Lecture 6 - VTE 2 Flashcards
High Risk for VTE score
> 4 points
Low risk for VTE score
0 - 3 points
Hospitalized, acutely ill pt, risk > 4, increased risk of thrombus then….
LMWH, LDUH, or Fondaparinux
if critically ill then use LMWH or LDUH
Hospitalized, acutely ill pt, risk > 4, with bleeding or at high risk for major bleeding then….
GCS or IPC (nonpharm)
switch to pharm treatment if bleeding risk decreases
Hospitalized, acutely ill pt, risk <3, low risk of thrombus then….
no med, can do nonpharm if want but don’t really need
Caveat to Hospizatilized, acutely ill pt….
no extension of anticoagulants after discharge
Go to for patients with solid tumors?
LMWH
treatment for chronically immobilized patients?
don’t have to do prophylaxis due to body adjusting
treatment for ppl traveling long distances and increased risk of VTE
moving, calf muscle exercises, use compression stockings (15-30mmHg @ Ankle)
Total Hip or total Knee Arthroplasty Treatment
10-14 days of LMWH (preferred), Fonda, apixaban, dabigatran, rivaroxaban, LDUH, warfarin, ASA or IPC
Hip Fracture Surgery Treatment
10-14 days of LMWH (preferred), Fonda, LDUH, warfarin, ASA or IPC
Major orthopedic surgery treatment
- extend therapy in outpatient period up to 35 days
- can add IPC
- use apixaban or dabigatran if don’t like injection, or rivaroxaban or warfarin
Lovenox (Enoxaparin) LMWH dosing most patients…
40 mg SQ daily
Lovenox (Enoxaparin) LMWH dosing for THA/HFS
40 mg SQ daily or 30 mg SQ q12h
Lovenox (Enoxaparin) LMWH dosing for TKA
30 mg SQ q12h
Lovenox (Enoxaparin) LMWH dosing CrCl < 30ml/min
30 mg SQ daily
Lovenox (Enoxaparin) LMWH dosing obesity/ BMI >40
increase dose by 30%
injection of Lovenox instructions
- Wash & Dry hands
- Sit or Lie comfortably so that you can see abdomen
- Choose area left or right side, 2in from Belly button (love handles)
- clean injection site
- pinch 1 inch of skin, inject, dispense syringe
** don’t expel air and rotate sites **
UFH dose in typical hospital?
5000 units SQ 8-12hr, won’t need renal adjustment
fondaparinux (Arixtra) dosing
2.5mg SQ daily for most ppl
Contraindicated <50 kg pts, CrCl 30-50ml/min
Dabigatran for prophylaxis dosing
110 mg PO 1-4hr after surgery and hemostasis, or 220 mg if not on day of surgery and after hemostasis
Counseling for Dabigatran
dyspepsia
don’t chew/crush
keep in same packaging
Dabigatran indications
THA
off-label for TKA
Rivaroxaban (Xarelto) for prophylaxis indications
THA, TKA, acutely ill patients
Rivaroxaban (Xarelto) for prophylaxis dosing (TKA + THA)
10 mg qd for 10-14 days (TKA) up to 35 days (THA)
Rivaroxaban counseling
Doses < 15mg can be taken without regard to meals, >15mg = need food
can crush/mix in applesauce or water
Rivoroxaban DI
avoid using with strong dual p-gp & CYP3A4 inhbitors/inducers
Eliquis for prophylaxis indications
THA or TKA
Eliquis for prophylaxis dosing
2.5mg BID starting 12-24 days post-op, for 10-14 days (TKA) up to 35 days (THA)
favored due to being safe
UFH for VTE Treatment dosing
80 unit/kg IV bolus (10K unit max)
18unit/kg/hr continuous, adjusted as needed using aPTT
UFH for VTE is preferred in….
pts who are hemodynamically unstable, need thrombectomy, renal failure, obesity?
Enoxaparin (Lovenox) VTE treatment dosing
1mg/kg SQ q12hr (preferred)
1.5 mg/kg SQ daily
If CrCL < 30, use 1mg/kg SQ daily
** Round to nearest 10mg **
Fondaparinux for VTE treatment dosing
< 50kg = 5 mg SQ daily
50-100 kg = 7.5 mg SQ daily
> 100 kg = 10 mg SQ daily
Fondaparinux for VTE renal impairment adjustment
CrCl 30-50 = use caution
CrCl < 30 = contraindicated
How to decide which oral option to use?
- Efficacy
- Safety
- Feasibility
- Cost
Warfarin Bridging
- Start therapeutic dose UFH, LMWH, or fondaparinux w/ Warfarin
- Bridge for atleast 5 day, INR > 2 for >24hrs
- Discontinue short-acting anticoagulants and dose adjust warfarin as needed
Dabigatran & Edoxaban switching
- Start with therapeutic dose UFH, LMWH or fondaparinux for 5 days
- Switch to dabigatran or edoxaban after that
Oral options without Bridge/Overlap
Rivaroxaban and Apixaban
Rivaroxaban Dosing VTE treatment
15 mg po BID X 21 days with meals, then 20 mg po daily with meals
avoid using in CrCl < 30ml/min
Apixaban Dosing VTE treatment
10 mg PO BID 7 days, then 5 mg PO BID
no adjustment necessary in renal impairment
reduce dose 50% if given with dual CYP3A4/p-gp inhibitor
Dabigatran Dosing VTE treatment
5 days of parenteral AC, then 150mg PO BID
Edoxaban Dosing VTE treatment
5 days of parenteral AC, then weight based….
>60kg = 60mg daily <60kg = 30mg daily
*** Don’t use if CrCl > 95ml/min = cleared to quickly **
also don’t use < 30 ml/min
Warfarin for VTE Treatment
cannot be started as monotherapy, must have appropriate bridging with parenteral AC
effective long term management of acute VTE
Typical starting dose Warfarin for VTE treatment?
5mg po
** 2.5 mg in 65+, frail, malnourished, live/kidney disease, HF, DI
Why do we still use warfarin?
- Renal impairemnt
- Obesity
- those high risk for bleeding bc they will be monitored frequently
Frequency of Warfarin monitoring
Inpatient - daily
out of INR range = 2-3 times per week
once stable for 1-2 weeks, every 2-4 weeks up to every 12 weeks
Provoked VTE duration of coag
3 months regardless of Risk of bleeding
Extend > 3 month if cancer associated or second VTE
Unprovoked VTE duration of coag
at least 3 months
Proximal DVT or PE, with low-mod risk of bleeding..extend > 3 months
with high risk of bleeding = 3 month
For patients at elevated risk of recurrent VTE, how long should they have anticoagulants therapy?
6 months atleast
Padua Score
>4 = high risk 0-3 = low risk
1 pt Padua Score
Age > 70 Heart or Respiratory Failure Acute MI or ischemic stroke Acute infection BMI > 30 Hormonal treatment
2 pt Padua Score
Recent trauma/surgery < 1 month
3 pt Padua Score
Active cancer
previous VTE
Reduce mobility
Already known thromboembolic condition
