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warfarin & injections
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Jackie2

1299 Posts

Posted:  29-Jul-2014 16:44 Log in to like this post
Reading the NHS website it says that if you are on warfarin you will have s/c injections as opposed to IM. Most travel vaccinations etc say they should be given IM so what do we do? Same applies to flu vacs. What do you all do?

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Jackie2

1299 Posts

Posted:  30-Jul-2014 13:21 Log in to like this post
Please could someone answer this as we have this scenario coming in next week! Thank- you.

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Lilywhite

1434 Posts

Posted:  30-Jul-2014 14:10 Log in to like this post
The answer is on page 27 of the Green Book:

"For individuals with a bleeding disorder, vaccines normally given by an IM
route should be given by deep subcutaneous injection to reduce the risk of
bleeding"

Please be aware this is my opinion only based on the evidence I have seen, and not meant to be taken as direction
tiredandemotional

4401 Posts



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Posted:  30-Jul-2014 15:09
But being warfarinised does not constitute a bleeding disorder.

Dental extractions and cataract surgery is currently performed when patients are in the therapeutic range. I would check an INR prior to vaccination, and if in range give IM. If not in range I would delay.
Lilywhite

1434 Posts

Posted:  30-Jul-2014 15:21
I agree - I always check if INR done recently and in range. I've vaccinated many many patients on warfarin that are well controlled with no issues at all.

Had a few patients slightly out of range that could not really delay vaccine so have given deep subcut - again with no issues. There may be a slight increase in local reactions with IM vaccines being given deep subcut but rarely in my experience.

Please be aware this is my opinion only based on the evidence I have seen, and not meant to be taken as direction
Jackie2

1299 Posts

Posted:  30-Jul-2014 15:53
So are patients on warfarin considered to be the same as those with bleeding disorders? It's this that causes confusion in our practice.
If we give an IM injection as s/c then this is against their licence. Do I gather that most of you give IM travel etc? Thanks for replying.

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Lilywhite

1434 Posts

Posted:  30-Jul-2014 16:16
It's not usually outside the license - in fact it is often explicitly stated - for example the SPC for Typhim states:

"4.2 Posology and method of administration
Adults and Children over 2 years of age: A single dose of 0.5 millilitre.
The preferred route of administration for this vaccine is intramuscular although it may be given subcutaneously."

you can check the SPC of each vaccine on:

http://www.medicines.org.uk/emc/

If the INR is in therapeutic range then I don't think it would be classed as a bleeding disorder. As far as I am aware a bleeding disorder is more a condition such as haemophilia, however if the INR is way out of therapeutic range (high) they are more likely to bleed and I would treat them in the same way in terms of giving injections - i.e do it subcut.

Interested in others opinions - this is just mine!


Please be aware this is my opinion only based on the evidence I have seen, and not meant to be taken as direction
tigger1

1121 Posts

Posted:  30-Jul-2014 19:27 Log in to like this post
As above I usually just ask them to apply firm pressure after the injection for a bit longer in ease they bleed. Never had a problem, not even a bad bruise in 26 years ( but now of course will have a major haematoma tomorrow unless I run outside spit and turn round three times ) 
lizita

28 Posts

Posted:  30-Jul-2014 19:50
Never had any problems giving IM injections to warfarinised patients, as above just ask them to apply bit more pressure and check bleeding has stopped before they go.
karen.rudd

12079 Posts

Posted:  31-Jul-2014 00:16
Agree patients who amble a long within range without any recent problems or bruising give i/m.
Those with more erratic history deep sub cut.

Worth mentioning that the inr might blip post vaccine temporarily and that climate abroad can also affect inr when travelling

Please be informed that the above is the opinion of the author and is in no way meant to be taken as instruction.

karen
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tjwizard

108 Posts

Posted:  04-Aug-2014 17:42 Log in to like this post
It's worth remembering that there's no real correlation between INR level and symptoms of bleeding. Some patients can bruise quite easily when their INR is at the upper end of their therapeutic range, while others can walk around symptom-free having just spiked an INR of 6 or 7! In assessing whether a patient is likely to bruise after injection I'd be more interested in any symptom history related to their anticoagulation, rather than their INR per se.

Dr Robert Treharne Jones
Clinical Director
humpty dumpty

725 Posts

Posted:  06-Aug-2014 14:06 Log in to like this post
Hi All
recently had cause to immunise a haemophiliac pt going all over the place and had to seek very detailed advice. I learned that there is an efficacy problem known with giving some imms deep S/c which had to be weighed against the risk of bleeding etc . I am not in front of the screen right now but from memory it was the rabies that was known to be less effective if administers in this way which potentially left reduction in cover against lethal disease.

for other imms little data available but considered deep S/C effective. Worth getting specialist advice depending on risk , history etc ? 


Lilywhite

1434 Posts

Posted:  18-Sep-2014 15:47
Bumping up

Please be aware this is my opinion only based on the evidence I have seen, and not meant to be taken as direction
Buckos

138 Posts

Posted:  18-Sep-2014 16:52
The influenza vaccine is licensed for IM or deep sub cut, and at training recently they said do with warfarin patients what you would do with all of the other patients but give them a plaster afterwards in case there is some bleeding.

You're not penetrating a vessel, the needle is just going in to synovial fluid and so it's unlikely to bleed heavily.
tiredandemotional

4401 Posts



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Posted:  18-Sep-2014 17:13
I agree Buckos about the plaster.

However we inject into the muscle and nowhere near the synovial fluid of a synovial joint.
Buckos

138 Posts

Posted:  18-Sep-2014 17:19 Log in to like this post
Yeah sorry what I meant is that you're not injecting in to or near any vessels, just muscle or deep subcutaneous tissue and fluid. That's what I was told anyway, and that's why not much risk of bleeding. Got muddled ha
Lilywhite

1434 Posts

Posted:  17-Sep-2015 18:59
Bumping up for Buffy

Please be aware this is my opinion only based on the evidence I have seen, and not meant to be taken as direction
GPN_London

26 Posts

Posted:  19-Aug-2016 15:38
I have been looking into this today. Do your HCAs give the flu vacs to patients on Warfarin? if in some cases its suggested to be given by S/C injection then ours are not trained in S/C injections. Also does anybody recall patients for repeat INR's 7 days post vaccination?

GPN_London
tjwizard

108 Posts

Posted:  19-Aug-2016 15:46
The possibility of flu vaccination causing an interaction with warfarin is controversial, but is not borne out by the evidence. Check out this paper http://www.ncbi.nlm.nih.gov/pubmed/3366059 as an example.

Robert
Della

1685 Posts

Posted:  19-Aug-2016 17:35
HI GPN,

Yes, my HCA gives flu vacc to pts on warfarin, and no, we don't do anything about rechecking INR after.

I do tell pts to mention that they have had their flu vaccine if they are having their INR checked within the following 2 weeks, just in case it affects it, having been told some years ago by an anti-coach nurse that there was some anecdotal evidence about causing fluctuation in levels, but may not even do that now having read the article that Robert cited.
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