APPENDIX 2 Protocol for the Management of Outpatients with Prolonged INR Secondary to Anticoagulant Therapy The following protocols are on the British Committee of Standards in Haematology Guidelines but take into account that the Anticoagulant clinic is a monitoring clinic staffed by Biomedical Scientists and an Anticoagulant Nurse Specialist. The BCSH guidelines and those given in the BNF, state that the use of Vitamin K for patients with an INR > 8.0 should only be considered for those with additional risk factors for bleeding (stated below) however, it is not feasible for clinic staff to assess whether any of these risk factors apply to patients in the community. Given there is good evidence in the literature that the risk of bleeding significantly increases with an increasing INR, we aim to ensure that haemorrhagic complications are kept to a minimum by recommending that Vitamin K is given to all patient’s with an INR >8. We are confident this policy will not put patients at risk of excessive anticoagulant reversal and at the same time simplifies the process for patients in the primary care setting. High Risk Factors* Age >70 years Previous GI bleeding Previous anticoagulant-related bleeding Cerebrovascular disease Hypertension Alcoholism disease Thrombocytopenia Recent surgery Receiving anti-platelet drugs e.g. NSAIDS Major Bleeding There are no generally accepted definitions of what constitutes a major bleeding episode. Acceptable criteria for are as follows (Makris 2001): Intracranial Retro-peritoneal (excluding conjunctival) Muscle haematoma with compartment syndrome If is evidence of any of the above, or if there is doubt concerning the possibility of major bleeding occurring, the patient will require referral to hospital as an emergency. This
APPENDIX 2 Protocol for the Management of Outpatients with Prolonged INR Secondary to Anticoagulant Therapy The following protocols are on the British Committee of Standards in Haematology Guidelines but take into account that the Anticoagulant clinic is a monitoring clinic staffed by Biomedical Scientists and an Anticoagulant Nurse Specialist. The BCSH guidelines and those given in the BNF, state that the use of Vitamin K for patients with an INR > 8.0 should only be considered for those with additional risk factors for bleeding (stated below) however, it is not feasible for clinic staff to assess whether any of these risk factors apply to patients in the community. Given there is good evidence in the literature that the risk of bleeding significantly increases with an increasing INR, we aim to ensure that haemorrhagic complications are kept to a minimum by recommending that Vitamin K is given to all patient’s with an INR >8. We are confident this policy will not put patients at risk of excessive anticoagulant reversal and at the same time simplifies the process for patients in the primary care setting. High Risk Factors* Age >70 years Previous GI bleeding Previous anticoagulant-related bleeding Cerebrovascular disease Hypertension Alcoholism disease Thrombocytopenia Recent surgery Receiving anti-platelet drugs e.g. NSAIDS Major Bleeding There are no generally accepted definitions of what constitutes a major bleeding episode. Acceptable criteria for are as follows (Makris 2001): Intracranial Retro-peritoneal (excluding conjunctival) Muscle haematoma with compartment syndrome If is evidence of any of the above, or if there is doubt concerning the possibility of major bleeding occurring, the patient will require referral to hospital as an emergency. This
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