treating dvt and pe using LWMH and warfarin

[Asterix]

I am aware that you initially start patients on LWMH alongside warfarin and the LWMH must be used for a minimum of 5 days before the warfarin inr is is range for 2 days but what is the need for this. What happens if it hits a month and there is not a consecutive inr readings, would you just keeo ahead with the warfarin

[johnep]

Warfarin is anti Vit K1 and takes a few days to take effect. LMWH is used to cover this period.
johnep

[Asterix]

What if the range isn't achieved for a long period of time johnep. It's about 3 days for warfarin to have its effect right

[Nik]

"warfarin resistance" into Google, and first result:

An algorithm for managing warfarin resistance

Perhaps could try an alternative anti-coagulant if patients need increasing doses of warfarin. Any anti-coag pharmacists out there ?

[Asterix]

Thanks for that article nik was a good read. What about trying a LWMH for treatment as it was being used for the cover anyway so carry on with that full time?

[Nik]

Best to get haematologist advice before going down that route. You'd need a pretty dedicated pt to self inject LMWH for up to 6 months anyway...

[Asterix]

i guess if poor compliance with warfarin was a reason, they wouldn't get much luck with a LMWH. Has anyone ever seen a patient discharged on unfractionated heparin before

[Nik]

i guess if poor compliance with warfarin was a reason, they wouldn't get much luck with a LMWH. Has anyone ever seen a patient discharged on unfractionated heparin before

Why would poor compliance with warfarin be a problem in hospital where daily administration is supervised ? The article quoted above mentions a whole host of other factors to consider.
So Asterix how would discharges on UH work in practice then ? LMWH's given once daily s/c, UH given by IV infusion... And monitoring of platelet count, APTT and U+E's (particularly K+) ? And osteoporosis prophylaxis ? I have seen people discharged on LMWH but this has always been on haematologist advice and in select patients.

[johnep]

My promotion of LMWH was based on the freeing of beds just because pt needed IV heparin, initially treatment at Out Pt clinic, then home self injection. Savings by hospital could be made at that point by getting GP to prescribe.
Following my hip op, I self injected LMWH for a month. Because my wife has a clotting tendency (not Factor V as first thought) she was treated with warfarin requiring observation and regular INR testing by haem nurse.
johnep

[crit care]

i've seen patients on long term LMWH...usually its those on chemotherapy and unable to take warfarin. if you aren't getting the inr into range within a few days of starting treatment, you need to ask yourself why??...and adjust the doe accordingly..they could be on other drugs which increases the metabolism of warfarin