Problem 14: Prophylaxis of Thromboembolism Flashcards
Does Anna need anticoagulation post-surgery
NICE guidelines in assessing the risks of VTE
Regard medical patients as being at increased risk of VTE if they
have had or are expected to have significantly reduced mobility for 3 days or more or
are expected to have ongoing reduced mobility relative to their normal state and have one or more of the risk factors shown in box 1. [2010]
1.1.3 Regard surgical patients and patients with trauma as being at increased risk of VTE if they meet one of the following criteria:
surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb
acute surgical admission with inflammatory or intra‑abdominal condition
expected significant reduction in mobility
Box 1 Risk factors for VTE
Active cancer or cancer treatment
Age over 60 years
Critical care admission
Dehydration
Known thrombophilias
Obesity (body mass index [BMI] over 30 kg/m2)
One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)
Personal history or first‑degree relative with a history of VTE
Use of hormone replacement therapy
Use of oestrogen‑containing contraceptive therapy
Varicose veins with phlebitis
Assess all patients for risk factors of bleeding before starting pharmacological VTE prophylaxis.
Are there any alternative agents instead of warfarin that Anna could use?
Apixaban: recommended as an option for preventing stroke and systemic embolism within its marketing aurthorisation that is in people with 1 or more risk factors such as 75+, hypertension, diabetes or symptomatic HF
Dabigatran etexilate is recommended for people with nonvalvular atrial fibrillation with one or more of the following risk factors; previous stroke or TIA,left ventricular ejection fraction of less than 40%, 75+ or 65+ with diabetes or coronary heart disease.
Rivaroxaban in those with congestive heart failure, hypertension 75+ diabetes risk factors
Describe the advantages and disadvantages of these alternative agents
3
Explain if Anna fits the criteria for using a DOAC
4
Describe how you would suggest switching from warfarin to the DOAC. Should warfarin be stopped or overlapped?
Prevention of stroke and
systemic embolism; stop
warfarin and initiate
rivaroxaban (normally 1st choice DOAC) once INR ≤3.0
Discontinue warfarin
and commence
apixaban as soon as
INR is <2.0.
Discontinue warfarin and
commence dabigatran as
soon as INR is <2.0
