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Patient on Anticoagulant Therapy

Specialties > Cancer

Background Knowledge 🧠

Definition

  • Use of medications to prevent blood clot formation.
  • Indicated for conditions such as atrial fibrillation, DVT, PE.
  • Common anticoagulants include warfarin, heparin, and DOACs.
  • Aim to reduce thromboembolic events while minimising bleeding risk.

Epidemiology

  • Increasing use due to ageing population and rising incidence of atrial fibrillation.
  • DOACs increasingly prescribed over warfarin.
  • Higher use in developed countries.
  • Significant impact on reducing stroke and thromboembolic events.

Aetiology and Pathophysiology

  • Atrial fibrillation: Irregular heartbeat leading to clot formation.
  • Deep vein thrombosis: Clot formation in deep veins, typically in legs.
  • Pulmonary embolism: Clot travels to lungs causing obstruction.
  • Hypercoagulable states: Genetic predispositions, malignancy.
  • Post-surgical prophylaxis to prevent venous thromboembolism.

Types

  • Vitamin K antagonists: Warfarin.
  • Heparins: Unfractionated heparin (UFH), low molecular weight heparin (LMWH).
  • Direct oral anticoagulants (DOACs): Apixaban, rivaroxaban, dabigatran.
  • Parenteral anticoagulants: Fondaparinux, argatroban.

Clinical Features 🌡️

Symptoms

  • Bleeding: Gum, nosebleeds, bruising, haematuria.
  • Thromboembolic events: Sudden shortness of breath, chest pain.
  • Signs of DVT: Leg pain, swelling, redness.
  • Signs of PE: Acute dyspnoea, pleuritic chest pain.
  • Anaemia symptoms: Fatigue, pallor, dizziness.

Signs

  • Ecchymosis (bruising) on examination.
  • Petechiae: Small red or purple spots on skin.
  • Haematoma: Localised collection of blood outside blood vessels.
  • Evidence of bleeding at surgical sites.
  • Signs of thromboembolic complications (e.g., tachypnoea, tachycardia).

Investigations 🧪

Investigations

  • Baseline bloods: FBC, U&Es, LFTs.
  • Coagulation profile: PT/INR for warfarin, aPTT for heparin.
  • DOACs: No routine monitoring, but specific tests available if needed.
  • Imaging: Doppler ultrasound for DVT, CT pulmonary angiography for PE.
  • Assessment of bleeding risk: HAS-BLED score.

Management 🥼

Management

  • Initial choice based on condition: DOACs often first-line for AF and DVT/PE.
  • Warfarin: Requires regular INR monitoring and dietary adjustments.
  • Heparin/LMWH: Used in hospital settings and for bridging.
  • Patient education on bleeding risks and signs of complications.
  • Consideration of reversal agents: Vitamin K, idarucizumab, andexanet alfa.
  • Regular follow-up for efficacy and safety.

Complications

  • Major bleeding: Gastrointestinal, intracranial.
  • Minor bleeding: Epistaxis, gum bleeding.
  • Thrombocytopenia (HIT) with heparin.
  • Allergic reactions or hypersensitivity.
  • Drug interactions: Warfarin affected by many medications.
  • Rebound hypercoagulability if therapy abruptly stopped.

Prognosis

  • Dependent on indication for anticoagulation and patient comorbidities.
  • Regular monitoring improves outcomes.
  • Increased risk of bleeding, but benefits outweigh risks in most cases.
  • Prognosis generally good with adherence to therapy.
  • Lifelong therapy may be required in chronic conditions.

Key Points

  • Patient education on medication adherence and monitoring.
  • Regular follow-up to adjust dosage and monitor complications.
  • Awareness of bleeding risks and prompt action for symptoms.
  • Utilisation of reversal agents in case of major bleeding.
  • Interdisciplinary approach for comprehensive care.

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Cancer