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Update in Hospital Medicine . October 26, 2012 Amy O’Linn, D.O. Clinical Associate, Department of Hospital Medicine olinna2@ccf.org. Fairview Hospital. 450 beds. Disclosures. None. Methods.
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Update in Hospital Medicine October 26, 2012 Amy O’Linn, D.O. Clinical Associate, Department of Hospital Medicine olinna2@ccf.org
Fairview Hospital 450 beds
Disclosures • None
Methods • Reviewed literature (primary studies and guidelines) relevant to hospital medicine from the past 12 months • Summarized most relevant studies
Talk Outline • Rivaroxaban: What it is and why you need to care about it this year • The patient’s perspective on anticoagulants • The ACCP (Chest) Guidelines and VTE • Hyperglycemia in the hospitalized, non-ICU patient • Current thinking on DVT prophylaxis • Hodge Podge
Case Presentation • ED calls: 72 year old man who was recently diagnosed with bladder cancer presents with acute shortness of breath, CT PE protocol diagnoses a right sided pulmonary embolus.
Which treatment would you choose? • LMWH SQ to VKA (warfarin) PO • Long-term LMWH (enoxaparin) • Dabigatran (Pradaxa) PO alone • Rivaroxaban (Xarelto) PO alone • Apixaban (Eliquis) PO alone • Fondaparinux (Arixtra) SQ daily • Idrabiotaparinux SQ weekly
Which treatment would you choose? LMWH SQ to VKA (warfarin) PO Long-term LMWH (enoxaparin) Dabigatran (Pradaxa) PO alone Rivaroxaban (Xarelto) PO alone Apixaban (Eliquis) PO alone Fondaparinux (Arixtra) SQ daily Idrabiotaparinux SQ weekly
Rivaroxaban alone to treat PE • Presented at ACC in March • Randomized, open-label, event-driven, noninferiority trial • 4832 patients w/ acute symptomatic PE • Rivaroxaban (15 mg BID x 3 weeks, followed by 20 mg qday) v. standard therapy with enoxaparin --> VKA for 3, 6, or 12 months Buller HR et al. NEJM 2012: 366(14), 1292.
EINSTEIN-PE Outcomes Buller HR et al. NEJM 2012: 366(14), 1292.
“What about me?”The patient’s voice • ACCP February 2012: Antithrombotic Therapy and Prevention of Thrombosis, 9th edition Evidence-Based Clinical Practice Guidelines. MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
One selection Summary of Results • Arnsten et al. 1997 • 132 (43 noncompliant and 89 compliant) warfarin patients • Case-control study • Telephone interviews • VTE/AF prophylaxis MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
One selection Summary of Results (cont’d) • “53% of noncompliant and 31% of compliant individuals reported that warfarin affected their lifestyle. 30% and 15% respectively, reported that warfarin restricted physical activity; 49% and 30% worried about bleeding complications while taking warfarin, and 60% and 34% reported that regular blood testing was problematic.” MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
Summary • Values and preferences vary from person to person. • Uncertain “average patient” values. • Higher disutility on stroke than GIB. • Much higher disutility on stroke than treatment burden. MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
CHEST Antithrombotic Guidelines (Continued) • Acute isolated distal DVT? Serial ultrasound (Grade 2C). • Anticoagulate empirically if high suspicion for PE (if low suspicion, can wait for test) (Grade 2C). • Early ambulation in acute DVT (Grade 2C). Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.
CHEST Antithrombotic Guidelines (Continued) • Proximal DVT or PE provoked by surgery or nonsurgical transient RF: recommend A/C x 3 months (Grade 1B). • Unprovoked proximal DVT or PE with low/mod bleeding risk: suggest extended A/C therapy (Grade 1B, 2B). If high bleeding risk, then 3 mos (Grade 2B). Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.
CHEST Antithrombotic Guidelines (Continued) • Early discharge in patients with low-risk PE whose home circumstances are adequate (Grade 2B). • In cancer patients with VTE, LMWH long-term recommended over LMWH to coumadin (Grade 2B). Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.
Which treatment would you choose? • LMWH SQ to VKA (warfarin) PO • Long-term LMWH (enoxaparin) • Dabigatran (Pradaxa) PO alone • Rivaroxaban (Xarelto) PO alone • Apixaban (Eliquis) PO alone • Fondaparinux (Arixtra) SQ daily • Idrabiotaparinux SQ weekly
You grab a cup of coffee… • .. And you run into an orthopedic colleague. • Is Rivaroxaban FDA-approved for post-TKR DVT prevention? • Yes • No
You grab a cup of coffee… • Is Rivaroxaban FDA-approved for post-TKR DVT prevention? YES
Options for VTE prevention post-TKR/THA Rivaroxaban Apixaban (Europe) Aspirin (reserve) Intermittent pneumatic compression • Coumadin • Low-dose unfractionated heparin • Fondiparinux • Pradaxa (Europe)
Case Presentation 89 woman s/p R total knee replacement this morning. Pt has h/o HTN, CKD III. Blood sugar 250. Previously taking metformin at home. You are consulted for medical management. What do you do?
What’s your reaction? • You do nothing. High sugars have nothing to do with mortality. • You add sliding scale. • Stop metformin, add long-acting insulin and prandial insulin. • Continue the metformin.
Example of Basal-bolus insulin in the mgmt of non-critically ill DMII pts Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38..
Example of Basal-bolus insulin in the mgmt of non-critically ill DMII pts Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38.
What’s your reaction? You do nothing. High sugars have nothing to do with mortality. You add sliding scale. Stop metformin, add long-acting insulin and prandial insulin. Continue the metformin.
Case Presentation Nurse pages you: Mrs. Smith is a medical patient with pyelonephritis refusing her SQ heparin for DVT prophylaxis.
The value of VTE prophylaxis Qaseem A, et al. Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med; 2011; 155:625-632.
The OUTs and INs OUT IN FEV1/FVC <0.70 Never smoker COPD Good early sepsis care (fluids, Abx) • FEV1(Vestbo J et al. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2012 Aug 9) • “emphysema” • “chronic bronchitis” • Xigris
The OUTs and INs OUT IN In stable pt, blood transfusion Hg <8 Normal Saline to prevent contrast nephropathy • Liberal blood transfusions (Carson JL, et al. Red Blood Cell Transfusion Guideliness from AABB, Ann Intern Med 26 March 2012.) • Confusing ways to write sodium bicarb (Klima T, et al. Sodium chloride vs. sodium bicarbonate for the prevention of contrast medium-induced nephropathy: a RCT. Europ Heart J (2012); 33, 2071.)
Readmissions • Reacting to 20% readmission rate, Medicare is reducing reimbursements for those hospitals that have high readmission rates.
Teach Me Back • Rivaroxaban • ACCP guidelines value patient preferences and suggest weighing risk of bleeding with VTE in every case. • Sugars are important • Universal VTE prophylaxis is not recommended. • Conservative blood mgmt. • NS for kidneys