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DVT Prophylaxis of the Medical Patient

DVT Prophylaxis of the Medical Patient. Nicole Artz, MD David Lovinger, MD August, 2006. Case. Mr. Smith- 71 y/o man admitted to general medicine ward service. HPI: gradually increased sob over 3 days assoc. with new productive cough, rhinorrhea, and fatigue.

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DVT Prophylaxis of the Medical Patient

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  1. DVT Prophylaxis of the Medical Patient Nicole Artz, MD David Lovinger, MD August, 2006

  2. Case • Mr. Smith- 71 y/o man admitted to general medicine ward service. • HPI: gradually increased sob over 3 days assoc. with new productive cough, rhinorrhea, and fatigue. • PMH: COPD, CHF (LVEF 35%), CRI (creat 2.5) • ROS: No h/o DVT/PE. • PE: VSS with SPO2 93% on RA • Barrel chested, b/l expiratory wheezes, prolonged expiratory phase, • CXR: hyperexpanded, no infiltrate, consolidation or edema. • DX: COPD Exacerbation

  3. Does this man need DVT prophylaxis? • Why worry about VTE in inpatients? • What is the prevalence of DVT/PE in hospitalized medical patients? • Is this man at risk for venous thromboembolism? • What are effective methods of prophylaxis? • What adjustments need to be made based on his history of renal insufficiency?

  4. Importance • What % of all hospital related deaths due to fatal PE? • 7-10% • What % of these pts had NO premorbid symptoms? • 70-90% • 200,000 potentially preventable annual deaths due to PE in the US Sandler DA JR Soc Med 1989; 82, Lindblad B Br Med J 1991; 302.

  5. Prevalence in Medical Pts • 3 large-scale randomized studies (5500 medically ill patients) • DVT identified w/ screening studies • Patients receiving no prophylaxis: • VTE 11-15% of patients • Proximal DVT- 4-5% of patients • Rates similar to moderate-high risk general surgery patients. • Samana, MM NEJM, 1999; Leizorovicz, A Circulation 2004; Cohen, AT J Thromb Haemost, 2003.

  6. Prevalence ACCP Guidelines, Chest. 2005.

  7. Prevalence Pendleton, R. Amer J. Hematology 2005.

  8. Prevalence • 3 out of 4 hospital pts dying from PE have NOT had recent surgery… • 2.5% of medical patients immobilized with multiple clinical problems suffer fatal PE. • National DVT Free Registry • 60% of patients dx with acute DVT were in the peri-hospitalization period • 60% of cases were in non-surgical patients! • Haas, S. Seminars in Thrombosis and Haemostasis, 2002; Goldhaber, SZ Am J Cardiol 2004.

  9. Risk Factors • Heterogeneous population! • Need to consider: • Acute medical condition (MI, pneumonia, etc.) • Underlying risk factors (h/o VTE, estrogen use, etc.) • Medical interventions (central venous catheters, chemotherapy, etc.) • Relative contribution of various risk factors still being defined.

  10. Risk Factors • Acute medical conditions well accepted as high risk: • MI (24% VTE risk) • Decompensated CHF (40% VTE risk) • Acute Stroke (30-75% VTE risk) • Spinal Cord Injury (up to 100%) • MICU admission (13-33*% VTE risk, *½ of these were proximal leg vein thromboses) • Central venous catheters (25-46% VTE risk) • Malignancy • Haas, S. Seminars in Thrombosis and Hemostasis, 2002; Pendleton, Amer J Hematology, 2005.

  11. Abstracted from Pendleton, R. Amer J Hemat 2005.

  12. Current Rates of Prophylaxis • IMPROVE study • Ongoing multinational observational cohort study in acutely ill medical patients • Only 34% of potentially at risk patients are receiving any prophylaxis! • Only ½ of patients who would have met criteria used for MEDENOX study received any VTE prophylaxis. Anderson FA, IMPROVE; Blood 2003.

  13. Current Rates of Prophylaxis • University of Utah • Pre and post intervention study • Pts stratified into high and low risk groups based on risk factors • Pre-intervention group • 75% of patients admitted to medical service were high risk • Only 43% received prophylaxis of any type. Stinnett, J American Journal of Hematology 2005.

  14. How Are We Doing at UCH? • Retrospective chart review by Linda Nahlik, Pharm-D, 2005. • 98 pts admitted to gen med service NOT on therapeutic anticoagulation. • 20% of pts had a contraindication to prophylaxis (active bleeding) • Only 4% had no risk factors for prophylaxis • 29% of pts had 1 major or 2 minor risk fxs, no contraindications, and yet had NO prophylaxis.

  15. What Should We Use for Prophylaxis? • Mechanical compression devices? (compression stockings, IPC devices) • Unfractionated heparin BID? • Unfractionated heparin TID? • Low Molecular Weight Heparin? (Enoxaparin, Daltaparin) • Fondaparinux?

  16. What Do We Know About Prophylaxis? • What are the most common regimens in the US? • UFH BID, mechanical compression devices • Which regimens have the least data to support them? • UFH BID, mechanical compression devices • What are characteristics of the ideal prophylaxis regimen? • Effective • Safe • Cost-effective

  17. Key VTE Prevention Trials **MEDENOX study included 20 mg enoxaparin arm which was no more effective than placebo. Pendleton, R. Amer J. Hemat. 2005

  18. *Remember that MEDENOX found enoxaparin 20 mg no more effective than placebo, therefore calling into doubt efficacy of bid heparin dosing.

  19. Complications of Prophylaxis • Bleeding • Major bleeding rates no different from placebo in major trials w/ enoxaparin, dalteparin, and fondaparinux (rates 0.2-1.7%) • HIT • Develops in 1.4% of medically ill pts exposed to preventive doses of UFH. • Potentially catastrophic- thrombosis rates as high as 60%. • LMWH’s 8-10X’s less likely to cause HIT. • Fondaparinux does not cause HIT. Girolami, B. Blood 2003; Warkentin TE, Br J Haematol 2003. Pendleton, R. Am J Hematol 2005.

  20. Special Populations • Obesity • Renal Insufficiency • Elderly

  21. Obesity • Anti Xa levels with fixed dose LMWH regimens correlate negatively with BMI in critically ill patients. (Priglinger U, 2003) • Standard prophylactic regimens twice as likely to fail in orthopedic pts with BMI >32. • BMI >32 VTE rate 32% vs 17% for BMI <32. (Samama, MM, 1995) • Non-randomized study in bariatric surg pts- suggested decreased DVT rates w/ enoxaparin 40 mg bid vs 30 mg bid. (Scholten, DJ, 2002) • No data to guide adjustments in therapy. • Options include: • Use standard dose • Add mechanical measures • Empiric dose adjustments

  22. Renal Insufficiency • Delayed renal clearance of LMWH’s and Fondaparinux problematic. • Lack of outcomes based data. • FDA approved enoxaparin 30 mg qd for pts with creat clearance <30 ml/min based on pharmacokinetic data alone. • Additional options include UFH, mechanical devices.

  23. Patients with HIT • Avoid UFH or LMWH’s. • ? Fondaparinux? Trials ongoing. • Mechanical compression devices +/- duplex US surveillance.

  24. Elderly Patients • Mahe et al. monitored anti-Xa levels in 68 consecutive hospitalized elderly patients (mean age 82) receiving enoxaparin for prophylaxis. • By day 2 over half had levels in the therapeutic range. • Lack of safety data with use of UFH as well. • Lack of outcomes data. • Consider empiric dose reduction or use of mechanical devices alone for elderly patients with low body weight and/or marginal creatinine clearance (30-60 ml/min). Mahe, I, Pathophysiol Haemost Thromb 2002., Pendleton R, Am J Hemat 2005.

  25. Take Home Points • The majority of hospitalized medical patients are at increased risk for VTE. • In the absence of contraindicatons, prophylaxis should be provided for patients based on assessment of risks. • Safe and Effective preventive regimens include: • Enoxaparin 40 mg SC daily • Daltaparin 5000 IU SC daily • Fondaparinux 2.5 mg sc daily • UFH 5000 units SC every 8hrs *Must use clinical judgement for unique patient groups with lack of data.

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