Anticoagulants are very useful medications but can also lead to haemorrhagic as well as thromboembolic complications when not used correctly or without proper medical attention. Anticoagulant’s complex pharmacology and pharmacokinetics contribute to its narrow margin of safety. Pharmacist’s unique knowledge of pharmacology, pharmacokinetics and interactions makes them well-suited to assist patients in maintaining safe and effective anticoagulation. Successful anticoagulation therapy implies fewer incidences of therapeutic failures and bleeding complications. The anticoagulation management service staffed by clinical pharmacists is a service established to monitor and manage oral and parenteral anticoagulants. In this research work, 40 patients each were included in the intervention and the control groups. In the intervention group, patient’s knowledge score on anticoagulation increased from an average of 5.6±3.2 to 13.8±0.94 (P=0.000) after clinical pharmacist’s counselling, whereas in the control group there was no significant improvement in patient’s baseline knowledge over the knowledge score at the end of the study (8.0±1.59 vs. 8.3±2.6) (P=0.218). In the intervention group, 73.45% of the international normalised ratio test results were within the therapeutic range, 8.45% supratherapeutic and 18.5% subtherapeutic during the 6 months data collection period. The corresponding data for the control group were 53.2 (P=0.000), 18.4 (P=0.000) and 28.4% (P=0.002), respectively. Forty four adverse drug reactions (ADRs) related to anticoagulants were identified in the intervention group as compared to 56 in the control group. These results revealed that the clinical pharmacist’s involvement in the anticoagulation management improved the therapeutic outcome of patients and demonstrate the benefits of clinical pharmacist guided anticoagulation clinics in India.

The long term anticoagulation with warfarin is associated with various bleeding risks which led to the need for newer drugs. With the developments in the anticoagulation therapy the newer agents like dabigatran, rivaroxaba, apixaban and edoxaban have gained popularity with their more predictable pharmacological properties and reduced need for drug monitoring.The United States of America has approved both rivaroxaban and dabigatran to be used in the treatment of VTE (Venous Thrombo Embolism). In Europe and Canada dabigatran is prescribed after elective hip or knee arthroplasty to prevent VTE. For a VTE prophylaxis after an orthopediac surgery and to prevent stroke in AF patient, Rivaroxaban is recommended according to RECORD study. Edoxaban is highly effective in treatment of VTE and acts as a preventive measure of stroke in NVAF (Nonvalvular Atrial Fibrillation). Through this article various pharmacological aspects, dosing regimens, bleeding associated risk will be illustrated.

Trastuzumab is a monoclonal antibody effective in treating metastatic breast carcinomas. Cardiotoxicity is the most commonly reported adverse event occurring when used in combination with anthracycline derivatives. Even though pulmonary toxicities are uncommon, immediate withdrawal of the drug is recommended and only reinitiates after the vitals of the patient have become normal. Here, we discuss the case of an 81-year-old female patient who was treated with Injection Trastuzumab for the treatment of breast cancer with metastasis to lungs and received 6 cycles without any major complications. However, 24 h post the last dose; the patient developed a sudden onset of breathlessness and desaturation and was intubated in view of severe metabolic and respiratory acidosis. Blood investigations revealed elevated brain natriuretic peptide, aspartate transaminase, and alkaline phosphatase. Her blood and urine cultures were found to be sterile. She was managed with IV antibiotics, nebulizations, IV fluids, and other supportive medications and had improved considerably. However, on the 11th day, her condition had deteriorated and developed bradycardia. The patient could not be revived and died. Review of the patient’s medication did not reveal the presence of any other possible drugs capable of producing pulmonary toxicity. Trastuzumab should be avoided in patients with underlying respiratory or cardiac issues.

Takayasu's arteritis (TA) is a rare large-vessel vasculitis that affects large arteries, mainly the aorta and its branches. It is also called a pulseless disease because of diminished or absent pulses in the upper extremities of the patient. The coronary, pulmonary and renal arteries are also affected in the progression of the disease. The prevalence of the disease is more in Asian countries and it has unknown etiopathogenesis. Here we discuss a case of TA in a 15 y old girl who was admitted with moderate LV dysfunction. The diagnosis was carried out from the results of CT aortogram which showed stenosis of right common carotid, left subclavian, left vertebral artery, right renal artery and lower lobe pulmonary arteries and other clinical examinations. Treatment was initiated with methylprednisolone and cyclophosphamide along with symptomatic treatment. But the disease progressed with the development of complications like peripheral leg ulcers. The patient was initiated palliative care in view of altered sensorium and severe LV dysfunction, but the patient succumbed to a sudden cardiac arrest. Early identification and initiation of aggressive treatment can help in symptom-free survival.

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