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Pre-operative management of anticoagulants in older hip fracture patients

Pre-operative management of anticoagulants in older hip fracture patients. Drug Summary Info Document Request / monitor Goal of therapy Action. Warfarin Vitamin K antagonist Long half life Metabolised by the liver Document indication, usual dose and time of last dose. INR INR < 1.5

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Pre-operative management of anticoagulants in older hip fracture patients

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  1. Pre-operative management of anticoagulants in older hip fracture patients Drug Summary Info Document Request / monitor Goal of therapy Action Warfarin Vitamin K antagonist Long half life Metabolised by the liver Document indication, usual dose and time of last dose. INR INR < 1.5 If INR >1.4 – give 2mg PO vitamin K in ED and aim for surgery the following day. If INR still >1.4 on day of surgery, give FFP and/or Prothrombinex (via haematology). Dabigitran (Pradaxa) Direct thrombin inhibitor Renally excreted Half life increases with decreasing CrCl (13-27hrs) Document indication, usual dose and time of last dose. TT, APTT and Haemoclot (thrombin inhibitor assay) Normal APTT, normal or mildly prolonged TT and dabigitran level < 50ng/ml No agent to reverse effect. Calculate creatinine clearance (not eGFR). Surgery likely to be delayed a minimum of 24hrs and more likely 48hrs depending on initial drug level and calculated creatinine clearance. Rivaroxaban (Xarelto) Factor Xa inhibitor Partial renal excretion Half life increases with decreasing CrCl (8-13hrs) Document indication, usual dose and time of last dose. PT, APTT, and rivaroxaban assay Normal APTT, normal or mildly prolonged PT and rivaroxaban level < 50ng/ml No agent to reverse effect. Calculate creatinine clearance (not eGFR). Surgery likely to be delayed a minimum of 24hrs depending on initial drug level and calculated creatinine clearance. The Orthogeriatric team should be made aware of these patients at the point of admission. In some patients, bridging anticoagulation is required and this may require an additional discussion with haematology or cardiology depending on indication. In cases of active bleeding, please contact the on call haematologist.

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