysis

10. Which of the following is a boxed warning on the LMWHs and fondaparinux?
a. Severe hypotensive fatal reactions, often resembling anaphylaxis
b. Excessive bleeding unresponsive to intervention with protamine
c. Epidural or spinal hematomas with neuraxial anesthesia or spinal puncture