Informing Patients about Their Medications Oral Anticoagulation Therapy

By the end of this session you should: Objectives By the end of this session you should: Know why it is important to inform patients about their medicines Know what points to cover when newly prescribing a patient an oral anticoagulant

30% of patients said they did not have the purpose of their 2012 National Patient Survey 30% of patients said they did not have the purpose of their medicines fully explained to them in a way they could understand 60% of patients said they were not fully told about which side effects to watch out for For CMFT

GMC Good practice in prescribing and managing medicines and devices 2013 “You should reach agreement with the patient on the treatment proposed explaining: The likely benefits, risks and burdens, including serious and common side effects What to do in the event of a side effect or recurrence of the condition How and when to take the medicine and how to adjust the dose if necessary, or how to use a medical device The likely duration of treatment Arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine, and for issuing repeat prescriptions. You should check that the patient has understood the information and encourage them to ask questions to clarify any concerns or uncertainty.” Relating to obtaining consent from patients when initiating treatments

NPSA Guidance on Anticoagulation In 2007 the NPSA issued a patient safety alert relating to oral anticoagulants and identified: “Anticoagulants are one of the classes of medicines most frequently identified to cause preventable harm and admission to hospital” As a doctor you should: Ensure patients receive appropriate verbal and written information at the start of therapy, at hospital discharge, on the first anticoagulant clinic appointment and when necessary throughout the course of their treatment.

Research Split into groups of three Research and come up with a list of the information you would tell the patient about warfarin when newly prescribing it to them You have 10 minutes!

GMC Good practice in prescribing and managing medicines and devices 2013 “You should reach agreement with the patient on the treatment proposed explaining: The likely benefits, risks and burdens, including serious and common side effects What to do in the event of a side effect or recurrence of the condition How and when to take the medicine and how to adjust the dose if necessary, or how to use a medical device The likely duration of treatment Arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine, and for issuing repeat prescriptions. You should check that the patient has understood the information and encourage them to ask questions to clarify any concerns or uncertainty.” Relating to obtaining consent from patients when initiating treatments

The Oral Anticoagulant Therapy Pack Every patient taking oral anticoagulation needs a “yellow book” It has four components Important information for patients booklet. For patients to keep at home for reference Record book to record INR and doses. This should be brought into hospital with the patient and to all anticoagulant clinic appointments Treatment sheets Anticoagulant alert card Patients should carry this with them at all times. Available on line at http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61777

Reasons for Prescribing Warfarin Patients need to know why they need to be prescribed warfarin and the consequences of not taking. The main indications for oral anticoagulation are: Deep Vein Thrombosis Pulmonary Embolism Atrial Fibrillation Mechanical Heart Valves The NPSA recommends when telling patients what warfarin does we use the phrase: “Makes your blood take longer to clot” Consequences include further VTE, stroke and death So as clinicians you need to explain what the diagnosis is and why it is necessary to treat with an anticoagulant

Duration of Therapy Patients should be told how long it is likely they will be taking warfarin Duration of therapy varies depending on indication and the minimum durations are below Calf vein thrombosis 6 weeks PE and proximal vein thrombosis 3 months Recurrent VTE 6 months AF and mechanical valves Lifelong

How to Take Warfarin Patients need to be told that the dose of warfarin is individual to them and their INR so their dose can vary Explain to the patient which strengths the tablets come in and their corresponding colour. The yellow book has pictures to illustrate this. Tell the patient to take at same time each day, on an empty stomach washed down with a full glass of water Patients are usually recommended to take their warfarin at 6pm so any alterations can be made on the day. However anytime of the day is fine if it aids compliance as long as it is at the same time each day. Patients need to be told to get further supplies from the GP and to ensure they always have at least a weeks supply at home

Checking Patients are Competent When telling patients how to take warfarin, take this opportunity to ensure the patients are able to calculate which tablets to take. A good question to ask is: “If you were told to take 7mg of warfarin which tablets would you take?” If you have any doubt about their ability and therefore safety you may need to reconsider this choice of treatment

Anticoagulation Clinic Visits Patients need to be told they will need to attend the anticoagulation clinic after discharge to have their INR monitored and their warfarin dosed Frequency of visits may vary but initially patients may need to attend weekly but over time they will become less frequent Patients must be told to take their yellow book to all clinic appointments and that they must not miss appointments. Anticoagulant clinics can be based in the hospital, GP surgeries and for some patients district nurses may visit the patients at home

Monitoring Requirements for Warfarin Patients need to be told the importance of having their INR measured Patients should be made aware of what their INR range is and what it signifies Recommended INRs are: Indication INR range INR target DVT 2 – 3 2.5 PE 2 - 3 Recurrent VTE whilst on warfarin 3 - 4 3.5 AF Mechanical valves Typical target is between 2.5 and 3.5

Side Effects of Warfarin The main side effect of concern with warfarin is haemorrhage which can present itself as bruising and bleeding. Patients should be advised to seek medical attention from either their clinic or A&E for any of the following: Prolonged bleeding from cuts Bleeding that doesn’t stop by itself Nose bleeds Bleeding gums Red or dark brown urine Red or black stool Bursed blood vessels in the eye Increased bleeding during periods Other side effects include GI disturbances, alopecia, rash and fatigue

What To Do If You Miss a Dose The following rules should be explained to patients about what to do if they miss a dose: You can take the missed dose up to 6 hours late Thereafter the dose should be omitted and the appropriate dose taken as normal the next day Make a note of the missed dose in your yellow book Never take two doses in one day If you miss 2 doses contact GP or clinic

A Few Simple Rules to Keep Patients Safe Patients should be advised that warfarin is safe as long as they follow a few simple rules and keep certain factors of their lifestyle the same. Diet Patients should be advised to eat a broad diet, keeping their intake of Vitamin K containing foods constant. eg:Leafy green vegetables, chick peas, liver, egg yolk, cheese, avocado and olive oil. Cranberry juice should be avoided Keep weight consistent. Discuss with clinic before commencing a diet 2) Alcohol Consumption Patients should be advised to keep their weekly alcohol intake constant and to stick to the recommended daily limits Binge drinking is dangerous and not recommended

A Few Simple Rules to Keep Patients Safe Patients should be advised to inform any healthcare professional that they are taking warfarin, this includes doctors, dentists chiropodists, nurses etc If the patient is female of child bearing age and may want to start a family they need to discuss this with their doctor before becoming pregnant Women should be advised that their periods may become heavier Any changes to lifestyle must be reported to the anticoagulation clinic and if possible discussed before any lifestyle changes are made Most importantly you must reassure the patient and answer any questions they may have

Other Medications and Warfarin Warfarin interacts with many medications so to avoid any problems patients need to be advised to: Remind any healthcare professional that they are taking warfarin if they are prescribing any medications, especially antibiotics Buy all non-prescription medication from a community pharmacy and ask for advice from the pharmacist when selecting products; this includes herbal medication Avoid aspirin or ibuprofen for pain relief and to use paracetamol +/- codeine when necessary Let the anticoagulation clinic know of any changes to their medication Due to other co-morbidities some patients may need to take both aspirin and warfarin, if this is the case they need to be re-assured that the combination is safe

Your turn to practice! Split into groups of three Nominate a “doctor”, “patient” and “observer” Doctor use your checklist to counsel your patient and the observer give feedback Then Swap over!

What to do now When on the wards find a patient who is newly started on warfarin and arrange to watch the ward pharmacist counsel the patient Practice! Arrange to be observed discussing warfarin treatment with a patient