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Last Updated: 4/16/2014  

Anticoagulation

  • Initiate anticoagulation therapy for:

    • Primary prophylaxis in patients with AF or mechanical heart valves to prevent systemic embolism and stroke

    • Primary prevention of VTE in patients with medical illnesses

    • Secondary prevention of VTE, treating with warfarin for at least 3 months

  • Use direct thrombin inhibitors (danaparoid, lepirudin, argatroban, bivalirudin) in the setting of heparin-induced thrombocytopenia.

  • Note that bleeding is a major risk and complication of anticoagulation therapy; bleeding from UFH is reversed with protamine, 1 mg, to neutralize each 100 U of UFH but bleeding associated with LMWH is only partially reversible.

  • Note that bleeding is the major adverse event associated with fondaparinux. Treat bleeding due to fondaparinux with supportive measures, such as fresh frozen plasma and factor concentrates or recombinant factor VIIa supplemented with vitamin K, as there are no specific therapies.

  • Monitor for heparin-induced thrombocytopenia by obtaining a platelet count frequently during the initial 2 weeks of therapy, usually every 2 to 3 days.

  • Treat heparin-induced thrombocytopenia by discontinuing all heparin products, including subcutaneous heparin and heparin flushes and substitute an alternative anticoagulant, such as a direct thrombin inhibitor (argatroban or lepirudin).

  • Note that the major adverse events associated with warfarin include bleeding, skin necrosis, and purple toe syndrome due to cholesterol embolization.

  • Note that the major risk associated with direct thrombin inhibitors is bleeding.

  • Note that lepirudin is associated with serious allergic reactions that may occur with the initial dose or with re-exposure.

  • Note that lepirudin is renally excreted and requires dose adjustment in patients with renal impairment, and that argatroban is metabolized by the liver and requires dose adjustment in patients with hepatic impairment.

  • Note that dabigatran is contraindicated in people with severe renal impairment, active clinically significant bleeding, organic lesions at risk for bleeding, impairment of hemostasis, and hepatic impairment.

DOI: 10.7326/physpro084
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Disclosures:
Elizabeth Battinelli, MD, PhD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Jack Ansell, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Olivia Wu, PhD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Louise Craig, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Olivia Wu, PhD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Editor in Chief, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Richard B. Lynn, MD, FACP, Editor, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
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