Anticoagulation, Warfarin

Guidance for medical examiners when assessing a patient for either a general topic or condition – Anticoagulation, Warfarin.

Aeromedical implications

Effect of aviation on treatment

  • Variable dietary control

Effect of treatment on aviation

  • Overt incapacitation
    • Distracting pain from gastrointestinal haemorrhage or cerebrovascular bleed
    • Loss of consciousness from cerebrovascular bleed
    • Sudden death.

Approach to medical certification

Based on the condition

  • Based on the underlying condition necessitating anticoagulation

Based on treatment

  • Acceptable, stable treatment without significant side effects

Demonstrated stability

  • When commencing warfarin, a minimum of three INRs are required at least one week apart and must be within the target range

Risk assessment protocol - information required

A report from the treating doctor will be required.

  • When commencing warfarin, a minimum of three INRs are required at least one week apart and must be within the target range
  • Monitoring regime including compliance with and stability of antiplatelet and anticoagulant medication
  • Subsequent serial INR results performed at least monthly or more frequently if operationally appropriate
  • Any side-effects should be notified to CASA
  • Estimate of annualised percentage risk of incapacitation
  • Follow-up plan

Indicative outcomes

  • Warfarin and Novel Oral Anticoagulants (NOACs) are approved by CASA AVMED for use by pilots and controllers whilst exercising the privileges of their medical certificate. However, Class 1 and Class 3 medical certificate holders using anticoagulation medication will be subject to multi-crew/proximity restrictions (see separate guideline on NOACs)
  • Pilots and controllers on Warfarin are to be grounded if their INR is outside the range 1.5 to 4.0. or if persistently outside designated target range for anticoagulant treatment
  • Pilots and Controllers prescribed Clexane will not be cleared to exercise the privileges of their certificate.  (Clexane may be used in combination with Warfarin during the initial treatment while grounded)
  • Initial notification to CASA and grounding is required on diagnosis of the underlying condition and commencement of Warfarin anticoagulation
  • Clearance by CASA is required before exercising privileges
  • Permanent multi-crew restriction will be likely if anticoagulation is required long term
  • Cumulative risk assessment performed by CASA includes:
    • risks associated with the medication
    • risks due to the condition for which anticoagulation is indicated
    • additive risks due to other co-morbid conditions.

Acceptable

Unacceptable

  • Clexane (acceptable during initial combination treatment with Warfarin but unacceptable for long term treatment)

Favourable

  • Satisfactory criteria met
  • Class 1 - multi-crew operations only
  • Class 3 - proximity restriction required
  • Class 2 - unrestricted

Unfavourable

  • Signifiant side-effects
  • Non-compliance

Pilot and controller information

  • Anticoagulation is an aero-medically significant treatment
  • The conditions which require warfarin treatment are serious. Poor control of warfarin can cause a large increase in health risks. This is why it matters that it is very carefully managed
  • Pilots and controllers who are commenced on anticoagulation are required to ground themselves and notify this treatment to their DAME and CASA.
  • Permanent multi-crew restriction will be likely if anticoagulation is required long term
  • Pilots or controllers considering point of care INR testing are strongly advised to discuss this with CASA Aviation Medicine

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.

Last updated:
Online version available at: https://www.casa.gov.au//licences-and-certificates/medical-professionals/dames-clinical-practice-guidelines/anticoagulation-warfarin
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