2.3 Blood clots

2.3.1 Blocked catheters and lines

Prostaglandins (Cardiovascular)

Epoprostenol (TLS Red)

2.3.2 Thromboembolism

• See local guidelines for Anticoagulant counselling resources, Antiplatelet guidelines, Guidance on switching between anticoagulants, 
• The British Journal of Cardiology article on assessing renal function and anticoagulants prescribing
• Please see the Optimising/ Reviewing PPI inhibitor guideline in local gastro-intestinal guidelines which highlights when prophylaxis may be indicated in high risk patients prescribed other medicines that increase risk of ulceration/bleeding

Recommended: (TLS Green)

Aspirin

Aspirin (off label) (TLS Green)

• To reduce the risk of colorectal cancer in people with Lynch Syndrome as per NICE Guideline 151: Colorectal Cancer

Clopidogrel

• TIA - not recommended by NICE as they cannot recommend treatment outside licence. However clopidogrel post TIA is endorsed by AGWS Cardiac and Stroke Network
• Peripheral Arterial Disease (PAD)
• Multivascular disease
• See 'BNSSG antiplatelet guidelines' for durations of treatment information, available on the Cardiovascular System Guidelines page

Dipyridamole modified-release in combination with aspirin (TLS Blue)

Dipyridamole (TLS Blue)

• NBT only as adjunct to oral anticoagulation in patients with prosthetic heart valves and to prevent access clotting in haemodialysis patients

Ticagrelor (TLS Amber Specialist Initiated)

• For secondary prevention of stroke and TIA in cases of clopidogrel resistance, or in patients with non-cardioembolic ischaemic stroke (NIHSS ≤ 5) or high-risk TIA 

Direct Oral Anticoagulants

Please see 'Anticoagulant Guidance' section of cardiovascular guidelines page for guidance such as  'Summary of Decisions when prescribing a DOAC' and 'DOAC decision aid tool'. 

Link to MHRA Prescribing medicines in renal impairment: using the appropriate estimate of renal function to avoid the risk of adverse drug reactions - applicable to DOACs

Information on how to order NHSE anticoagulant resources for patients (such as anticoagulant patient alert cards) can be found on the Specialist Pharmacy Services (SPS) website.

Note: there are different TLS colours for apixaban, rivaroxaban, edoxaban, dabigatran depending on the indication

Rivaroxaban co-administered with an antiplatelet (TLS Amber Specialist Recommended)

- Prevention of adverse outcomes after acute management of acute coronary syndrome NICE TA335

- Prevention of athero-thrombotic events in people with coronary or peripheral artery disease NICETA607

See Shared Decision Making Tool here

Prescribing considerations for combination antiplatelet therapy and anticoagulant therapies

Combination therapy increases risk of major bleeding events. There are, however, benefits of combination therapy resulting in a reduced risk of atherothrombotic events. 

Prescribing considerations: 

• Confirm that there is an indication for prescribing combination antiplatelet (e.g. recent ACS) and anticoagulant therapy (e.g. atrial fibrillation, history of DVT/PE).
• When starting oral anticoagulation, antiplatelet therapy can usually be stopped unless it is for secondary prevention of cardiovascular disease or peripheral vascular disease. For secondary prevention, the time of the last cardiovascular event should be established. If it was greater than 1 year ago, the antiplatelet can usually be stopped.
• If a patient has a proven history of a bleed from the stomach or duodenum or proven ulcer, gastroprotection should be considered including any key drug interactions. See SPCs or BNF for information on drug interactions, as well as the BNSSG Guidance on Optimising and Reviewing PPIs.
• Bleeding risk should be carefully assessed using clinical judgment and, where appropriate, validated tools, considering modifiable and non-modifiable risk factors, co-prescribed medicines, and treatment duration to minimise harm while ensuring thrombotic protection.
• Monitoring should be guided by individual bleed risk and patient circumstances, with regular review of thrombotic and bleeding risk. Patients should be counselled on signs of bleeding and undergo routine kidney and liver function tests, full blood counts, and INR monitoring if on warfarin.
• Any discontinuation of combination treatment should be clearly documented, and specialist advice sought in cases of high bleed risk, complex comorbidities, treatment failure.

BNSSG Antiplatelet guidance is underway, to include further detail on prescribing considerations for combination therapy.

Rivaroxaban (TLS Red)

• For Primary Thromboprophylaxis post fontan completion

Factor Xa Inhibitors

Fondaparinux

• Unstable angina and non ST- segment elevation acute MI undergoing early invasive <72 hours management or conservative but not including urgent invasive management <120 minutes
• Also ST - segment elevation acute MI managed with thrombolytics, or initially no other form of reperfusion therapy.
• Patients refusing animal products
• Heparin induced thrombocytopenia
• For systemic anticoagulation to prevent clotting in the extracorporeal circuit for patients with confirmed Type II Heparin Induced Thyrombocytopenia (HIT) who cannot achieve a satisfactory haemodialysis with anticoagulation free haemodialysis or with Citrasate^® dialysate

Specific Reversal of Apixaban or Rivaroxaban Anticoagulation

Andexanet Alfa (TLS Red)

• NICE TA697 Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban

Heparinoids

Danaparoid (TLS Red)

• Restricted to heparin induced thrombocytopenia (HITS) and extra-corporeal circuit anticoagulation (dialysis) in patients who have had HITS

Heparins

For prophylaxis (TLS Amber)

Dalteparin

• Restricted to Obstetrics. For use where enoxaparin not appropriate for obstetric patients due to allergy/reaction.

Enoxaparin

• Inhixa^® is the preferred brand for new patients.
• Specify brand when prescribing Inhixa^®, Clexane^®, Arovi^®
• Brands are not interchangeable. Patients should remain on the same brand post discharge

Tinzaparin

• NBT only (renal use only)

For Treatment (TLS Green)

Dalteparin

• Restricted to Obstetrics. For use where enoxaparin not appropriate for obstetric patients due to allergy/reaction

Enoxaparin

• Inhixa® is the preferred brand for new patients.
• Specify brand when prescribing Inhixa^®, Clexane^®, Arovi^®

• Brands are not interchangeable. Patients should remain on the same brand post discharge

Tinzaparin

• NBT only (renal use only)

Specific indication: (TLS Red)

Heparin Sodium

Heparin Calcium

• Gastroenterology at UHB only

Protamine Sulphate

Protamine (TLS Red)

Fibrinolytics

Alteplase (TLS Red)

• For treatment of adult patients with iliofemoral (proximal) deep vein thrombosis (DVT) with catheter-directed thrombolysis (CDT) at NBT

Tenecteplase (TLS Red)

• For thrombolysis of acute ischaemic stroke prior to thrombectomy on advice of stroke specialist. For patients who are eligible for thrombolysis and thrombectomy treatment only. For use at NBT only.
• NICE TA990 Tenecteplase for treating acute ischaemic stroke

Thrombin Inhibitors

Argatroban

• Restricted to heparin induced thrombocytopenia (HITS) and extracorporeal circuit anticoagulation (dialysis) in patients who have had HITS - TLS Red

Bivalirudin

• For peri-procedure use in patients undergoing PCI for the treatment of an acute coronary syndrome, in place of Abciximab except in those very high risk patients (eg giant thrombus) after PCI.
• See NICE NG185 ACS guideline

Idarucizumab (TLS Red)

• Specific reversal agent for dabigatran

Defibrotide (TLS Red)

• In accordance with NHS England Policy B04/P/c Use of defibrotide in severe veno-occlusive disease following stem cell transplant

Tirofiban (TLS Red)

• Acute coronary syndrome
• Tirofiban may only be prescribed according to chest pain protocols. 

Tissue Plasminogen Activators

Urokinase (TLS Red)

• To restore patency of intravenous catheters and cannula blocked by fibrin clots.
• For intrapleural instillation for relief of distressing dyspnoea due to malignant effusion resistant to simple drainage (on advice of respiratory consultant) NBT only
• Management of blocked tunnelled intrapleural catheters which would otherwise need to be removed or replaced (on advice of respiratory consultant) NBT only

Vitamin K Antagonists

Recommended: (TLS Green)

Warfarin

• If any new medication is initiated in a patient already taking warfarin please consider any potential drug interactions, and inform relevant warfarin clinic if appropriate as closer monitoring of INR may be required.

See BNSSG Guidance on the management of High INR in the community

Information on how to order NHSE anticoagulant resources for patients (such as anticoagulant patient alert cards) can be found on the Specialist Pharmacy Services (SPS) website.

Specific indications:

Phenindione

• Where warfarin is inappropriate

IIa/IIIb Inhibitors

Eptifibatide (Integrellin^®) (TLS Red)

• For used in interventional radiology to treat thromboembolic events complicating interventional procedures and to prevent intracranial stent thrombosis

Others

Emicizumab (TLS Red)

• As per NHS England Clinical Commissioning Policy: Emicizumab as prophylaxis in people with severe congenital haemophilia A without factor VIII inhibitors (all ages) Ref: 170134P

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