Nursing Pharmacology Discussion: Anticoagulant Considerations before Starting Therapy Please answer the following question:  The Nurse Practitioner is prescribing anticoagulant therapy. What diagnostic studies should she evaluate prior to initiation of therapy and why? Anticoagulants: Considerations Before Starting Therapy

In addition to a valid indication, several patient factors also warrant consideration to determine if the risk of hemorrhage outweighs the benefit of therapy.

Baseline laboratory values including PT, INR, aPTT, urinalysis, CBC (with platelet count), and a liver profile are recommended before initiating anticoagulation. In women of childbearing age, laboratory testing for β-human chorionic gonadotropin is strongly encouraged to rule out pregnancy. Obtaining the patient’s telephone number and an alternative contact, such as a responsible family member or neighbor (obtain consent to contact others per HIPAA guidelines), is also advised. In addition, rule out any active major bleeding from the central nervous system (CNS) or gastrointestinal (GI) tract. A digital rectal examination or guaiac test to detect blood in the stool is recommended. A detailed medical, surgical, and medication history, including over-the-counter (OTC) medications and dietary supplements, is needed to assess the patient’s risk of bleeding events or inadequate anticoagulation. It is also important to document the indication for anticoagulation, which determines the duration of therapy, and, if warfarin is selected, to define the corresponding target INR, which defines the intensity of anticoagulation. When all these issues are addressed, anticoagulation is initiated (Witt, 2010). For patients receiving an LMWH or DOAC, body weight (kg), serum creatinine, and estimation of renal function creatinine clearance (CrCl) should be calculated. For patient receiving UFH, body weight (kg) should also be obtained. Although not currently recommended as a routine practice, a bleeding risk estimate for patients with AF may be obtained from calculating the HAS-BLED score and is discussed later in this chapter (http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/ or via a mobile phone app AnticoagEvaluator available from the ACC at http://www.acc.org/tools-and-practice-support/mobile-resources). The HAS-BLED score has only been validated in patients taking vitamin K antagonists (VKAs) and not in patients receiving parenteral anticoagulants or DOACs.

Arcangelo V. P., Peterson A. M., Wilbur V., & Reinhold J. A. (2016). Pharmacotherapeutics for Advanced Practice. [Yuzu]. Retrieved from https://reader.yuzu.com/#/books/9781496374066/