Ref No:
Shared Care Agreement for
Transfer of Prescription and Supply of Tinzaparin
Version:
V1 Final
Ratified by:
Drugs and Therapeutic Committee
Area Prescribing Committee
Date ratified:
January 2015
Title of originator/author:
Consultant Haematologists
Pharmacist Medicines Evaluation
Anticoagulation Team
NHS Rotherham CCG Medicine
Management
Title of responsible
committee/individual:
Anticoagulation Group
Date issued:
January 2015
Review date:
January 2018
Target audience:
TRFT
Rotherham CCG
Copyright © 2015 The Rotherham NHS Foundation Trust
Version 1a
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Page 1 of 9
Version
Date
Version 1a
February
2013
Draft
This is a new protocol
Version 1a
March
2013
Draft
Circulated
Consultant Haematologists
Anticoagulation Specialist Nurses
NHS Rotherham Medicines Management
Version 1b
November
2014
Draft
Comments incorporated
Approved January 2015
Renamed as Version 1 Final
Version 1a
Author
Status
Comment
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Shared Care Protocol
Prescribing and Supply of Tinzaparin
This should be read in conjunction with the current Summary of Product Characteristics
http://medicine.org.uk
1
Indications
Licensed:
Prevention of VTE in surgical patients
Treatment of VTE and PE
Unlicensed:
Prevention and treatment of VTE in pregnancy
2
Patients suitable for
Primary Care
continuation
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Injectable drug users
Pregnant patients with VTE or at high risk of VTE
Patients with contraindications to vitamin K antagonists
Patients unable to be stabilised on Vitamin K antagonists
Patients undergoing cancer therapies or with metastatic disease
3
Contraindications
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Active bleeding
Sever hypertension 230/120mmHg or higher
Severe hepatic disease
Severe renal disease
Haemophilia and other untreated inherited bleeding disorders
Acute bacterial endocarditis
Recent neurosurgery or eye surgery
Thrombocytopenia with platelets less than 75x109/L
History of heparin Induced Thrombocytopenia (HIT)
Hypersensitivity to heparin, tinzaparin or other low molecular weight
heparins
4
Drug interactions
5
Adverse drug reactions
6
Base line investigations
By TRFT
7
Monitoring by GP
Version 1a
Clopidogrel
NSAIDS
Dypyridamole
Increased risk of bleeding
ACE inhibitors
Angiotensin II receptor antagonist
increased risk of hyperkalaemia
Anticoagulant effect enhanced
Haemorrhage
Thrombocytopenia
Hyperkalaemia
Osteoporosis with prolonged use
Alopecia
Injection site reactions
Skin necrosis
Hypersensitivity reactions
These will be undertaken by TRFT:
Day 1 - FBC, U&E , eGFR , LFT
Day 5 - FBC
FBC – Day 14
Patient’s weight when represcribing tinzaparin
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Page 3 of 9
8
Tinzaparin preparations
Prefilled syringes
Strength
9
Syringes available
Use prefilled syringes only
10000 units/mL
2500 units in 0.25 mL
3500 units in 0.35mL
4500 units in 0.45 mL
Do not use vials
20000 units/mL
10000 units in 0.5 mL
14000 units in 0.7 mL
18000 units in 0.9mL
Doses
Tinzaparin Prescribing Advice See Appendix 1
Doses are based on weight and renal function (eGFR).
10
Route
Subcutaneous
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Pharmaceutical aspects
Assessment and training of patients for self-administration.
To consider care by district nurses for patients unable to self-administer.
Disposal of syringes: sharps bins will be provided with the syringes.
Disposal of sharps bins: patient will be given information regarding collection
of sharps bins by Rotherham Council.
12
Secondary care
Contact information
If stopping medication or needing advice, please contact
 Consultant initiating treatment with tinzaparin
 Consultant haematologist
13
Criteria for shared care
Prescribing responsibility will only be transferred when:
 Treatment is for specified indication and duration.
 Treatment has been initiated and established by the secondary care
specialist.
 The patient’s initial reaction to and progress on the drug is satisfactory.
 The GP has agreed in writing in each individual case that shared care is
appropriate.
 The patient’s general, physical, mental and social circumstances are such
that he/she would benefit from shared care arrangements.
14
Responsibilities of
initiating consultant
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Initiate treatment.
Undertake base line monitoring.
Prescribe dose based on indication/weight/eGFR.
Monitor patients initial reaction to and progress on the drug.
Ensure that patient has an adequate supply (14 days) of medicine until
GP supply can be arranged.
Continue to monitor and supervise the patient according to this protocol,
while the patient remains on this drug.
Provide GP with:
 Diagnosis, relevant clinical information and baseline results, treatment to
date, treatment plan, duration of treatment before consultant review.
 Patient weight and baseline eGFR, platelet, potassium levels.
 Provide GP with details of outpatient consultations, ideally within 14 days
or inform GP if the patient does not attend appointments.
 Advice on when to stop drugs.
 Informed consent to therapy.
 Understanding of potential side effects and appropriate actions.
 Understanding of the role of monitoring.
15
Responsibilities of
primary care
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Version 1a
Accept referral from secondary care.
Reinforce educational points provided by the hospital.
Monitoring of FBC on day 14 to complete monitoring for heparin induced
thrombocytopaenia (HIT).
Monitor for hyperkalaemia in those patients at higher risk of raised
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16
Supporting
documentation
17
Patient monitoring
booklet
GP letter
18
Version 1a
plasma potassium concentrations (those with diabetes mellitus, chronic
renal failure, acidosis, raised potassium concentrations, those taking
potassium sparing drugs/potassium supplements or patients on long
term treatment).
Monitoring should be done regularly in these patients according to the
judgement.
Reweigh non-pregnant patients on long term tinzaparin at a frequency
according to clinical judgement.
Monitor renal function and seek advice if there is deterioration.
Keep records or register of all patients for whom tinzaparin has been
prescribed.
Records should include details such as indication, concurrent medication,
dose, start date, expected duration, monitoring details, adverse
incidents, consultants involved in treatment, any advice or actions.
To ensure that monitoring and dosage record is kept up to date
Discontinue treatment if the patient experiences severe side effects and
the relevant contact at the hospital is not available.
Conformation letter to patient and/or carer if treatment is discontinued.
Conduct audit /annual review as deemed appropriate.
Tinzaprin patient information leaflet given with sharps bins:
 For prevention
 For treatment
None
Attached below
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Page 5 of 9
References:
National Institute of Clinical Excellence
Venous thromboembolism: reducing the risk: Reducing the risk of venous thromboembolism (deep vein
thrombosis and pulmonary embolism) in patients admitted to hospital (CG92; 2010)
http://publications.nice.org.uk/venous-thromboembolism-reducing-the-risk-cg92
Royal College of Obstetrics and Gynaecology
The acute management of thrombosis and embolism during pregnancy and the puerperium, the acute
management (37b; 2010)
http://www.rcog.org.uk/files/rcog-corp/GTG37b_230611.pdf
Royal College of Obstetrics and Gynaecology
Reducing the risk of thrombosis and embolism during pregnancy and the puerperium
http://www.rcog.org.uk/files/rcog-corp/GTG37aReducingRiskThrombosis.pdf
National Patient Safety Agency
Reducing treatment dose errors with low molecular weight heparin
http://www.nrls.npsa.nhs.uk/resources/?q=0%c2%aclow+molecular+weight+heparin%c2%ac
Department of Health
Accurate patient weight
Medical patient weighing scales
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_114048.pdf
All Wales Medicines Strategy Group
Prescribing of low molecular weight heparin in Wales
http://www.wales.nhs.uk/sites3/Documents/371/Published%20to%20website%20v1.5.pdf
Sheffield Teaching Hospitals NHS Foundation Trust and NHS Sheffield
Shared Care Protocol for the prescription and supply of dalteparin (2012)
All Wales Medicines Strategy Group
Template for Shared Care Protocols
(Adapted)
Leo Pharma
Summary of Product Characteristics
Innohep
Version 1a
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Page 6 of 9
Patient name
The Rotherham NHS Foundation Trust
Unit No
Tinzaparin Shared Care Form
Date of birth
Fax this form referral to GP for ongoing prescription of Tinzaparin in accordance with the
TRFT Tinzaparin Shared Care Agreement.
TRFT will provide initial 14 days supply and monitor full blood count on day 1 and 5 – 7.
GP to monitor full blood count on day 12 - 14
GP to continue prescribing and carry out further monitoring as appropriate.
Patient’s medical care remains with the hospital consultant who initiated tinzaparin.
Refer to Consultant Haematologist for further thrombosis care where appropriate.
1. REFERRING CONSULTANT
Referring Consultant_______________________Consultant contact number____________________ Fax Number ________________
Next consultant clinic appointment___________________________GP/Practice referral____________________________
2.INDICATION FOR TINZAPARIN
VTE Prophylaxis
VTE treatment
□ Pregnancy
□ Central line
□ Surgery
□ Cancer
□ Pregnancy
□ Injectable drug use
□ Associated cancer/ cancer therapies
□ Unsuitable for oral anticoagulants
3. TREATMENT INFORMATION
Patient details:
Weight ____________kg Dose of tinzaparin_________________units ONCE/TWICE daily (delete as appropriate)
Proposed duration of treatment: 6 weeks□
Tinzaparin to be administered by:
3 months□
Patient or carer□
6 months□
long term□
Other___________________
District nurse □ (fax this form together with DN referral)
Further relevant information (clinical problems, concurrent medication):□
4. MONITORING REQUIREMENTS
Baseline results: eGFR____________micromol/1.73m2 Platelets________________(X109/L) Potassium__________________(mmol/L)
□ Heparin induced thrombocytopenia (HIT) monitoring is complete (Day 1, 5 and 14)
or
□GP to monitor FBC day 14 to HIT monitoring.
5. FORM COMPLETED BY
Signature__________________________Print name___________________________Designation___________________________
Contact No. (bleep/ext)__________________Date_____________________
Faxed by:_____________________________Time________________________________Date_____________________
Received at GP practice by: _____________ ______Time__________________Date_______________________________
(Sign and fax back to sender to confirm referral has been received)
This fax is confidential and is intended for the person to whom it is addressed. If you have received this fax in error, please notify us immediately and return in the post to us. If the
reader of this fax is not the intended recipient you are hereby notified that any distribution or copying of the message is strictly prohibited.
Version 1a
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Page 7 of 9
Tinzaparin Shared Care Agreement
for Transfer of Prescribing and Monitoring from Hospital to Primary Care
Patient………………………………………………
Consultant…………………………………………
Speciality………………………………………….
Name of General Practitioner: Dr…………………………………………………………………………....
Name of GP Practice: ………………………………………………………………………………………………
□
I am happy that from………/………/20…………… the practice will take over the prescribing of
Tinzaparin for the above patient in accordance with the shared care guidelines which are
attached.
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The practice is happy to supply Tinzaparin for the duration stated.
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The practice is happy to undertake monitoring as above.
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I also confirm that I will take appropriate action, in accordance with the above- mentioned
Guidelines in the event of abnormal blood tests or other adverse reactions, and will
inform the patient’s Consultant if I advise the patient to stop
□
Tinzaparin treatment
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I am aware that the consultants are happy to be contacted about their patients via
their secretaries if there are any concerns.
GP Signature………………………………………………………Print Name……………………………………………..
Date…………………………………………………
Please FAX once complete to the Consultant.
Version 1a
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Appendix 1
Tinzaparin prescribing chart
(to insert following review January 2015)
Version 1a
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Page 9 of 9