VTE treatment Flashcards
What is the treatment for VTE?
- 1st: apixaban or ribaroxaban
If this is not suitable: - LMWH for at least 5 days followed by dabigatran or edoxaban
OR - LMWH with warfarin till therapeutic anticoagulation is achieved (INR 2-3)
What would you give to a VTE patient with renal impairment/failure or increased risk of bleeding?
UFH and warfarin
Why does warfarin need to be given with heparin?
Warfarin takes 48-72hrs to reach its therapeutic range at which heparin can be discontinued
When would you give fondaparinux to a VTE patient?
An alternative to LMWH for prophylaxis
• All heparins are porcine in origin. Muslims, Jewish, Hindus, vegetarians and vegans (20% of population) may not accept to receive these products.
How long do you continue anticoagulation for after a VTE?
o 3 months of warfarin if obvious reversible cause
o > 3 months of warfarin if cause is unclear, recurrent VTE, irreversible underlying cause (thrombophilia)
o 6 months of LMWH in active cancer
o Pregnancy: LMWH is continued until the end of pregnancy
Why are surgery patients at risk of VTE?
- Bed-rest increases risk with increased duration
- Increase in acute reactants after surgery
Fibrinogen, factor VIII and vWF
What mechanical interventions can be applied to prevent VTE?
- Anti-embolism stockings (AES)
- Intermittent pneumatic compression sleeves (IPC)
What would you use for pharmacological prophylaxis of VTE?
- LMWH
- UFH
- DOACs
DO NOT USE WARFARIN
What is the mechanism of action of heparin?
Binds to antithrombin, increasing its ability to inhibit thrombin, factor Xa and IXa
What needs monitoring when LMWH is given for >7 days?
Potassium
What is UFH reversed with?
Protamine sulphate
What would you monitor with UFH?
APTT
What is the side effects of heparin?
- Increased bleeding
- Heparin induced thrombocytopenia (HIT)
- Osteoporosis
- Hyperkalaemia
What are the contraindications of heparin?
- Bleeding disorders
- Low platelets
- Previous HIT
- Peptic ulcer
- Cerebral haemorrhage
- Severe TN
- Neurosurgery
What is the mechanism of action of warfarin?
Inhibits the reductase enzymes responsible for regenerating the active form of vitamin K
How do you monitor warfarin?
INR monitoring
What reverses warfarin?
Vitamin K
What are the contraindications of warfarin?
- Bleeding disorders
- Severe HTN
- Pregnancy
- Caution in elderly and past GI bleeds
What is the mechanism of action of apixaban?
Factor Xa inhibitor
What is the mechanism of action of rivaroxaban?
Factor Xa inhibitor
What are the contraindications of apixaban?
Pregnancy
What are the adverse reactions of apixaban?
- Bleeding
- Bruising
- Nausea
- Anaemia
What is the mechanism of action of dabigatran?
Direct thrombin inhibitor
What are the contraindications of edoxaban?
- Pregnancy
- Cirrhosis with coagulopathy
