Bleeding risk

Due to bleeding risk, individuals on anticoagulant therapy or individuals who are vitamin K-deficient should not take vitamin E supplementation without close medical supervision. Absent of that, vitamin E is a well-tolerated relatively non-toxic nutrient. A tolerable upper intake level of 1,000 mg daily of a-tocopherol of any form (equivalent to 1,500 IU of RRR a-tocopherol or 1,100 IU of all-rac-a-tocopherol) would be, according to the Food and Nutrition Board of the Institute of Medicine, the highest dose unlikely to result in haemorrhage in almost all adults. 

If history of aspirin-induced bleeding or bleeding risk factors present, use lower doses (i.e., 75-81 mg daily)... 

Contraindications to anticoagulation (e.g., serious bleeding risk, coagulopathic, thrombocytopenic, metastatic brain cancer, and fall risk)... 

NSTE ACS, class I recommendation for all patients. Severe bleeding risk... 

NSTE ACS, class I recommendation for all hospitalized patients in whom a non-interventional approach is planned. In PCI in STE and NSTE ACS, class I recommendation. In STE ACS with fibrinolytics, large randomized trial data published after 2004 guidelines. Severe bleeding risk... 

If possible, withhold for at least 5 days in patients in whom CABG is planned to decrease bleeding risk (class I recommendation)... 

Agent Fibrin Specificity TIMI-3 Blood Flow Complete Perfusion at 90 Minutes Systemic Bleeding Risk/ICH Risk Administration Average Wholesale Price3 Other Approved Uses... 

Doses and contraindications to glycoprotein Ilb/IIIa receptor blockers are described in Table 5-2. Major bleeding and rates of transfusion are increased with administration of a glycoprotein Ilb/IIIa receptor inhibitor in combination with aspirin and an anticoagulant,30 but there is no increased risk of intracranial hemorrhage in the absence of concomitant fibrinolytic treatment. The risk of thrombocytopenia with tirofiban and eptifibatide appears lower than that with abciximab. Bleeding risks appear similar between agents. 

Stroke Prevention All patients with paroxysmal, persistent, or permanent AF should receive therapy for stroke prevention, unless compelling contraindications exist. A decision strategy for stroke prevention in AF is presented in Fig. 6-9.27 In general, most patients require therapy with warfarin in some patients with no additional risk factors for stroke, aspirin may be acceptable. For some patients, serious consideration of the benefits of warfarin versus the risks of bleeding associated with warfarin therapy is warranted. The potential bleeding risks associated with warfarin may outweigh the benefits in... 

Increased Anticoagulation Effect Decreased Anticoagulation (Increase Bleeding Risk or T INR) Effect (4- INR)... 

Randomized trials have been completed assessing the role of antiplatelet therapy with aspirin for primary stroke prevention. The use of aspirin in patients with no history of stroke or ischemic heart disease reduced the incidence of non-fatal myocardial infarction (MI) but not of stroke. A meta-analysis of eight trials found that the risk of stroke was slightly increased with aspirin use, especially hemorrhagic stroke. Major bleeding risk was also increased with aspirin use.4 Aspirin is beneficial in the primary prevention of MI, but not for primary stroke prevention. 

NSAIDs may also cause kidney diseases, hepatitis, hypersensitivity reactions, rash, and CNS complaints of drowsiness, dizziness, headaches, depression, confusion, and tinnitus. All nonselective NSAIDs inhibit COX-l-dependent thromboxane production in platelets, thereby increasing bleeding risk. NSAIDs should be avoided in late pregnancy because of the risk of premature closure of the ductus arteriosus. 

The AHA/ASA guidelines recommend that antiplatelet therapy as the cornerstone of antithrombotic therapy for the secondary prevention of ischemic stroke and should be used in noncardioembolic strokes. Aspirin, dopidogrel, and extended-release dipyridamole plus aspirin are all considered first-line antiplatelet agents (see Table 13-1). The combination of aspirin and clopido-grel can only be recommended in patients with ischemic stroke and a recent history of myocardial infarction or coronary stent placement and then only with ultra-low-dose aspirin to minimize bleeding risk. 

Use heparin lock-flush solution with caution in infants with disease states in which there is an increased danger of hemorrhage. The use of the 100 unit/mL concentration is not advised because of bleeding risk, especially in low-birth-weight infants. 

WARNING Systemic absorption of oral route may cause neuro/oto/nephrotox may result resp paralysis possible w/ any route of administration Uses Hepatic coma, bowel prq) Action Aminoglycoside, poorly absorbed PO -1- GI bacterial flora Dose Adults. 3-12 g/24- h PO in 3-4 doses Peds. 50-1 (X) mg/kg/24 h PO in 3-4 doses Caution [C, /-] Renal failure, neuromuscular disorders, hearing impair Contra Intestinal obst Disp Tabs, PO soln SE Hearing loss w/ long-term use rash, NA EMS Use neuromuscular blockers w/ caution, reduced dose may be necessary t bleeding risk w/ concurrent anticoagulant use OD May cause neuromuscular block and kidney failure calcium salts can be used to revise neuromuscular block... 

Dose Initial 0.25 mg PO tid, wkly 10.25 mg/dose, to 3 mg max max 4 mg for RLS Caution [C, /-] Sev e CV, renal, or hepatic impair Contra Component allergy Disp Tabs SE Syncope, postural X BP, NA, HA, somnolence, dosed-related hallucinations, dyskinesias, dizziness Interactions t Risk of bleeding W/ ASA, NSAIDs, fevCTfew, garlic, ginger, horse chestnut, red clover, EtOH, tobacco t effects OF amitriptyline, Li, MTX, theophylline, warfarin t risk of photosensitivity W/ dong quai— use sunscreen, St. John s wort X effects W/ antacids, rifampin X effects OF ACEIs, diuretics EMS t Bleeding risk w/ concurrent EtOH, tobacco, ASA, and NSAID use t effects of warfarin OD May cause N/V, drowsiness, hypotension, and CP symptomatic and supportive... 

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