informing patients about their medications oral anticoagulation therapy
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Informing Patients about Their Medications Oral Anticoagulation Therapy. 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. - PowerPoint PPT PresentationTRANSCRIPT
Informing Patients about Their Medications
Oral Anticoagulation Therapy
• 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
Objectives
30% of patients said they did not have the purpose of theirmedicines fully explained to them in a way they couldunderstand
60% of patients said they were not fully told about which sideeffects to watch out for
2012 National Patient Survey
“You should reach agreement with the patient on the treatment proposedexplaining:
• 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 andencourage them to ask questions to clarify any concerns or uncertainty.”
GMC Good practice in prescribing and managing medicines and devices 2013
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.
• 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!
Research
“You should reach agreement with the patient on the treatment proposedexplaining:
• 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 andencourage them to ask questions to clarify any concerns or uncertainty.”
GMC Good practice in prescribing and managing medicines and devices 2013
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 athttp://www.nrls.npsa.nhs.uk/resources/?EntryId45=61777
Reasons for Prescribing WarfarinPatients need to know why they need to be prescribed warfarinand 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 doeswe use the phrase:
“Makes your blood take longer to clot”
Consequences include further VTE, stroke and death
• 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
Duration of Therapy
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
• 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
Anticoagulation Clinic Visits
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 2.5
Recurrent VTE whilst on warfarin
3 - 4 3.5
AF 2 – 3 2.5
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 patientsabout what to do if they miss a dose:1) You can take the missed dose up to 6 hours late2) Thereafter the dose should be omitted and the
appropriate dose taken as normal the next day3) Make a note of the missed dose in your yellow book4) Never take two doses in one day5) 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.
1) DietPatients 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 avoidedKeep weight consistent. Discuss with clinic before commencing a diet
2) Alcohol ConsumptionPatients should be advised to keep their weekly alcohol intake constant and to stick to the recommended daily limitsBinge drinking is dangerous and not recommended
A Few Simple Rules to Keep Patients Safe
3) Patients should be advised to inform any healthcare professional that they are taking warfarin, this includes doctors, dentists chiropodists, nurses etc
4) 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
5) Women should be advised that their periods may become heavier
Any changes to lifestyle must be reported to theanticoagulation clinic and if possible discussed before anylifestyle changes are made
Most importantly you must reassure the patient and answer any questions they may have
• 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
Other Medications and Warfarin
• 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!
Your turn to practice!
• 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
What to do now