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Venous Thromboembolism Anticoagulation Update

Venous Thromboembolism Anticoagulation Update. Wendy Cantrell, Pharm. D., BCPS, BCNSP, CACP. Joint Commission National Patient Safety Goals. The organization implements a defined anticoagulant (AC) management program to individualize care AC inpatient service

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Venous Thromboembolism Anticoagulation Update

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  1. Venous ThromboembolismAnticoagulation Update Wendy Cantrell, Pharm. D., BCPS, BCNSP, CACP

  2. Joint Commission National Patient Safety Goals • The organization implements a defined anticoagulant (AC) management program to individualize care • AC inpatient service • Use only oral unit dose products and pre-mixed infusions • Warfarin is dispensed in accordance with established monitoring procedures • Must use the Warfarin Initiation Form • A written policy addresses baseline and ongoing laboratory tests that are required for heparin and low molecular weight heparin therapies

  3. Joint Commission National Patient Safety Goals • The organization uses approved protocols for the initiation and maintenance of AC therapy • Must fill in the Heparin Order Sheet (make sure you determine the initial bolus and infusion rate) • For patients started on warfarin, a baseline INR is available, and current INR is availabe to monitor and adjust therapy • Must use warfarin order form for Initial Dose this will ensure a baseline and follow-up INR’s • The organization provides education regarding AC therapy to prescribers, staff, patients, and families • Thanks for being here, this is part of meeting the national patient safety goals….

  4. Joint Commission Venous Thromboembolism (VTE) Core Measures • Assessment for VTE prophylaxis • The day of or the day after hospital admission (or surgery) • The day of or the day after ICU admission • Must use VTE prophylaxis assessment form • VTE with AC overlap therapy • At least 5 days overlap of parenteral AC and warfarin with an INR≥ 2 for at least 24 hrs • VTE pts receiving heparin with dosages/platelet count monitoring by protocol or nomogram • Once again must use heparin protocol • VTE Discharge instructions • The AC pharmacists are taking care of this • Incidence of Potentially preventable VTE

  5. The DVT prophylaxis assessment form was completed and prophylaxis was indicated for a patient admitted for decompensated HF Which of the following would be appropriate prophylaxis if this patient has a CrCl of 70 ml/min and weighs 150 kg? A) Heparin 5000 units tid B) Enoxaparin 40 mg daily C) Enoxaparin 30 mg bid D) Enoxaparin 40 mg bid E) IPC

  6. CHEST Guidelines 2008: Mechanical prophylaxis • We recommend that mechanical methods of thromboprophylaxis be used primarily in patients at high risk of bleeding, or possibly as adjunct to anticoagulant-based thromboprophylaxis (2A) • We recommend that careful attention be directed toward ensuring the proper use of, and optimal adherence with, these methods (1A)

  7. CHEST Guidelines 2008:Dosing and Minotoring in Special Situations • In obese pts given LMWH prophylaxis or treatmetn, we suggest weight-based dosing (2C). • The existing data, however, suggest that weight based prophylactic dosing is preferable to fixed dosing for obese pts.

  8. CHEST Guidelines 2008: Bariatric Surgery • For pts undergoing inpatients bariatric surgery, we recommend routine thromboprophylaxis with LMWH, LDUH tid, fondaparinux, or the combinatin of one of these methods with optimally used IPC (1C) • For pts undergoing inpatient bariatric surgery, we suggest that higher doses of LMWH or LDUH than ususal for nonobese pts be used (2C)

  9. What would the appropriate prophylaxis be if the patient was receiving dialysis and weighed 80 kg? A) Fondaparinux 2.5 mg daily B) Heparin 5000 units tid C) Enoxaparin 30 mg bid D) Enoxaparin 40 mg daily E) Enoxaparin 30 mg daily

  10. CHEST Guidelines: Renal Impairment • Depending on the circumstances, we recommend one of the following options: avoiding the use of an anticoagulant that bioaccumulates in the presence of renal impairment, using a lower dose of the agent, or monitoring the drug level or its anticoagulant effect (1B) • Enoxaparin has not been studied in dialysis • Fondaparinux is contraindicated when the CrCl < 30 ml/min

  11. A 45 year old woman developed a DVT 3 weeks after breaking her leg (DVT developed in broken leg). How long should she receive warfarin? A) 6 weeks B) 3 months C) 6 months D) Indefinitely

  12. CHEST Guidelines: Duration of Anticoagulant Therapy • For patients with DVT secondary to a transient (reversible) risk factor, we recommend treatment with warfarin for 3 months over treatment for shorter periods (1A)

  13. How should this patient receive warfarin if it was a first episode unprovoked proximal DVT (idiopathic)? A) 3 months, goal INR 2-3 B) 6 months, goal INR 2-3 C) Indefinitely, goal INR 2-3 D) 3 months at a goal INR of 2-3 followed by a goal INR of 1.5-1.9 indefinitely

  14. CHEST Guidelines: Duration of Anticoagulant Therapy • For patients with unprovoked DVT, we recommend treatment with warfarin for at least 3 months (1A). • After 3 months of anticoagulant therapy, all patients with unprovoked DVT should be evaluated for the resk-benefit ration of long term therapy (1C). • For patients with a first unprovoked proximal DVT, and in whom risk factors for bleeding are absent and for whom good anticoagulant monitoring is achievable, we recommend long-term treatment (1A)

  15. CHEST Guidelines: Intensity of Anticoagulant Effect • In patients with DVT, we recommend that the dose of warfarin be adjusted to maintain a target INR of 2.5 (range 2-3) for all treatment durations (1A) • For patients with unprovoked DVT who have a strong preference for less frequent INR testing to monitor their therapy, after the first 3 months of conventional-intensity anticoagulation, we recommend low intensity therapy (range 1.5 to 1.9) with less frequent INR monitoring over stopping treatment (1A)

  16. How long should this patient receive parenteral anticoagulation (enoxaparin in this patient) overlap with the warfarin given the following response to warfarin? Day 1: INR 1 A) 4 days Day 2: INR 1.2 B) 5 days Day 3: INR 1.7 C) 6 days Day 4: INR 1.8 Day 5: INR 2.2 Day 6: INR 2.5

  17. CHEST Guidelines: Initial Anticoagulation of Acute DVT of the Leg • In patients with acute DVT, we recommend initial treatment with LMWH, UFH, or fondaparinux for a least 5 days and until the INR is ≥ 2.0 for 24 hrs (1C)

  18. On day 6, it is noted that the patient’s platelets have dropped significantly (250 120 K/mm3). HIT is considered. What assessment tool would be useful to determine the likelyhood of HIT in this patient? A) CHADS 2 Score B) 4 T Score C) Framingham risk score D) TIMI Risk Score

  19. 4T Score

  20. HIT was determined to be likely in this patient. How should this patient be treated at this time? A) Discontinue enoxaparin and continue warfarin B) Discontinue enoxaparin and warfarin, and initiate argatroban C) Discontinue enoxaparin and warfarin, administer vitamin K and argatroban

  21. CHEST Guidelines: Nonheparin Anticoagulants for Treating HIT • For patients with strongly suspected (or confirmed) HIT, whether or not complicated by thrombosis, we recommend use of an alternative nonheparin anticoagulant (danaparoid, lepirudin, argatroban, fondaparinus,, bivalirudin over the further use of UFH, or LMWH or initiation/continuation of warfarin (1B)

  22. CHEST Guidelines: Reversal of Warfarin • For patients receiving warfarin at the time of diagnosis of HIT, we recommend use of Vitamin K (10 mg po or 10 mg IV) (1C)

  23. The enoxaparin was D/C’d, Vit K 10 mg po was administered, and argatroban was started. At what point can warfarin be restarted? A) As soon as a therapeutic PTT is achieved on argatroban B) After 5 days of argatroban therapy C) After platelet recovery has occurred (usually to at least 150)

  24. CHEST Guidelines: Management of DTI-Warfarin Overlap • For patients with strongly suspected or confirmed HIT, we recommend against the use of warfarin therapy until after the platelet count has substantially recovered (ie, usually to at least 150) over starting warfarin therapy at a lower platelet count (1B)

  25. Argatroban interferes with the INR, so how is a therapeutic level to be determined in this patient after the warfarin is restarted? A) Continue argatroban until the INR is > 2 then discontinue B) Continue the argatroban until the INR is > 4 then discontinue C) Continue the argatroban until the INR is > 4, hold the argatroban for 6 hours and recheck INR. If > 2 then discontinue the argatroban.

  26. An INR > 2 generally correlates to an INR of > 4 if the PTT is in the therapeutic range while receiving argatroban • Argatroban should be cleared after 4-6 hours (it will take longer in patients with heart failure, multiple organ system failure, severe anasarca, post-cardiac surgery, and hepatic insufficiency)

  27. Several months later, the patient complains of returned redness and swelling of the leg in which she developed the DVT. The swelling dissipates up upon elevation of the leg. She is diagnosed with Post thrombotic syndrome (PTS). What percent of patients with DVT develop PTS? A) 5-10% B) 10-20% C) 20-50% D) 50-70%

  28. Was there anything else that could have been done to prevent the occurrence of PTS in this patient?

  29. CHEST Guidelines: Postthrombotic Syndrome • For a patient who has had a symptomatic proximal DVT, we recommend the use of an elastic compression stocking with an ankle pressure gradient of 30 to 40 mm Hg if feasible (1A). • Compression therapy, which may include the use of bandages acutely, should be started as soon as feasible after starting anticoagulation therapy and should be continued for a minimum of 2 years, and longer if patients have symptoms of PTS.

  30. Clinical Risk Factors for VTE • Age ≥40 years • Cardiac dysfunction • Prolonged immobility • Varicose veins • Stroke or paralysis • Central venous catheters • Previous VTE • Inflammatory bowel • Obesity disease • Malignancy • Nephrotic syndrome • Major surgery • Pregnancy • Trauma • Estrogen use • Cancer therapy • Hypercoagulable conditions • Respiratory failure Geerts WH, et al. Chest 2004; 126 (suppl 3): 338-400

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