Transcript: Treating Anticoagulated Patients

Liz Rohr:
First thing's first, when you have a patient on your schedule, you walk into the room or before you walk into the room, you have somebody who's on anticoagulants, the first thing you want to think about is, why? What is the rationale? What are they taking and why are they taking it? What is the indication?

Well, hey there, it's Liz Rohr from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

This episode, I want to talk about treating patients on anticoagulants. When I started putting this together, I was like, wow, there are so many things to say and so many places to go. I think it really highlights why this is a requested topic from the Real World NP community. It's because it's a bit complicated. It involves pharmacology that can be a little bit confusing. So in this episode, I want to start by doing a high-level approach of a very common scenario that I found myself in as a new grad, but I still find myself in the situation, and especially if you're an experienced NP coming to primary care for either the first time or coming back after a while, hopefully this will be a helpful grounding place to start.

First thing's first, when you have a patient on your schedule, you walk into the room or before you walk into the room, you have somebody who's on anticoagulants, the first thing you want to think about is, why? What is the rationale? What are they taking and why are they taking it? What is the indication? Because that leads to everything. From that place, it helps you go a couple of different directions.

Number one, what medicine are they taking? Why are they taking it? What medicine do they need? There are specific indications for specific anticoagulants depending on the diagnosis. So atrial fibrillation, for example, DOACs are appropriate. The direct oral anticoagulants. I'm trying not to use brand names, I'm not going to say them because I'm going to use brand names by accident, but the DOACs, that category. Warfarin is also an option. There's a couple of different anticoagulants to use and how you know which diagnosis goes with which type of anticoagulant is based on the prescribing information. There's a little bit of digging involved here. That's why this is a big topic, and so I'm trying to give this overview approach. But here's the doorway of where you would go next if you're trying to get more comfortable with this topic is learning what the anticoagulant options are, and once you kind of get a general familiarity with them, you can kind of see, oh, which one goes with which one. I'll talk about a really phenomenal resource that I have in a second.

What is the reason they're taking it? What medication are they on? Is that appropriate for this diagnosis? One kind of point I also want to put in there is that there's a difference between initial dosing and maintenance dosing. The typical scenario that I had when I was a new grad, and even to this day, is that somebody is coming to me for the first time after an ER discharge because they had a DVT, they had new onset atrial fibrillation. There was something that happened in the ER, they were given a medicine, and then they're like, oh, okay, follow up with primary care and go from there. I was very overwhelmed by that. And honestly, it's still a lot to manage.

When you're going into the room, same things. What was their diagnosis? What are they taking? Are they on their initial dosing or are they on their maintenance dosing? And there's a reason that this is a doorway type of video of, okay, well now we know that when I look at this patient in front of me, I'll just look at the prescribing information. What is the maintenance dose and what is the starting dose? And each of them have different prescribing things depending on the med. That's why this is such a big topic. But these are the general themes to keep in mind.

The next thing to think about on those topics related to the diagnoses and the medications is every diagnosis has a set amount of time that that person needs to be taking that medicine for. I saw this all the time in primary care where somebody had a change in providers and there was some miscommunication, there's some confusion, and it's like, why is this person taking this medicine still? Do they need to be taking it? Because they had a DVT a while ago? Stuff like that. And again, this is an overview episode, so what you want to look at is the diagnosis. Is that the first DVT that they've ever had? Or have they had recurrent DVTs and now it's recommended they actually have it for a much longer duration than the initial three months or so?

The next piece to think about is safety. Is this safe for this patient? And what I mean by that is that some medications, this again overarching theme is there are some things that you need to change based on the person in front of you. Typically, if they just went to the ER, are just being released into your care, they have had a many, many sets of eyes on their chart, on their health condition, and they're all set up for success. But you never know, and you also don't know if this is the first time you're seeing somebody and who knows where they came from, what the history was.

But the safety pieces you want to think about in terms of general themes is what is their renal status? Because most of the medications need some sort of renal adjustment, and that is determined by their serum creatinine level or their creatinine clearance, and that's dependent on the medication choice. You just look at the medication rack itself. What does it say about renal dose adjustment and what is this person's kidney status? Do they have any liver problems? Do they need liver adjustment? Is this still appropriate for them? If they've been on it for a while, if they have a liver change. Those are things you want to think about.

You want to think about childbearing pregnancy status, you want to think about age. Some of the DOACs have recommendations of dose decreases if a person's age is a certain amount. There are a couple of other considerations to make, but those are the main ones. Then you want to think about if somebody has cancer, if that's part of the reason they have anticoagulation in the first place, or if they develop a new cancer, absolutely take some time and get some support with that to think through what are the changes that need to be made.

The last pieces are about monitoring, managing bleeding, and then resources. I kind of lump them all together because one of the important things that you're going to need to do or you're already doing for patients with anticoagulation is thinking about what monitoring do they need? I do have an episode on the channel about Warfarin. In my experience working in a federally qualified health center, we do a lot of Warfarin, although DOACs are a lot more available now than they used to be in terms of other options. But I do have an episode about managing Warfarin and that type of process. But what is the monitoring that needs to happen for this patient with this diagnosis, with this specific medicine related to the anticoagulant itself? So INRs are typically monitored with Warfarin. What are the other pieces that you want to think about? We also want to think about their creatinine level. We also want to think about their liver function, things like that.

In terms of bleeding, there are a couple, like I said, this is enormous topic, but you really do want to think about bleeding. This really ties into resources because in reality, this is a very dangerous category of medications, potentially dangerous because it can lead to just so many problems, whether they're under-dosed because a provider is concerned and then they're not protected from the thing that they're needing it for versus they're overdosed versus who knows, right? There's just a lot of risk with a anticoagulant medication, so what are the monitoring parameters that you have in place in terms of a protocol.

Both monitoring and bleeding, this really should be a discussion from your clinic, whether they've set up protocols already, whether they have a nursing staff type of protocol of how to monitor these patients or standing orders, or protocol for how soon to follow up. Those things really should be on the systems level of your clinic to protect our collective patients. This is not entirely on you to do it all by yourself. I mean, really, if you're faced with that situation and you're looking at a medication or a diagnosis that you haven't encountered either recently or before, you have some sort of clotting disorder that you haven't seen before, you need to dig and look at each of those specific patients and specific medicines. But generally speaking, your clinic should be set up to support you and your patients for success and to mitigate the risks of bleeding and mitigate the monitoring needs and dose titration needs and all those types of things.

Then the last thing, aside from the resource of your actual clinic and the protocols that hopefully can be set up, and again, it doesn't have to be you. I've encountered many a new nurse practitioner with huge ambitious go-getter goals and takes writing protocols on top of their getting used to this role. It doesn't have to be you, it's okay. But the other thing is, what are the resources? Because really this is an overview episode with very few of the specifics of the dosing and the names and the categories and all that stuff. But really you can set aside some time and do a deep dive of like, okay, now I feel really comfortable with the difference between Dabigatran and Rivaroxaban. I'm probably mispronouncing all those names, but taking some time to look through all of those and kind of bring that back and what's the monitoring for DOACs and what's the monitoring for Warfarin and all that stuff. Also, you can take that approach of like, hey, I have this person in front of me. I need to deal with this diagnosis, this medication, this monitoring right now.

If you're looking for those types of resources, my favorite one, UpToDate is amazing. I'm not affiliated with them, I just use it all the time. Then the other one is called Prescriber's Letter put out by the Therapeutic Resource Center. Again, I'm not affiliated with them, but I absolutely love their resources and they have a phenomenal anticoagulation set of toolbox and resources and patient handouts and how to change between the different types of Warfarin to DOACs or DOACs to Warfarin. Beautiful, beautiful resources. As much as I would love to cram this all into one episode, I think it's probably more supportive to have a framework of how to approach that patient sitting in front of you and the protocols of your clinic and what are the resources that can help you get more comfortable with each of those medicines in practice.

Hopefully this episode was helpful for you. If you haven't grabbed the Ultimate Resource Guide for the New NP, head over to RealWorldNP.com/guide. You'll get these episodes sent straight inbox every week with notes from me, patient stories, and bonuses. I really just don't share anywhere else. Definitely check out in the description below all of the resources that I'm talking about here and also to check out that Warfarin episode to help you with managing patients on Warfarin. See you soon.