Updated: 11/23/09  
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Pharmacy Resource and Information Management Exchange

ANTICOAGULATION Resources

Topic links will connect the user via email to the developer of content.  The form, policy or tool will then be provided by the contact person.

Protocols/Nomograms/Order Forms
Heparin Dosing Guidelines & Nomograms
Low Molecular Weight Heparin Dosing Guidelines & Nomograms
Warfarin Tools/Resources/Dosing Nomograms
Direct Thrombin Inhibitors
Bridging
DVT Prophylaxis
Anticoagulation Reversal
Other Contributions


Heparin Dosing Guidelines & Nomograms
The use of dosing protocols improves time in the therapeutic range, reduces the need for laboratory tests, improves documentation of infusion rates, and shortens the time needed to achieve anticoagulation goals.^{1, 2}  Protocol use also reduces variability in prescribing heparin and may minimize errors associated with writing out titration parameters.  Readers should note that the APTT range in any heparin protocol should be determined individually for each institution and for each lot of reagent.¹  Ideally, this range should be correlated with plasma heparin concentrations.

UWHC Guidelines for Therapeutic Dosing - Procedure for dosing and administering heparin by infusion.  Includes low, medium and high intensity regimens.  Low and medium intensity targeted to heparin levels of 0.1 - 0.3.  High intensity targeted to a heparin concentration of 0.3 - 0.7.  Includes contraindications.  Last review: October 2008
Agnesian Heparin Order Form - Has standard and reduced dose on same form.  Uses adjusted body weight. Last update: March 2008
Meriter Therapeutic Dose - Order form and monitoring form. Two versions available. One uses heparin levels for adjustments and the other use APTTs. Uses adjusted body weight for dosing and adjusts dose for age and indication. Therapeutic range 0.3 – 0.6 anti Xa units/ml. Last review: January 2009
Meriter Hospital Pharmacy Heparin Protocol - Algorithm incorporates labs and other information required at baseline, monitoring, and required documentation (including wording of progress note). Includes initial dosing for age, indication, INR, and other factors. Also includes strategy for patients receiving thrombolytics or GP IIb/IIIa platelet inhibitors and a section describing management of bleeding complications.
 

Low Molecular Weight Heparin Tools/Resources/Dosing Nomograms
Properly trained health-system pharmacists have demonstrated the ability to manage low molecular weight heparin therapy in ambulatory and inpatient settings.  The following are examples of tools, resources, and protocols that may help guide their work.  Due to the number of variables affecting anticoagulation, any protocol will have to be modified for some patients.  The use of a protocol should not be a substitute for clinical judgment.

Middleton VA Procedure for Transitioning Between Anticoagulants - Used to determine the timing of anticoagulant administration when transitioning a patient from UFH infusion to LMWH and vice versa. Last Updated March 2009
Middleton VA Inpatient Pharmacist Responsibilities for Low Molecular Weight Heparins and Fondaparinux - Pharmacist responsibilities for checking doses of LMWHs and fondaparinux prior to processing orders.  Includes guidelines for ordering baseline labs and documenting provider interactions. Last Updated April 2009
ThedaCare Enoxaparin Dosing in Special Populations - Chart describes dosing in pediatrics, renal failure, body weight extremes. Also includes use in pregnancy and in the setting of neuraxial anesthesia.  Last review: August 2009

Warfarin Tools/Resources/Dosing Nomograms
Properly trained health-system pharmacists have demonstrated the ability to manage oral warfarin therapy in ambulatory and inpatient settings.  The following are examples of tools, resources, and protocols that may help guide their work.  Due to the number of variables affecting oral anticoagulation, any protocol will have to be modified for some patients.  The use of a protocol should not be a substitute for clinical judgment.

Dosing Nomograms/Guidelines
Fort HealthCare Warfarin Protocol - Inpatient dosing protocol designed to achieve therapeutic INR.  Includes nomogram for INR ranges of 2 - 3 and 2.5 - 3.5.  Considers age, weight, interactions, albumin and LFTs.  Includes monitoring sheet, data from >200 patients, and modifications based on QI data.  Last review: June 2010
ThedaCare Warfarin Dosing Guidelines - Outlines criteria for pharmacist management, default INR targets, default treatment duration, selection of initial warfarin dose and subsequent dose adjustment.  Section on drug interactions provides strength of support for interaction and some examples of expected onset.  Last review: January 2009
Upland Hills Health Warfarin Initiation Guideline - Includes factors increasing or decreasing warfarin requirement as well as those that increase bleeding risk. Last review: September 2008
Meriter Hospital Pharmacy Guidelines for Initial Dosing of Warfarin - Includes order form for pharmacy dosing service. Includes adjustments for factors that increase or decrease warfarin requirement. Last update: January 2006

Other Tools and Resources
WHMI Warfarin Discharge Checklist - Includes points of instruction, list of documents to be sent home with patient, and information to be transferred to next provider.
WHMI Vitamin K Patient Handout - Brief, one-page handout describing rationale for consistent vitamin K intake and a brief list of foods containing vitamin K.  Last review: December 2008
WHMI PowerPoint Presentation - Describes the rationale for attention to anticoagulation, expected elements of care, factors affecting warfarin requirement, and location of resources.
Rehab Hospital of Wisconsin Warfarin Monitoring Sheet - Monitoring spreadsheet that automatically graphs INRs.
Upland Hills Health Hypercoagulability Reference - Table summarizes various lab tests used to diagnose hypercoagulability disorders and includes a brief description of each test and sample requirements from the University of Wisconsin Hospital Lab Services document.  Includes a citation from a 2003 Journal of Family Practice article that outlines an approach to working up these patients, complete with an algorithm.
Middleton VA Inpatient Anticoagulation Program Policy and Procedure: - This document is primarily a policy and procedure for an inpatient anticoagulation program.  The middle section contains a warfarin dosing nomogram for warfarin naïve patients and maintenance dosing as well as patient characteristics that warrant higher or lower warfarin dosing. Last Updated March 2009
ThedaCare Patient Education for Warfarin: Phase 1 - For use in hospital setting. Three pages of basic information including alcohol, diet, and when to call physician. Designed for patients starting warfarin. Last review: November 2009
ThedaCare Patient Education for Warfarin: Phase 2 - Used in the outpatient setting. Ten pages of more detailed information than in Phase 1 document. Includes INR information, administration hints, symptoms and prevention of bleeding/thrombosis, dietary and drug interactions, and travel tips. Last review: November 2009

Direct Thrombin Inhibitors
These agents are frequently used in the setting of confirmed or suspected heparin-induced thrombocytopenia.

Argatroban
UWHC Guidelines for Use - Includes background, indications, precautions/cautions and monitoring parameters.  Also includes section on initiating oral anticoagulation therapy and table on dosing.  Last review: November 2006
Meriter Order Form - Includes laboratory monitoring and adjustments for APTT. Uses designated PTT ranges rather than multiple of baseline PTT for dose adjustment.  Last update: October 2007
ThedaCare Protocol, Order Form and Monitoring Form - Designed for use in the setting of heparin-induced thrombocytopenia. Includes initial questions to ask physician and criteria to choose hepatic/critically ill nomogram or regular nomogram. Adjusts dose for obesity. Uses designated PTT ranges rather than multiple of baseline PTT for dose adjustment. Also includes section on initiating oral anticoagulation therapy and table on dosing.  Last review: August 2009

Bivalirudin
Meriter Order Form and Monitoring Sheet - Includes dosing for HIT, ACS, PCI and subq VTE prophylaxis. Form addresses laboratory tests and monitoring, renal adjustments, and dose adjustments for APTT. Uses designated PTT ranges rather than multiple of baseline PTT for dose adjustment. Last review: October 2007

Lepirudin
UWHC Guidelines for Use - Includes background, indications, warnings/precautions and monitoring.  Also includes section on dosing based on whether the patient has had a thrombotic event or not.  Last review: October 2008
Meriter Order Form and Monitoring Sheet - Includes lab tests and monitoring, renal adjustments, and dosing for APTT. Uses designated PTT ranges rather than multiple of baseline PTT for dose adjustment. Last review: October 2007
ThedaCare Protocol, Order Form and Monitoring Form - Designed for use in the setting of heparin-induced thrombocytopenia. Includes renal adjustments and monitoring. Uses designated PTT ranges rather than multiple of baseline PTT for dose adjustment.  Last review: July 2009

Bridging
Interruption of oral anticoagulation presents a challenge to clinicians who must weigh the risks and benefits of "bridging" with parenteral anticoagulants.  The following guidelines may assist with balancing these risks.

UWHC Guideline for Periprocedural Anticoagulation Therapy for Adults on Long-Term Warfarin - Includes background section and tables to determine risk for thromboembolism and estimated bleeding risk according to procedure/surgery to decide if periprocedural anticoagulation is needed.  Also gives dosing recommendation based on treatment of prophylaxis dosing and when to start based on warfarin/INR.  Last review: November 2008
UWHC Guideline for Outpatient Treatment of DVT - Includes inclusion/exclusion criteria to determine if patient is eligible and a duration of therapy table.  Also includes monitoring parameters, recommended prescriptions and a proposed timeline for days 1 - 6. Last review: August 2006
ThedaCare Warfarin Dosing Guidelines - Bridging Recommendations - Table summarizes ACCP bridging recommendations for patients at various degrees of thrombosis risk.  Last review: January 2009
Middleton VA Anticoagulation Management Service Guidelines for Outpatient Peri-procedural Bridging - Step-by-step guide to timing and administration of warfarin and LMWH (enoxaparin) peri-procedurally.  Includes tables of high thromboembolic risk conditions and high bleeding risk procedures.  Also includes dosing recommendations for enoxaparin in special populations (e.g. renal dysfunction and obesity). Last Updated March 2009


DVT Prophylaxis
Venous thromboembolism (pulmonary embolism) is the leading cause of preventable hospital death.³  Health-system pharmacists are frequently involved in designing strategies to protect patients at high risk of developing venous thromboembolism.

ThedaCare Recommendations on VTE Prophylaxis and Treatment in Patients with Cancer - Summary of ASCO recommendations for hospitalized and ambulatory patients with cancer.  Last review: January 2009
BAMC Computerized DVT Risk Assessment - Automatically creates a DVT risk profile using information obtained from nursing interview at admission and active medications.  Also calculates risk scores for both Caprini and Kutcher scales.  Uses MEDITECH hospital information system.  Last review: December 2007
Meriter VTE Prophylaxis Guideline - Includes tables for risk assessment, suggested prophylactic regimens and contraindications to chemical prophylaxis. Last update: May 2007

Anticoagulation Reversal
Guidelines for the use of anticoagulation reversal agents have been developed to minimize the risk of bleeding in patients who are over anticoagulated and/or who are bleeding.

UWHC Guideline for Use of Recombinant Factor 7 - Includes background, appropriate indications, inappropriate indications and warnings/precautions.  Also has dosing guidelines, including authorized prescribers: trauma surgeons, neurosurgeons, hematology and critical care physicians.  An algorithm is included to treat coagulopathic patients.  Last review: December 2008
UWHC Guideline for Phytonadione to Reverse Warfarin-Induced INR Elevation - Includes background, indications and precautions.  Also has administration guidelines which include expected onset, time of maximal effect and preferred route.  Clinical scenario section gives recommendations for elevated INR, with and without bleeding, and for surgical reversal.  Last review: November 2008
WMHI Anticoagulation Professional Reference - Includes guideline for warfarin reversal including risk stratification for bleeding and thrombotic risk.  Last review: November 2008
ThedaCare Warfarin Dosing Guidelines - Management of Elevated INRs - Table describes reversal strategy for various INRs/bleeding severities.  Last review: January 2009
BAMC Warfarin Reversal Guideline - Table describes reversal strategy for various INRs/bleeding severities.  Includes list of factors associated with slow return to therapeutic INR.  Does not include use of prothrombin complex concentrate or factor 7.  Last review: November 2008


Other Contributions
Meriter Hospital Pharmacy Anticoagulation Handbook - Comprehensive, well referenced 47 page document includes VTE prophylaxis and treatment, heparin and low molecular weight heparin, direct thrombin inhibitors, warfarin, oral antiplatelet therapy, IV antiplatelet agents, thrombolytic therapy and information on special populations that require anticoagulation. Most sections include pharmacokinetics, indications, precautions, monitoring, dosing, and combination therapy.


¹ Nutescu E, Dager W. Heparin, low moecular weight heparin, and fondaparinux. In: Gulseth M, ed. Managing anticoagulation patients in the hospital. Bethesda, MD: American Society of Health-System Pharmacists; 2007:177 - 202.
² Dobesh PP, et al. Unfractionated heparin dosing nomograms: road maps to where? Pharmacotherapy; 2004: 24(8 Pt 2): 142S - 145S.
³ AHRQ. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. Accessed April 4, 2009.

Disclaimer: Use of any website content and/or requested documents is not meant to replace professional judgment. Documents and materials have not been peer reviewed.  Pharmacists should always exercise caution and cross reference materials while caring for patients. PSW and the other contributors to this site do not assume legal or other liability for errors made while using this information.