The current body of evidence consists mostly of small studies and case reports. However, once thrombosis has occurred, anticoagulation therapy aims to … Antidotes for warfarin. To reverse the effects of warfarin, vitamin K1 can be given. This is one of the best antidote for warfarin. Vitamin K1 is available as an oral tablet or as an ampoule for intravenous (IV) or oral administration. Correction of Supratherapeutic Anticoagulation with Warfarin Management of warfarin reversal and bleeding events is summarized below: 1. Risk of bleeding on warfarin increases significantly with INR results >5,0. [ 15] With regard to prehospital emergency care, initiate … In cases of life-threatening bleeding or serious warfarin overdose, prothrombin complex concentrate replacement therapy is indicated, supplemented with 10 mg of vitamin K 1 by slow intravenous infusion; this can be repeated, according to the INR. Overdose of apixaban may result in a higher risk of bleeding. Attach a warfarin warning label on main Drug Prescription and Administration Record chart, and write “warfarin” in the regular prescription section, and “see Contact on-call haematologist for more advice. Warfarin is a racemic mixture of stereo isomers, which are 99 percent bound to albumin. Warfarin also increases the risk of serious perinatal bleeding during delivery. Anticoagulation Related Bleeding - Guideline Summary Oct 18 Page 7 of 19 ACTIONS TO BE TAKEN FOR HIGH INR (WITH NO BLEEDING) INR >8.0 Stop VKA Give Vitamin K orally using the IV preparation Recheck INR at 24 hours Repeat Vit K administration orally if INR remains high Restart Warfarin when INR <5.0 INR 5.0-8.0 Stop VKA for 1-2 doses Overdose of the oral anticoagulant warfarin (Coumadin), or drug interactions with warfarin, can lead to toxicity. Warfarin is the most recommended anticoagulant drug for patients undergoing heart valve replacement. The oral anticoagulants warfarin sodium, acenocoumarol and phenindione, antagonise the effects of vitamin K, and take at least 48 to 72 hours for the anticoagulant effect to develop fully; warfarin sodium is the drug of choice. Aug. 31, 2011 (Paris) -- The anti-clotting drug warfarin is safe and beneficial for people aged 80 and over, according to a new report. But the drug is being prescribed to fewer than half of older people with a heart condition that puts them at high risk of stroke who would benefit from warfarin, a second study suggests. Use of Vit K iv/po/sc is not discussed or the use of FFP. Re-assess regularly. SRU (pronounced "shrew") = Shock Resuscitation Unit. 3. II. Adapted from the 2008 Warfarin Reversal Guidelines from the American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy (Ansell et al, Chest 2008). There are two main types of oral anticoagulants: vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). This guideline reviews the indication for warfarin, duration or treatment for patients with a PE and/or lower limb DVT, the initiation of treatment, the management of peri-operative anticoagulation, the management of patients who are bleeding or with an elevated INR including those with a head injury and finally includes a section on patients on warfarin who also require an anti-platelet agent. A Patient's Guide to Taking Warfarin. Blood Reviews (1998)12, 91-98 D 1998 Harcourt Brace & Co. Ltd Haemostasis and thrombosis Management of warfarin (coumarin) overdose T. Baglin Treatment with coumarin oral anticoagulants, such as warfarin, is effective antithrombotic therapy, but patients treated with these drugs are at significant risk of bleeding. Management of warfarin (coumarin) overdose Treatment with coumarin oral anticoagulants, such as warfarin, is effective antithrombotic therapy, but patients treated with these drugs are at significant risk of bleeding. This determines whether they need bridging therapy (therapeutic subcutaneous tinzaparin). Guidelines for warfarin maintenance dosing adjustments. Initially 5–10 mg, to be taken on day 1; subsequent doses dependent on the prothrombin time, reported as INR (international normalised ratio), a lower induction dose can be given over 3–4 weeks in patients who do not require rapid anticoagulation, elderly patients to be given a lower induction dose; maintenance 3–9 mg daily, to be taken at the same time each day. †Oral or parenteral rapid-onset anticoagulants. Warfarin Antidotes. Please note why the patient is taking warfarin and whether they are at high, moderate or low risk of thrombosis. • Give Vitamin K 1 mg -2.5 mg orally. This guideline replaces the previous BCSH guidelines on oral anticoagulants ( Baglin & Rose, 1998 ; Baglin et al , 2006 ). The goal of urgent warfarin reversal, therefore, is to increase the available amount of Vitamin–K dependent clotting factors which will lead to a decrease in INR. OTOH, overdose with warfarin can be treated by administering vit K. - I wonder if a bleeding stroke is what made her fall in the first place? 11 The drug is metabolized in the liver and kidneys, with the … Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. Warfarin overdose guidelines. Vitamin K antagonists. Hold 1-2 doses of warfarin. The most rapid way of reversing the anticoagulant effect of warfarin is by transfusing fresh frozen plasma. 8. Warfarin may also be used for purposes not listed in this medication guide. Treatment strategies for acute toxicity following massive ingestion of warfarin are not well described in the literature. OCTAPLEX is the PCC of choice used in the Republic of Ireland.. Octaplex is a pooled plasma coagulation factor concentrate. Spontaneous IPH: Reversal Guide for Warfarin; Guidelines for Reversal of Anticoagulants; Head Injury in Anticoagulated Patients; UW - CT Surgery Perioperative Hemostasis Plan; Heparin-Induced Thrombocytopenia (HIT) Guidelines for Management of HIT; Pre-Test Probability Scoring for HIT; Guidelines for the Use of Bivalirudin in HIT The stable patient with minor bleeding can also be managed with oral vitamin K, but at a higher dose (e.g., 2.5–5 mg), in combination with correction of the bleeding source. Guideline for the Laboratory Monitoring of Oral Anticoagulation (Warfarin) CLP014 Revised September, 2008 Warfarin is the most commonly prescribed vitamin K antagonist in Canada. For completeness, these recommendations have been included below. Olson KR, ed. Diagnosis and effective treatment can be delayed if patients are on warfarin treatment, as the bleeding symptoms may be erroneously attributed to this agent. Stop warfarin for 1 – 2 days, until INR has fallen to therapeutic levels and bleeding has stopped. Switching to oral warfarin after initial treatment with a DTI is necessary in most patients. released a guideline for anticoagulation reversal in intracranial hemorrhage (1). Switching from ELIQUIS to warfarin: ELIQUIS affects INR, so that initial INR measurements during the transition to warfarin may not be useful for determining the appropriate dose of warfarin. Stop edoxaban when INR ≥ 2.0. Too much can cause a dangerous amount of bleeding; too little can allow new clots to form. *No clinical trial data are available to guide converting patients from XARELTO® to warfarin. Patients should not take a loading dose of warfarin in order to promptly achieve a stable INR. jantoven. Fatal rodenticide poisoning with brodifacoum. Clinical Pharmacology & Therapeutics. GUIDELINES FOR MANAGEMENT OF BLEEDING AND EXCESSIVE ANTICOAGULATION WITH ORAL ANTICOAGULANTS This guideline covers the management of patients being treated with Vitamin K antagonists (VKA): Warfarin Acenocoumarol Phenindione Direct oral anticoagulants (DOACs*): Apixaban (see also Appendix 2), Rivaroxaban (see also Appendix 3) PMID: 14639058 Current dosing recommendations are reviewed, and practical guidelines for the optimal use of warfarin … Warfarin Duration of Therapy by Indication; Indication Duration of therapy; 1. Warfarin and other coumarin anticoagulants act by inhibiting the synthesis of functional vitamin K-dependent coagulation factors II, VII, IX and X.4 Anticoagulants have no direct effect on an established thrombus, nor do they reverse ischaemic tissue damage. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Pharmacogenetics-Guided Warfarin Dosing: 2017 Update. Monitoring 7. Warfarin. Warfarin and related rodenticides. Warfarin is a vitamin K antagonist used as an anticoagulant used for treatment and prevention of a variety of coagulopathic and thromboembolic disorders. The guideline panel developed and graded the recommendations and assessed the certainty in the supporting evidence following the GRADE approach. Her INR is greater than 8.0 (target INR range: 2.0-3.0). Read More. I possess 14 2.5mg tablets. Switching from warfarin to ELIQUIS: Warfarin should be discontinued and ELIQUIS started when the international normalized ratio (INR) is below 2.0. Peak effects are observed by 72 hours. Indications 2. released a guideline for anticoagulation reversal in intracranial hemorrhage (1). Current treatment options for reversal of supratherapeutic INR include withholding Instructions for administration of IV phytonadione: 1. Establish baseline FBC, LFTs, U&Es and clotting screen. I have been taken off Warfarin, prescribed after surgery. Their use is challenging because their therapeutic range is narrow and dosing is affected by many factors including genetic variation, drug interactions, and diet. กรณีศึกษาที่ 1 Warfarin overdose - 2 - A: Atrial fibriilation and Mitral valve replacement with 1. These are beyond the scope of this Guideline. For Adult. Dabigatran is available as a fixed-dose medication for the prevention of systemic embolism and stroke in patients with nonvalvular atrial fibrillation.13 The ACCP guidelines … Background: Heparin-induced thrombocytopenia (HIT) can lead to catastrophic thromboembolic complications and requires treatment with an alternative, rapidly active anticoagulant, such as a direct thrombin inhibitor (DTI), either to prevent or treat these complications. Warfarin Initiation. 8. Warfarin (brand names Coumadin and Jantoven) is a prescription medication used to prevent harmful blood clots from forming or growing larger. Low thrombotic risk group Omit 4 doses of warfarin; check that INR is ≤1.5 prior to surgery. The risk of haemorrhage increases with increasing intensity of anticoagulation and overanticoagulation is common. The antidote for a warfarin overdose is vitamin K, which can be given in tablet or injectable form. These treatments must be done carefully. If too much vitamin K is given, this can reverse the effect of warfarin so much that it is no longer effective for preventing blood clots. Training in, and managing, the SRU is one of the crown jewels of our residency. This dose may be adjusted based on the time it takes for your dog’s blood to clot (also known as prothrombin time, or “PT”). Typical Dosage. an increased risk of bleeding (relative risk 95% CI, Warfarin overdose is almost always managed initially 5.96; 3.68–9.67; P < 0.0001), compared with patients in the ED. for surgery) • Hold warfarin. Anticoagulation - oral: Summary. guideline. If you suspect you have taken more than the recommended dosage of acetaminophen, contact your poison control center (1-800-222-2222) or get medical help right away. Anyone wishing to use this guideline outside QCH should refer to their local Medicines Committee before using. Warfarin reduces the formation of blood clots. But there is a limit to how much acetaminophen you can take in one day. [58] He had also taken 14, 300 mg tablets of allopurinol. Rapid warfarin reversal: a 3-factor prothrombin complex concentrate and recombinant factor VIIa cocktail for intracerebral hemorrhage Clinical article Ravi Sarode M.D. Use an insulin syringe to measure required volume before adding to 100ml glucose 5% and infusing over 15 – 30 minutes. When used as directed, acetaminophen is safe and effective. Warfarin reversal guidelines Developed by the ECI from “An update of consensus guidelines for warfarin reversal” Huyen A Tran, Sanjeev D Chunilal Huy Tran Erica M Wood and Alex S Gallus Medical Journal of Australia2013;198(4):198-199 Updated May … Warfarin: Management of high INR or bleeding Warfarin tablets are prescription blood thinners that prevent blood from clotting, which can lead to a heart attack.The tablets come in strengths from 1-10 milligrams and are sold under different brand names in addition to being sold under the generic name warfarin. The main side effect of warfarin is bleeding. Discharge 9. 19 Warfarin overdose is primarily associated with major bleeding particularly from the mucous membranes, gastrointestinal tract, and genitourinary system. Anticoagulation with warfarin … • In overdose, their elimination half-life is weeks to months. Warfarin is a vitamin-K dependent clotting factor inhibitor, specifically Factors II, VII, IX, and X. The American College of Chest Physicians Evidence-Based Clinical Practice Guidelines state, “For patients with INRs >9.0 and no significant bleeding, we recommend holding warfarin therapy and administering a higher dose of vitamin K (2.5 to 5 mg) orally, with the expectation that the INR will be reduced substantially in 24 to 48 h. Isbister GK, Hackett LP, Whyte IM. Kruse JA, Carlson RW. Vitamin K . Symptoms of overdose can include yellowing of your skin or the whites of your eyes, nausea or vomiting, loss of appetite, fatigue, and unusual bruising or bleeding. FFP contains clotting factors at their normal concentration in the plasma (it … Interactions with other drugs must be considered, and therapy in elderly patients requires careful management. This is particularly true for patients with higher baseline INRs, older age, decompensated congestive heart failure and active malignancy, in whom INR correction is prolonged. Superwarfarin poisoning. Clinical Pharmacogenetics Implementation Consortium. Vortioxetine is in a class of medications called serotonin modulators. Warfarin should usually be started at a dose of 5 mg per day.A 10-mg dose more frequently results in a supratherapeutic international normalized ratio (INR). Indications and target INR This guideline refers to target INRs rather than target ranges though the target range is generally taken to be within 0.5 of the target, i.e. Can You Overdose on Melatonin? 5. In adults and adolescents, hepatotoxicity may occur following ingestion of greater than 7.5 to 10 grams (g) (eg, 24 regular-strength or 15 While guidelines exist for management of a supratherapeutic international normalized ratio following therapeutic warfarin use, these guidelines are not designed for management of the acute warfarin overdose. Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for pharmacogenetics-guided warfarin dosing: 2017 update. Dose depends on INR elevation: A reasonable initial dose may be ~10-15 cc/kg, followed by repeat INR. an increased risk of bleeding (relative risk 95% CI, Warfarin overdose is almost always managed initially 5.96; 3.68–9.67; P < 0.0001), compared with patients in the ED. This guideline covers diagnosing and managing atrial fibrillation in adults. In addition, the Clinical Haematology department has developed guidelines to support clinician’s management of warfarin and low molecular weight heparin (Clexane). Doesn't have much info about the treatment of warfarin overdose/toxicity. Warfarin is used to treat or prevent blood clots in veins or arteries, which can reduce the risk of stroke, heart attack, or other serious conditions. Doses of 1-2 mg/kg/day over a period of 15 days have been fatal in humans. Management of life-threatening bleeds in patients on warfarin in the ED a. KCentra (4-factor PCC) is first line unless otherwise contraindicated b. This protocol gives relatively aggressive reversal of warfarin. Acute acetaminophen overdose is defined as an ingestion of a toxic amount of acetaminophen occurring within a period of 8 hours or less. INR <10 hold warfarin and restart when INR therapeutic INR >10 hold warfarin give 1-2.5 mg PO vitamin K These doses depend on your individual patientʼs risk factors and can be adjusted accordingly At our shop, we have a middle ground. Caravati EM, Erdman AR, Scharman EJ, et al. This guideline covers the following: 1. Guidelines for warfarin management in the community - ii - Disclaimer This guideline has been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Inpatient Guideline for Management of Significant Warfarin Drug-Drug Interactions with Antimicrobial Agents Purpose: The purpose of this guideline is to provide assistance with dose adjustment of warfarin when initiating antimicrobial therapy that may affect the INR Recommendations are intended for patients with expected antimicrobial interaction duration ≥3 days Whilst off warfarin or sub-therapeutic INR Whilst on warfarin within therapeutic range 2.5 3.5 2.0-3.0 3.0-4.0 6 months to long term Long term Non-valvular AF with CHA 2 DS 2-VASc score ≥2 (see AF guideline) CHA2DS2-VASc items 2.5CHA2DS2-VASc Score Congestive heart failure or left ventricular dysfunction 1 Hypertension 1 Age ≥75 2 Anticoagulation Guidelines Version 12 Page 5 of 59 September 2020 10.1.6 10.2 10.3 added. 3 , and Joseph E. Beshay M.D. Ingestion Management of superwarfarin ingestion should be based on amount ingested as related to circumstance of ingestion. Patients presenting > 24 hours. Indefinite therapy is defined as after first 3 months of treatment and with no scheduled stop date.. All patients receiving extended or indefinite therapy should be reassessed at periodic intervals for continuing use of therapy. This guideline assumes the physician has reviewed the indications for warfarin and the duration of therapy as these are not discussed in this guideline. ELIQUIS to warfarin in clinical trials in patients with nonvalvular atrial fibrillation. Mayo Clinic. This guideline, combined with guidelines from AHA, ACCP, ACC and the Institute for Safe Medicine Practices (ISMP) provide the basis for the development of the recommendations for warfarin reversal for acute hemorrhage included in this guideline (1-6). 4. One unit of FFP is 250 ml, so 10-15 cc/kg equates to roughly 3-4 units of FFP. warfarin two days before discontinuing dabigatran. ... Cobaugh DJ. The average daily maintenance dose is usually around 5 mg daily; however, there is wide variation, and the daily dose may be between 1–15 mg for some people. 1 , Cynthia Rutherford M.D. Guidelines, however, By mouth. 1 , Karén Matevosyan M.D. 11 The drug is metabolized in the liver and kidneys, with the … The incidence of warfarin embryopathy is greatest at 6-12 weeks of gestation. Acetaminophen and Other Risk Factors for Excessive Warfarin Anticoagulation. Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Related documents Authorising Policy and Standard/s: • Queensland Health List of Approved Medicines Procedures, Guidelines and Protocols: • Guidelines for Anticoagulation Using Warfarin • Guidelines for Managing Patients on Dabigatran (Pradaxa ®) For patients on 60mg dose – co-administer edoxaban 30mg daily with warfarin. Clinical Guideline Apixaban for stroke prevention in atrial fibrillation – clinical guideline, v1 Principal author: Alice Foster ... e.g. Description. Warfarin and other vitamin K antagonists (VKAs, also called coumarins; eg, acenocoumarol, phenprocoumon, fluindione) are used in a variety of clinical settings. Specialist advice should be sought if the person has a prolonged baseline prothrombin time. Loading doses of warfarin are not warranted and may result in bleeding complications. 2 , Christopher Madden M.D. The need to restart warfarin depends on the clinical picture. Warfarin indications re-written based on latest BCSH guidelines, warfarin management and reversal re-written based on new oral anticoagulant prescription charts and section on rivaroxaban and dabigatran included for the first time. Thrombolysis of STEMI (contingency 2020) Ticagrelor. The patient has warfarin toxicity and a significant intracranial bleed. It is associated with few side effects apart from haemorrhage. Warfarin is the primary oral anticoagulation agent used in the treatment of thromboembolic disease, and patients with acute toxicity are at risk for life-threatening hemorrhages. When used in dogs the dosage typically starts at 0.1 mg/lb. Amanda Barnhart Warfarin tablets come in strengths ranging from 1 to 10 milligrams. acute overdose or during repeated overdose. Warfarin 1 mg or 2 mg daily is generally an acceptable starting dose. Ann Emerg Med 1992;21:331-6. ... Warfarin is the most common oral anticoagulant in current use Ann Intern Med.1994;120:897-902. Administration 6. Route - ingested, inhaled, topical exposure. Dosing Adjustments. treatment plan. Label,19 Epistaxis, ecchymoses, as well as renal and hepatic bleeding are also associated. The half life of the coagulation factors are 6, 24, 40 and 60 hours (VII, IX, X and II, respectively) and hence it takes 12 hours for any effect of warfarin to become recordable. Anderson IB. Recommendations • Warfarin is safe and effective if used carefully, but it’s a balancing act. Guidelines for the management of patients on warfarin experiencing major or non-major bleeding or over-anticoagulation were included in a recent BCSH guideline on oral anticoagulation with warfarin (Keeling et al, 2011). AF is the leading preventable cause of ischaemic stroke, and strokes due to AF have a higher mortality and morbidity. ↑ Hylek, E et al. Consistent with other guidelines, we recommend a dose of 5–10 mg. 25, 34, 35 Our recommendations for managing patients on warfarin therapy with bleeding are summarised in Box 5. Warfarin and other coumarin anticoagulants act by inhibiting the synthesis of functional vitamin K-dependent coagulation factors II, VII, IX and X.4 Anticoagulants have no direct effect on an established thrombus, nor do they reverse ischaemic tissue damage. Contraindications 3. Request PDF | Warfarin Overdose: A 25-Year Experience | Warfarin, a vitamin K antagonist, is widely used for the prophylaxis and treatment of thromboembolic disease. J.K. Aronson, in Side Effects of Drugs Annual, 2011 Drug overdose. May 12, 2021. Common Questions and Answers about Warfarin overdose guidelines. Information in this guideline is current at time of publication. -warfarin does take a day or two to have full effect, and that's why they bridge with heparin if necessary in acute situations. • In overdose, their elimination half-life is weeks to months. WITHHOLDING WARFARIN Withdrawal of warfarin results in a slow return of supratherapeutic INR values to the therapeutic range. Amiodarone, fluconazole, metronidazole, trimethoprim-sulfamethoxazole, and many other drugs inhibit the metabolism of warfarin. Warfarin withdrawal alone is an option in patients with INR values above 4.5, but runs the risk of prolonging the period of WAC and associated bleeding risk. While it was initially marketed as a rodenticide, it has been used as a medication for more than a half-century. Clin Toxicology 2007;45(1):1-22. The effect of warfarin has great inter- and intra-individual variation based on a variety of genetic, dietary, and medication effects. Chua JD, Friedenberg WR. It works mainly by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. aspirin; salicylate; overdose; guideline; evidence based medicine; Although the overall mortality in salicylate poisoning is low, such figures can be very deceptive as severe poisoning may cause metabolic acidosis, convulsions, coma, hyperpyrexia, pulmonary oedema, and renal failure. If ELIQUIS must be discontinued for a reason other than pathological bleeding, consider coverage with another anticoagulant [see Dosage and Administration (2.3)]. Long-acting anticoagulant rodenticide poisoning: an evidence-based consensus guideline for out-of-hospital management. The most appropriate way to reverse the anticoagulant effect of warfarin depends on the clinical circumstances. Postoperatively restart warfarin as below. Similarly, toxicity can result from exposure to superwarfarins, which are long-acting anticoagulants used in rodenticides. Medical Journal of Australia 2004; 181(9):492-487. Pharmacist-managed anticoagulation clinics provide individualized care, consistent monitoring and patient education. The objective of this guideline is to provide healthcare professionals with clear guidance on the indications for and management of patients on warfarin. Clinical guideline Enoxaparin – prescribing, administration and monitoring Enoxaparin is the low molecular weight heparin (LMWH) used at WUTH. Warfarin Guideline Version 2 (ปรับปรุง) > > Warfarin_Guideline_Version2.pdf . Intentional warfarin overdose. For example, you might have trouble stopping the bleeding from a cut on your hand or a nosebleed. Warfarin crosses the placenta and foetal exposure to warfarin is associated with a characteristic embryopathy, CNS abnormalities, foetal bleeding and increased foetal loss. The gastrointestinal tract can also be affected by a warfarin overdose, with one of the most obvious issues being blood in the vomit. Some patients are more apt to notice tarry, black stools, often indicating old blood. On the other hand, some people may see bright red blood in their stools, which is an indicator of fresh blood. If patient requires rapid warfarin reversal but has no bleeding, insignificant bleeding or bruising: Vitamin K 30 mcg/kg by slow IV infusion over 10-20 minutes (to avoid anaphylaxis). Quick Reference Document on Anticoagulation with Warfarin. This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network . 2017; doi:10.1002/cpt.668. The guideline describes: 1) warfarin initiation, 2) international normalized ratio (INR) monitoring with optimal ranges, and 3) warfarin dosage adjustment. 6th ed.The McGraw-Hill Companies; 2012. • Give Vitamin K 2 mg -4 mg orally (INR should be reduced within 24 hours). 2017 Sep;102(3):397-404. doi: 10.1002/cpt.668. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a heart attack, stroke, deep vein thrombosis or pulmonary embolism. From warfarin apixaban Discontinue warfarin and start apixaban when the INR is < 2 From anticoagulant o ther than ... o Well documented overdose: Oral charcoal (give if ingestion occurred within 2 to 6 hours ... Apixaban Guideline for Use
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