Principles of rationalising anticoagulants in palliative care
Follow the principles of medication rationalisation when rationalising anticoagulants in palliative care.
The use of anticoagulants in patients with palliative care needs can be complex, with competing priorities to prevent or treat thromboembolic events while minimising the risk of bleeding. Patients are often at increased risk of both bleeding and thromboembolism because of comorbidities (eg kidney and liver impairment, cardiovascular or cerebrovascular disease, diabetes), advanced age, low body weight and disease progression. Patients with advanced cancer are at higher risk of venous thromboembolism (VTE) because of the thrombogenic effects of cancer. Assess each patient’s risk of bleeding (see Assessment of bleeding risk for anticoagulant therapy in the Cardiovascular guidelines) compared to their risk of thromboembolism, which is dependent upon the indication for the anticoagulant; see:
- Rationalising anticoagulants used for VTE treatment in palliative care
- Rationalising anticoagulants used for VTE prophylaxis in palliative care
- Rationalising anticoagulants used to prevent stroke or thromboembolism.
Warfarin can become increasingly difficult to manage in advanced illness—see Considerations for warfarin use in palliative care.
Patients with advanced disease are often at greater risk of adverse effects because of changes in pharmacokinetics and pharmacodynamics due to a variety of causes including altered organ function and weight loss.
For patients in the last weeks of life who require anticoagulant therapy and cannot swallow, consider switching from an oral anticoagulant to a low molecular weight heparin (LMWH) if regular subcutaneous injections are acceptable to the patient.
For advice on starting treatment and prophylaxis of venous thromboembolism in palliative care, see Venous thromboembolism in palliative care.