Anticoagulation: Maximizing safety, quality and outcomes

The UW Health Anticoagulation Clinic offers management services for patients on warfarin, dabigatran, rivaroxaban and apixaban from pharmacists specializing in anticoagulants.

Anticoagulation Clinic services

Our Anticoagulation Clinic gives patients a consistent method for assessment, monitoring and education for patients on anticoagulation medications. As a patient, you can expect:

• To speak with a pharmacist each time you need your (international normalized ratio) INR checked

• The opportunity to speak with the pharmacist about any concerns you may be having with your warfarin

• The chance to review dietary, physical and social changes that may affect your warfarin

• Instructions on what dose of warfarin you should take and when you need to have your INR checked again

Eligible patients

To be managed by the Anticoagulation Clinic, patients must:

• Have a UW Health or UnityPoint Health (UPH) primary care provider or have a UW Health or UPH specialty provider involved in their ongoing care, including decisions about their long-term anticoagulation therapy plan of care

The Anticoagulation Clinic is not able to accept patients with Dean or GHC insurance.

Each year two million people are affected by DVT or deep vein thrombosis, a blood clot that forms in a vein, and of those, 600,000 are hospitalized and 300,000 die.

Risk for blood clots

You may be at risk if:

• You travel often, especially on long flights or car/bus rides

• You take birth control pills

• You are pregnant or have just had a baby

• You are in the hospital for surgery or are confined to bed for greater than 2 days

• You have had a stroke

• You are receiving treatment for cancer

• You broke your leg, hip or other bone

• You had a blood clot in the past

• You have a history of a clotting disorder

• You have a primary family member (mother, father, sister, brother) who has had a blood clot

Signs of blood clots

People who might have a blood clot in a vein might feel or see:

• Leg cramping or skin that is tender to a light touch

• Swelling

• Warm skin

• Redness of the skin

• Pain near the vein

• A vein that looks blue

People who might have a blood clot in the lungs may:

• Have a hard time breathing

• Feel chest pains

• Feel lightheaded

• Feel their heart beating hard or fast

• Cough up blood 

If you believe you may be experiencing signs or symptoms of a blood clot, talk to your doctor immediately or go to the nearest emergency department immediately.

Preventing blood clots

You can prevent blood clots by:

• Getting up and walking around once per hour, flexing your feet or squeezing your toes for 15 seconds every hour, and wearing compression stockings during long flights or car rides.

• Taking blood thinners prescribed by your doctor

• Using an injectable blood thinner or compression stockings while you’re in the hospital.

• Staying as active as possible

• Stopping smoking

If you are taking a medication called warfarin, you will need to have your blood checked often and will need to work closely with your doctor or clinic to keep you safe while taking it.

What does warfarin do?

Warfarin, like all blood thinners, helps prevents blood clots, which may form in patients being treated for:

• Stroke

• Atrial fibrillation

• Heart failure

• Heart valve replacement

• Deep vein thrombosis

• Pulmonary embolism 

Warfarin and your INR

Since there is no standard dose for warfarin, it must be monitored to know if it is working effectively and safely for you. Monitoring is done through the INR blood test.

Sometimes it might seem like your INR result is always changing. There are many things that can cause the number to be high or low.

Stabilizing your INR

Here are some tips on how you can help keep your INR number as stable as possible:

• Take your warfarin exactly as prescribed

• Take your warfarin dose at the same time every day

• Never double a dose for a missed dose

• Keep all scheduled visits or call promptly to reschedule

• Tell your health care provider if you start any new medication

• Tell your health care provider before you start any over-the-counter product or dietary supplement

• Eat a consistent diet

• Maintain the same number of servings and the same serving sizes of vitamin K foods each week

• Avoid alcohol

• Keep your activity level the same and tell your health care provider if you plan to increase or decrease your activity level

What is apixaban?

Apixaban (Eliquis) is a drug that blocks the activity of the clotting factor called anti-Xa (anti-10-a). This causes the blood to take longer to form a clot. It can also prevent a clot from getting bigger.

Why do I need a blood thinner?

Apixaban is used to prevent stroke in patients with a heart rhythm called atrial fibrillation. Apixaban can also be used to prevent or treat blood clots or for other conditions specified by your doctor.

How should I take apixaban?

The usual dose of apixaban is 5 mg, twice daily. It should be taken about 12 hours apart. Patients who are over the age of 80, have lower body weight, decreased kidney function, or are taking interacting medications may require a lower dose of 2.5 mg twice daily.

Swallow the tablet whole. Do not chew or crush. It may be taken with or without food. Take with food if it causes an upset stomach. Do not stop taking apixaban unless instructed by your doctor.

What happens if I miss a dose?

If you miss a dose of apixaban, take it as soon as you remember. Skip the dose if it is less than six hours until your next dose. Never double up on a dose to make up for a missed dose. Never change your dose or stop taking Apixaban unless your doctor has told you to do so.

Will I need routine blood checks?

You will not need regular blood tests to monitor apixaban. You will need to have your kidney and blood counts monitored once to twice a year. Based on the results, your rivaroxaban dose may need to be changed or the drug may need to be stopped.

How should I store apixaban?

Apixaban should be stored at room temperature. Avoid areas of excessive heat or moisture (not in a bathroom).

Possible side effects of apixaban

These are less serious side effects. Call your doctor if these symptoms persist or worsen:

• Upset stomach

• Low blood counts

• Elevated liver enzymes 

Minor bleeding may also occur while on apixaban:

• Bruising more than usual

• Occasional nose bleeds

• Prolonged menstrual bleeding (heavier than normal)

• Prolonged bleeding after minor cuts 

If you have any questions about whether your bleeding is a concern call your doctor. If you have a serious fall, hit your head or if you are having any of these major bleeding side effects, call your doctor or go to the emergency room right away:

• Any bleeding that lasts for more than 10 minutes

• Red, black or tarry stool

• Vomiting or coughing up blood

• Red or dark brown urine

• Severe headache or stomach ache 

Surgical, dental or other medical procedures

Tell all members of your health care team (surgeons, dentist, etc.) that you are taking a blood thinner. You might need to stop taking it before certain procedures. Be sure to tell your doctor or pharmacist if you were told to stop or hold your apixaban. They may need to change you to another type of blood thinner before your procedure.

Interactions with other medicines

Ask your doctor or pharmacist before starting any other medicine, including over-the-counter medicines, vitamins and herbal products. The dose of apixaban may need to be adjusted if an interacting medicine is started.

Pregnancy

If you think you are or might become pregnant, tell your doctor right away. It is unknown how apixaban will affect a fetus. If you become pregnant, your doctor will instruct you about your treatment options.

What is Dabigatran?

Dabigatran etexilate (Pradaxa) is a drug that blocks the activity of the clotting factor called thrombin. This causes the blood to take longer to form a clot. It can also prevent a clot from getting bigger.

Why do I need a blood thinner?

Dabigatran is used to prevent stroke in patients with a heart rhythm called atrial fibrillation. Dabigatran can also be used to treat or prevent blood clots or for other conditions specified by your doctor.

How should I take dabigatran?

The usual dose of dabigatran is 150 mg twice daily. It should be taken about 12 hours apart. Patients with decreased kidney function or those taking interacting medications should take a lower dose of 75 mg twice daily. Swallow the capsule whole. Do not chew, open or crush. It may be taken with or without food. Take with food if it causes an upset stomach. Do not stop taking dabigatran unless instructed by your doctor.

What happens if I miss a dose?

If you miss a dose of dabigatran, take it as soon as you remember. Skip the dose if it is less than six hours until your next dose. Never double up on a dose to make up for a missed dose. Never change your dose or stop taking dabigatran unless your doctor has told you to do so.

Will I need routine blood checks?

You will not need regular blood tests to monitor dabigatran. You will need to have your kidney, liver and blood counts monitored once to twice a year. Based on the results, your dabigatran dose may need to be changed or the drug may need to be stopped.

How should I store Dabigatran?

Dabigatran should be stored in the original container (blister package or bottle) at room temperature. Avoid excessive heat or moisture (not in a bathroom). Loose dabigatran capsules must not be stored in a medication box or organizer. Only capsules that are in the blister packs can be stored in a pill box. Dabigatran is good for four months after the bottle is opened. If you have not used the capsules within four months, you must dispose of the remaining capsules and start a new bottle.

Possible side effects of Dabigatran

These are less serious side effects. Call your doctor if these symptoms persist or worsen:

• Upset stomach

• Heartburn

• Mild abdominal pain 

Minor bleeding may also occur while on dabigatran:

• Bruising more than usual

• Occasional nose bleeds

• Prolonged menstrual bleeding (heavier than normal)

• Prolonged bleeding after minor cuts 

If you have any question about whether your bleeding is a concern call your doctor. If you have a serious fall, hit your head or if you are having any of these major bleeding side effects, call your doctor or go to the emergency room right away:

• Any bleeding that lasts for more than 10 minutes

• Red, black or tarry stool

• Vomiting or coughing up blood

• Red or dark brown urine

• Severe headache or stomach ache 

Surgical, dental or other medical procedures

Tell all members of your health care team (surgeons, dentist, etc.) that you are taking a blood thinner. You might need to stop taking it before certain procedures. Be sure to tell your doctor if you were told to stop or hold your dabigatran. They might need to change you to another type of blood thinner before your procedure.

Interactions with other medicines

Ask your doctor or pharmacist before starting any other medicine, including over-the-counter medicines, vitamins and herbal products. The dose of dabigatran may need to be adjusted if an interacting medicine is started.

Pregnancy

If you think you are or might become pregnant, tell your doctor right away. It is unknown how dabigatran will affect a fetus. If you become pregnant, your doctor will instruct you about your treatment options.

What is rivaroxaban?

Rivaroxaban (Xarelto) is a drug that blocks the activity of the clotting factor called anti-Xa (anti-10-a). This causes the blood to take longer to form a clot. It can also prevent a clot from getting bigger.

Why do I need a blood thinner?

Rivaroxaban is used to prevent stroke in patients with a heart rhythm called atrial fibrillation. Rivaroxaban can also be used to prevent or treat blood clots or for other conditions specified by your doctor.

How should I take my rivaroxaban?

The usual dose of rivaroxaban is 20 mg once daily with your evening meal. Patients with decreased kidney function should take a lower dose of 15 mg once daily. Rivaroxaban should be taken with the evening meal. Food helps to make sure the drug is absorbed. You can crush this medication if you need to, but be sure to take it within four hours of crushing. Do not stop taking rivaroxaban unless instructed by your doctor.

What happens if I miss a dose?

If you miss a dose of rivaroxaban, take it as soon as you remember. Skip the dose if it is less than 12 hours until your next dose. Never double up on a dose to make up for a missed dose. Never change your dose or stop taking rivaroxaban unless your doctor has told you to do so.

Will I need routine blood checks?

You will not need regular blood test to monitor rivaroxaban. You will need to have your kidney and blood counts monitored once to twice a year. Based on the results, your rivaroxaban dose may need to be changed or the drug may need to be stopped.

How should I store rivaroxaban?

Rivaroxaban should be stored at room temperature. Avoid areas of excessive heat or moisture (not in a bathroom).

Possible side effects of rivaroxaban

These are less serious side effects. Call your doctor if these symptoms persist or worsen:

• Rash

• Mild back pain

• Swelling of the extremities 

Minor bleeding might also occur while on rivaroxaban:

• Bruising more than usual

• Occasional nose bleeds

• Prolonged menstrual bleeding (heavier than normal)

• Prolonged bleeding after minor cuts 

If you have any question about whether your bleeding is a concern call your doctor. If you have a serious fall, hit your head or if you are having any of these major bleeding side effects, call your doctor or go to the emergency room right away:

• Any bleeding that lasts for more than 10 minutes

• Red, black or tarry stool

• Vomiting or coughing up blood

• Red or dark brown urine

• Severe headache or stomach ache 

Surgical, dental or other medical procedures

Tell all members of your health care team (surgeons, dentist, etc.) that you are taking a blood thinner. You may need to stop taking it before certain procedures. Be sure to tell your doctor or pharmacist if you were told to stop or hold your rivaroxaban. They may need to change you to another type of blood thinner before your procedure.

Interactions with other medicines

Ask your doctor or pharmacist before starting any other medicine, including over-the-counter medicines, vitamins and herbal products. The dose of rivaroxaban may need to be adjusted if an interacting medicine is started.

Pregnancy

If you think you are or might become pregnant, tell your doctor right away. It is unknown how rivaroxaban will affect a fetus. If you become pregnant, your doctor will instruct you about your treatment options.

• Clot Care Online Resource

• A patient's guide to taking Warfarin

• Blood Thinner Pills: Your Guide to Using Them Safely

• Stop the Clot

• VTE Risk and Bleeding Risk Assessment for Medical Patients

• VTE Risk and Bleeding Risk Assessment for Surgical Patients

• Therapeutic Unfractionated Heparin Infusion Guideline

• Therapeutic Unfractionated Heparin Infusion Guideline – Pediatrics

Inpatient Warfarin management

• Inpatient Warfarin Management Guideline

• Inpatient Warfarin Protocol

• Warfarin Dosing Algorithm (pdf)

Ambulatory Warfarin management

• Ambulatory Warfarin Management Guideline

• Ambulatory Warfarin Management Protocol

Referral information

1. Must have a UW Health or Unity Point Health (UPH) PCP or have a UW Health or UPH Specialty Provider involved in their ongoing care, including decisions about their long-term anticoagulation therapy plan of care.

2. Cannot have Dean, GHC or VA insurance

Referrals can be made by placing a "Consult to Anticoagulation Clinic - Inside UW Health" order in Epic. All fields must be completed. Once signed, the referral will come to the Anticoagulation Clinic, and we will enroll in our clinic when we are able. Referring provider is responsible for INR and Warfarin management until the Anticoagulation Clinic notifies your office that patient has been enrolled in our clinic.

• Atrial Fibrillation (AF): Management - Adult - Inpatient/Ambulatory/Emergency Department Guideline Summary

Oral anticoagulation: Direct oral anticoagulants

Direct Oral Anticoagulant Dosing Chart (pdf)

Anticoagulation reversal

Anticoagulant Reversal Guideline (pdf)

Periprocedural management of antithrombotics

Periprocedural Management of Antithrombotics Guideline

Heparin-induced thrombocytopenia

Heparin-Induced Thrombocytopenia Guideline