VTE Treatment Protocol

Question 1

Q: What are the treatment strategies for different risk levels of pulmonary embolism (PE)?

Answer 1

A:
- Low-risk PE (e.g., sPESI = 0):
- Consider outpatient anticoagulation.
- Review Drug Therapy for VTE section for treatment options.

• Intermediate or high-risk PE:
  
  • Initiate anticoagulation.
  • Consult with PERT/HELP team.
• Segmental PE:
  
  • Anticoagulation is required.
  • Review Drug Therapy for VTE section for treatment options.
• Isolated subsegmental PE:
  
  • Consider clinical surveillance if no concomitant proximal DVT and no contraindications (e.g., high bleed risk).
  • Instruct patients not anticoagulated to return if symptoms persist or worsen.

Question 2

Subsegmental PE vs Segmental PE refers to the location and size of the pulmonary embolism within the pulmonary arteries:

Answer 2

Segmental PE:
Involves a larger branch of the pulmonary artery (often a segmental artery), typically more central in the lung.
More likely to cause significant symptoms or compromise lung function, leading to more aggressive treatment.
Subsegmental PE:
Involves smaller branches of the pulmonary arteries, distal to the segmental arteries.
These are smaller clots, and their clinical significance may be less severe, especially if there’s no accompanying proximal DVT or other risk factors.
May sometimes be managed with clinical surveillance, especially in low-risk patients or when bleeding risk is a concern

Segmental PE:
Involves a larger branch of the pulmonary artery (often a segmental artery), typically more central in the lung.
More likely to cause significant symptoms or compromise lung function, leading to more aggressive treatment.
Subsegmental PE:
Involves smaller branches of the pulmonary arteries, distal to the segmental arteries.
These are smaller clots, and their clinical significance may be less severe, especially if there’s no accompanying proximal DVT or other risk factors.
May sometimes be managed with clinical surveillance, especially in low-risk patients or when bleeding risk is a concern.

Question 3

Q: What are the high-risk concomitant features to consider when deciding whether to treat isolated subsegmental pulmonary embolism (PE)?

Answer 3

A:
Consider treatment for isolated subsegmental PE if the patient has any of the following high-risk features:

Acute proximal deep venous thrombosis (DVT)
CT pulmonary angiogram is of high certainty
Hospitalization or immobility
High pretest probability (e.g., Wells score ≥5)
Symptomatic presentation
Active cancer
Elevated D-dimer
COVID-19 infection
Pregnancy
High risk for recurrent VTE

Question 4

Q: What are the preferred therapies for cancer-associated venous thromboembolism (VTE), and what considerations should be made?

Answer 4

A:
- Warfarin is considered inferior for cancer-associated VTE and should only be used if DOACs or enoxaparin are not options (e.g., lack of prescription benefits).

• DOAC (Apixaban or Rivaroxaban):
  
  • Preferred agents.
  • Consider long-term anticoagulation for patients with active cancer unless contraindications (e.g., major bleeding).
  • Apixaban is comparable in safety to LMWH and can be used in GI cancer patients after multidisciplinary discussion.
  • If Apixaban is not an option for GI cancer, use LMWH over rivaroxaban, edoxaban, or dabigatran.
  • Caution in high-risk bleeding scenarios (e.g., GI bleeding, uterine bleeding, thrombocytopenia, high-risk intracranial lesions, or unresected GI/GU cancers).
• Enoxaparin:
  
  • Preferred in patients with gastric or gastroesophageal lesions.
  • Dosing:
    
    • 1 mg/kg twice daily for the first month, then once daily dosing may be considered.
    • Adjust doses in thrombocytopenia.

This card covers the key agents and considerations for cancer-associated VTE therapy. Let me know if you need further details!

Question 5

Enoxaparin dose modifications in the setting of cancer-induced thrombocytopenia

Answer 5

Question 6

Q: What are the recommended anticoagulation therapies for VTE during pregnancy?

Answer 6

A:
- Enoxaparin:
- Preferred over oral anticoagulation in pregnancy and for patients planning pregnancy.
- Duration: At least 3 months, consider up to 6 weeks postpartum, whichever is longer.
- Dose adjustments are recommended based on maternal weight gain during pregnancy.
- Monitoring: Anti-Xa levels should be monitored due to changes in volume of distribution.

• DOACs: Should be avoided during pregnancy.

Question 7

Q: What are the anticoagulation considerations for VTE management after bariatric surgery?

Answer 7

A:
- Enoxaparin or Fondaparinux:
- Use actual body weight for dose selection.
- Duration of parenteral therapy: At least 4 weeks for any VTE patient (remote, chronic, or acute) in the early post-surgical phase after bariatric surgery.
- Switch to oral anticoagulant (warfarin or DOAC): Consider after at least 4 weeks of parenteral therapy, but not typically longer than 6 months. The timing is at the provider’s discretion.
- DOAC Monitoring: A DOAC trough level is suggested to assess absorption and bioavailability post-surgery. However, DOAC drug levels don’t have proven clinical correlation, so dose adjustments based on levels are not appropriate. If levels are outside the expected range, consider an alternative agent.
- Consultation: If DOAC levels are indicated, it’s recommended to consult with antithrombosis stewardship services.

Question 8

Unusual site thrombosis
Superficial venous thrombosis (SVT)
a. Recommendations are extrapolated from lower extremity SVT as there is limited data in upper extremity SVT

Answer 8

Question 9

Unusual site thrombosis
Q: What is the recommended treatment for Cerebral Venous Thrombosis (CVT)?

Answer 9

• Anticoagulation should be considered for at least 3 months.
• Initial treatment: Therapeutic dose LMWH is preferred over UFH.
• Long-term treatment:
  
  • Warfarin is a reasonable oral option for long-term therapy.
  • DOACs have been shown to be safe and effective, but require a multidisciplinary discussion and shared decision-making.

Question 10

Unusual Site Thrombosis
Q: How should Upper Extremity DVT (UEDVT) be treated?

Answer 10

• Treatment: Managed similarly to lower limb DVT.
• If CVC-associated (e.g., PICC, midline):
  • Removal of CVC: Not recommended if the device is still functional, well-positioned, and not infected.
  • Prompt removal: Should be pursued if the CVC is no longer needed, non-functioning, or potentially infected.
  • Further treatment: Refer to Drug therapy for VTE for additional management options.

Question 11

Drug therapy for VTE

Answer 11

Question 12

Q: What should be included in the hospital discharge checklist for patients on anticoagulation therapy?

Answer 12

1. Anticoagulation Prescription:
   
   • Send prescription to 4ACC Discharge Pharmacy or patient’s preferred pharmacy.
   • Comment in eRX to notify team about copay.
   • For uninsured or indigent patients, request case management assistance for medication access.
2. Prior Authorization:
   
   • Follow DOAC discharge prior auth process if required.
3. Affordability:
   
   • If patient cannot afford the copay:
     
     • Consider transitioning to an alternative anticoagulation and cancel the original prescription.
   • If patient can afford:
     
     • Ensure prescription is for the full treatment duration (starter pack + refills).
     • Notify pharmacy to fill prescription.
4. Education:
   
   • Provide teach-back education using handouts, dosing calendars, and videos.
   • Document education in Powerchart using the “Education Anticoagulation Therapy Form”.
5. Follow-Up:
   
   • Schedule follow-up with UNM Anticoagulation Clinic or outside PCP.
     
     • Warfarin INR check: within 5-7 days post-discharge.
     • DOACs check: within 2-3 weeks of initiation.

Question 13

Bleed risk prediction scores

just be familiar

Answer 13

Question 14

Heparin Protocol (summary): High intensity, low intensity, and non-weight based

Answer 14

Question 15

Q: How should heparin therapy be monitored, and when should aPTT vs anti-Xa be used?

Answer 15

A:
1. aPTT Monitoring:
- Preferred method for unfractionated heparin (UFH) monitoring in most patients.
- Used to ensure that UFH is within the therapeutic range for VTE (Venous Thromboembolism) and acute coronary syndrome (ACS) treatment.
- Target aPTT: 1.5–2.5 times the control value (usually 60–80 seconds).

2. Anti-Xa Monitoring:
   
   • Recommended when aPTT is unreliable (e.g., in pregnancy, obesity, renal failure, or when patient is on low molecular weight heparin (LMWH)).
   • Useful for LMWH therapy, such as enoxaparin, especially if dosing is unclear or if there’s a need to adjust based on renal function or bleeding risks.
   • Target anti-Xa levels for LMWH:
     
     • Typically, 0.5–1.0 IU/mL for VTE treatment.
     • Lower levels may be acceptable for VTE prophylaxis.