VTE

Question 1

What are the components of the modified Well’s Score for pulmonary embolism?

Answer 1

History:
Active Cancer (1)
Hemoptysis (1)
Prior VTE (1.5)
Recently Bedridden Surgery (1.5)

Physical Exam:
Symptoms of DVT (3)
Tachycardia (1.5)

No alternative diagnosis (3)

A score of > 4 indicates high probability of PE.

Question 2

What are the components of the Well’s score for DVT?

Answer 2

History:
Active Cancer (< 6 months)
Recent Lower Limb Immobilization
Recently Bedridden > 3d or surgery (w/in 4 weeks)

Physical Exam:
Tenderness along deep veins
Evident collateral veins
Calf swelling > 3 cm (10cm below tibial tuber.)
Pitting Edema
Non varicose superficial veins

Minus 2 for alternative diagnosis

High probability > or = 3 points
Moderate probability 1-2 points
Low probability = 0

Question 3

How long do you treat a provoked VTE?

Answer 3

At least 3 months (up to 6 months)

Question 4

Which DOACs require pre-treatment with LMWH for 5-10 days?

Answer 4

Dabigatran

Edoxaban

Question 5

Which cancer patients should receive DVTp?

Answer 5

Per ASCO 2020 clinical practice guidelines, consider DVTp with a DOAC in patients who are at high risk (Khorana score > or = 2)

Question 6

What are the DOACs (and doses) that may be considered for DVTp in high risk cancer patients?

Answer 6

Apixaban 2.5 mg PO BID

Rivaroxaban 10 mg PO OD

Question 7

What are the components of the Khorana score?

Answer 7

(1) Cancer Site

(2) Blood Work
(3) BMI

Question 8

In which types of malignancies should you avoid using DOACs for management of VTE (3)?

Answer 8

GU
GI
Intracranial Malignancy

Question 9

What is the weight/BMI at which you should consider using LMWH over a DOAC for treatment of VTE?

Answer 9

Weight > 120 kg OR

BMI > 40

Question 10

In which comorbidities would you avoid the use of DOACs for treatment of VTE?

Answer 10

(1) APLA
(2) Liver Failure (Child Pugh B or C)
(3) Renal Failure CrCl < 30

Question 11

What are the therapeutic doses of dalteparin, enoxaparin and tinzaparin?

Answer 11

Dalteparin - 200U/kg daily
Enoxaparin 1 mg/kg SC BID
Tinzaparin 175U/kh SC daily

Question 12

In a patient with unprovoked VTE on full dose DOAC, when can you consider step down therapy?

Answer 12

You can consider step down to low dose DOAC after 6-12 months with:

Apixaban 2.5 mg PO BID
Rivaroxaban 10 mg PO Daily

Question 13

When would you consider thrombolysis in the setting of a pulmonary embolism?

Answer 13

If hemodynamic instability is present (defined as SBP < 90 mmHg for > 15 minutes) with no high risk of bleeding.

Question 14

What is the “men continue and HERDOO2” rule?

Answer 14

(1) Men continue indefinite anticoagulation for unprovoked VTE.
(2) Women with > or = 2 HERDOO score continue anticoagulation indefinitely.

H - Hyperpigmentation OR
E - Edema OR
R - Redness in either leg
D - Dimer > or = 250 ug/L
O - Obesity (BMI > or = 30)
O - Older age (> or = 65)

Question 15

How do you manage a superficial venous thrombosis?

Answer 15

(1) ≤ 3 cm from saphenofemoral junction —> full dose anticoagulation x 3 months
(2) > 3 cm from SFJ AND ≥5 cm long —> prophylactic anticoagulation x 45d (rivaroxaban 10 mg daily or Fonda 2.5 mg SC daily)
(3) > 3 cm from SFJ + < 5 cm long —> NSAIDS and monitor with serial U/S (except in pregnancy, cancer, surgery, trauma or previous hx of DVT/SVT)

Question 16

What is the reversal agent for dabigatran?

Answer 16

Idarucizumab

Question 17

How would you reverse apixaban/rivaroxaban/edoxaban?

Answer 17

4 Factor PCC (Octaplex)

Question 18

If a patient on warfarin comes in supratherapeutic, with INR 10, and they are not bleeding, how would you manage?

Answer 18

If INR > 9, hold warfarin and given vitamin K 2.5-5 mg PO. Otherwise if they are not bleeding and INR < 9 you can just hold warfarin and monitor INR.

Question 19

If a patient is on warfarin and is experiencing a life threatening bleed, or is in need of an imminent procedure, how would you manage their anticoagulation?

Answer 19

IV vitamin K

PCC

Question 20

How would you reverse LMWH in the setting of a life threatening bleed?

Answer 20

Protamine

Question 21

If a patient has a recurrent VTE while on a DOAC or VKA, how would you manage their anticoagulation if they were compliant/therapeutic?

Answer 21

Switch to LMWH for at least 1 month

Question 22

How would you manage a patient’s anticoagulation if they had a recurrent VTE while on LMWH?

Answer 22

Increase the dose by 25-30%

Question 23

How would you change the patient’s LMWH dosing based on their platelet count?

Answer 23

Full dose if platelets > 50
Half dose if platelets 20-50
Hold if platelets < 20