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Our Mission
The Anticoagulation Forum is a multidisciplinary nonprofit organization of healthcare professionals that will improve the quality of care for patients taking antithrombotic medications.
Board of Directors
David Garcia, MD
Jack Ansell, MD
Mark Crowther, MD
Janet Delaney, MSN, ARNP
Alan Jacobson, MD
Scott Kaatz, DO
Stephan Moll, MD
Edith Nutescu, PharmD
Lynn Oertel, MS
Terri Schnurr, RN
Daniel Witt, PharmD
Ann Wittkowsky, PharmD
Contact Us
Executive Director
Anticoagulation Forum
This newsletter is provided for informational purposes only and is not intended to provide specific medical advice, diagnosis, or treatment. You should always seek advice from a physician or other qualified health care provider for your individual medical needs. The AC Forum does not endorse or recommend any commercial products. |
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Register Now for THSNA!
May 3-5, 2012
Don't miss out on the opportunity to attend the Thrombosis and Hemostasis Summit of North America (THSNA)!
There are a limited number of discounted hotel rooms left! Click here to reserve your spot at the Hyatt Regency Chicago. The exhibit hall is already sold out and hotel rooms are going quickly as well.
Network, learn and share information, research and best practices needed to improve the quality of patient care with thrombosis and hemostasis disorders! Register here for the conference!
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Lunch and Learn Webinar
Wednesday, February 29, 2012
12:00 PM EST
Please join us for a special Leap Year AC Forum Lunch and Learn Webinar on Wednesday, February 29 at 12:00 pm EST.
AC Forum board members Lynn Oertel and Ann Wittkowsky will discuss how to identify key educational components to achieve good clinical outcomes and review practical tips on educating patients and families about new oral anticoagulants. Dr. Scott Kaatz will moderate questions.
Space is limited.
Title: AC Forum Webinar - Leap into Patient Education for New Anticoagulants
Date: Wednesday, February 29, 2012
Time: 12:00 pm - 1:00 pm EST
After registering you will receive a confirmation email containing information about joining the webinar. We hope to have you in the audience! |
Ask Janet
Janet Delaney, MSN, ARNP, one of AC Forum's new board members, will be writing a monthly column answering questions posed by Anticoagulation Forum members. Please send your questions to Janet-Delaney@smh.com and she will answer the most common questions in her upcoming columns. Thank you for your insight, Janet!
Q: 20 y/o female with hx of DVT on warfarin using condoms for birth control. Condom breaks and patient wants options for emergency contraception. Do you recommend Plan B with levonorgestrel only, paraguard (? High occurrence of heavier menses), or the Mirena which is not FDA approved for emergency contraception.
--Laura P., RN, BSN, MSN
Excellent question.
The American College of Obstetricians and Gynecologists (ACOG) have published guidelines for the use of hormonal contraceptives in the female patient on OAC. (1) Warfarin is a known teratogen and pregnancy is not recommended for childbearing females on warfarin without careful consideration of the risks and a plan for anticoagulation management prior to and during conception.
The Veterans Administration has published "Special Consideration for Women of Reproductive Age on Anticoagulation, January 2012" and is summarized below (2) and these recommendations follow that of ACOG.
Emergency contraceptive pills can be used safely in childbearing females after a contraceptive emergency.
- Levonorgestrel (Plan B One-step, Next Choice) is available without a prescription to those 16 years of age and older.
- It is most effective the sooner it is taken after unprotected or inadequately protected intercourse. For this reason patients should be advised to keep a supply on hand. However, it can be administered up to 5 days after a contraceptive emergency.
- The effectiveness of Plan B may be reduced by repeated unprotected sex, obesity, or treatment beyond 72 hours. Placement of a copper bearing IUD may be preferred in these cases.
- Ulipristal acetate is another alternative agent recently approved by the FDA. It may be more effective than Plan B for obese females; however, both agents effectiveness is reduced in obese females.
- Yes, the Paraguard can increase menstrual bleeding in female on anticoagulation, and Mirena is not recommended for emergency contraception.
Now you know the information but what do you do in the real world?
If this were my patient, I would recommend Plan B within 72 hours or the IUD. Bleeding is not common with IUD placement but can occur. Additionally if this patient was > 3 months on therapeutic anticoagulation I would decrease their warfarin dose temporarily to control bleeding by bringing their INR range down to 1.8-2.2.
Pregnancy is not recommended with anticoagulation use, but what do you do for contraceptive options in this patient population?
All childbearing female patients should be routinely assessed for the use of effective contraception to avoid unplanned pregnancy. But we are all humans and mistakes, missteps and a great date night can throw a curveball into any females' good intentions.
With that being said this is what I currently do with my patients.
If they were not planning on having a child in the next few years I would recommend the Mirena to prevent pregnancy and decrease the risk of increased menstrual bleeding.
If the patient is done having children I would suggest Mirena, Depot-Provera, tubal ligation or partner vasectomy.
If all else fails I would put this patient on a second generation OC. Although this is controversial, it may be the best strategy for some patients to prevent pregnancy, reduce menstrual bleeding and control uterine cramping.
OH NO, U DIDN'T JUST SAY THAT! Yes I did and here is why.
First, therapeutic anticoagulation may offset the increased thrombotic risk associated with combined OC's. The ACOG guidelines for the use of hormonal contraception in women with coexisting medical conditions supports the use of combination oral contraceptives in patients who are well anticoagulated to reduce menstrual bleeding and decrease the risk of hemo-peritoneum. Additionally ACOG finds it acceptable to use combined OC's in patients who have a remote history of precipitated VTE, but not for those who have a history of idiopathic VTE , VTE associated with pregnancy or exogenous estrogen use or those with severe thrombophilia.
Ideally, you would want to use a progestin only products for these females, because they have been shown to decrease thrombotic parameters; however, they produce significantly more irregular bleeding then combined OC's.
The use of second generation OC's (30ug ethinyloestradiol and 150us levonorgestrel) is preferred over third generation OC's (30ug ethinyloestradiol and 150ug desogestrel). A small study published in 2003 demonstrated that third generation OC's have a greater effect on the anticoagulant protein C system then second generation OC's particularly in patients with heterozygous FVL. Third generation OC's in this study were associated with a decrease in Protein S and an elevated resistance to APC. This study also observed that APC resistance correlated inversely with the dose of levonorgestrel, suggesting that high concentrations of levonorgestrel counteract the increase in APC resistance. (2)
Therefore, if this were my patient and they really wanted their BCP I would carefully evaluate the cause of their DVT, the location, and risk of recurrence. At that point we would discuss at length all of the above options and if this patient makes an informed decision to start or return to combined OC, I would advise the use of second generation OC's, maintain therapeutic anticoagulation and educate on the s/s of recurrent VTE.
1. American College of Obstetricians and Gynecologists (ACOG). Use of hormonal contraception in women with coexisting medical conditions. Washington (DC); American College of Obstetricians and Gynecologists
(ACOG); Vol. 107, No. 6, June 2006. pg. 1453. Updated in 2000 and 2011.
2. Schwarz, E.B. Special Considerations for Women of Reproductive Age on Anticoagulation. Pharmacy Benefits Management Services, Medical Advisory Panel, VISN Pharmacist Executive and Women's Health Strategic Healthcare Group. January 2012
3. Kemmeren, J.M., Algra, A., Meijers, J. C. et al. Effect of second and third generation oral contraceptives on the protein C system in the absence or presence of the factor V Leiden mutation: a randomized trial. Blood First Edition Paper, October 9, 2003; DOI 10.1182/blood-2003-04-1285. |
IPRO Convenes Task Force to Reduce Preventable Adverse Drug Events
(Albany, NY, January 25, 2012) - IPRO is launching a major initiative aimed at reducing warfarin-related adverse drug events across the state of New York. As the Medicare-funded Quality Improvement Organization (QIO) for New York, IPRO is charged with working with providers to improve the quality of care provided to New York's seniors.
Anticoagulation therapy is prescribed for the prevention of harmful and life threatening blood clots. The most commonly prescribed anticoagulant is warfarin (Coumadin). Although anticoagulants can be life- saving when used appropriately, they also carry the risk of serious bleeding. A study published recently in the New England Journal of Medicine demonstrated that warfarin-- whether used alone or in combination with other drugs -- is the medication most often associated with preventable adverse drug events among the elderly.
The U.S. Centers for Medicare & Medicaid Services (CMS) is directing IPRO to focus on supporting measurable reductions in warfarin-related adverse drug events affecting New York's Medicare population. Accordingly, IPRO has launched the New York State Anticoagulation Coalition, led by nationally recognized leaders in antithrombotic therapy, including Jack Ansell, MD, and Elaine Hylek, MD. The Coalition's first meeting took place November 2, with participation by experts drawn from medicine, pharmacy, and nursing, as well as representatives of the Anticoagulation Forum and the National Blood Clot Alliance.
"I am delighted to participate in this important endeavor," said Dr. Ansell, founder of the Anticoagulation Forum and Chairman of the Department of Medicine at Lenox Hill Hospital, New York. "As demonstrated in multiple studies, warfarin therapy has a narrow therapeutic range and requires expert dose management to keep patients within that range so that complications, such as bleeding, are prevented. Management is complex and labor intensive and may not be performed well. This effort by IPRO, to reduce warfarin-related adverse events by improving dose management, is a critical step to the overall improvement of anticoagulation care, especially for New York seniors who are the major recipients of anticoagulation therapy."
For more information regarding the New York State Anticoagulation Coalition, please contact Dr. Darren Triller, IPRO's Senior Director of Drug Safety at dtriller@nyqio.sdps.org.
As the Medicare QIO for New York State, IPRO's activities target the quality of healthcare provided to the state's more than three million Medicare beneficiaries. IPRO supports providers across the state with evidence-based, clinical interventions and objective expertise to improve healthcare processes and patient care. For more information visit www.ipro.org |
Sanofi Aventis Resumes Lovenox® Patient Assistance Program
Sanofi Aventis is reinstating its individual patient assistance program (PAP) for Lovenox®, effective February 15, 2012. Several safety-net provider groups, including SNHPA (Safety Net Hospitals for Pharmaceutical Access) had appealed to Sanofi to reinstate the program. As it is a brand new program - now called Sanofi Patient Connection (SPC) - providers will have to reapply to request access to Lovenox® for their patients. Any patients that were enrolled in the previous program must re-enroll using the new process. The application will be available on February 15. Replacement product may be requested for past dates of service in the hospital outpatient setting only for dates of service beginning February 15, 2012 and moving forward.
Hospitals wishing to restart Lovenox® individual patient assistance and product replacement should contact Sanofi Aventis directly by phone at 888.847.4877 or fax at 888 847.1797, between 9 a.m. and 8 p.m. EST, Monday through Friday. |
SAVE THE DATE!
12th National AC Forum Conference
May 9-11, 2013, Phoenix AZ
Announcing the 12th National AC Forum Conference! Please save the date and join us May 9-11, 2013 at the JW Marriott in Phoenix, Arizona. Attendees will gather to hear expert speakers present on the newest research as well as practical, evidence-based information that can be applied in daily practice to enhance the quality of anticoagulation care.
Progam planning has begun! We would love your input for this meeting. Please send topic and speaker suggestions to info@acforum.org |
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