Venous thromboembolism (VTE) represents a spectrum. Outpatient Management of Acute Deep Venous Thrombosis DEEP VENOUS THROMBOSIS

Size: px
Start display at page:

Download "Venous thromboembolism (VTE) represents a spectrum. Outpatient Management of Acute Deep Venous Thrombosis DEEP VENOUS THROMBOSIS"

Transcription

1 DEEP VENOUS THROMBOSIS Outpatient Management of Acute Deep Venous Thrombosis Case Study and Commentary, Victor F. Tapson, MD INSTRUCTIONS The following article, Outpatient Management of Acute Deep Venous Thrombosis, is a continuing medical education (CME) article. To earn credit, read the article and complete the CME evaluation form on page 71. OBJECTIVES After participating in the CME activity, primary care physicians should be able to: 1. Discuss the efficacy and safety of low-molecularweight heparin (LMWH) and unfractionated heparin for treatment of deep venous thrombosis (DVT) 2. Evaluate the benefits of outpatient versus inpatient therapy 3. Describe components of an outpatient treatment program for DVT 4. Discuss economic aspects of treatment with LMWH Venous thromboembolism (VTE) represents a spectrum of disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE). Both DVT and PE are frequently clinically unsuspected, leading to significant diagnostic and therapeutic delays and accounting for substantial morbidity and mortality. An estimated 600,000 cases of VTE occur annually; however, more than half of these are never diagnosed [1]. Although many patients who die from acute PE have coexisting terminal illnesses, this disease entity is responsible for the deaths of approximately 50,000 to 100,000 patients with an otherwise good prognosis, and many of these deaths would appear to be preventable [2,3]. It is crucial that clinicians know the risk factors for and recognize the symptoms of DVT and/or PE so that appropriate diagnostic testing and therapy can proceed as quickly as possible, as anticoagulation has been shown to reduce mortality in this disease. When DVT or PE are diagnosed or strongly suspected, parenteral anticoagulation should promptly be instituted unless contraindications exist. Confirmatory diagnostic testing should be undertaken if anticoagulation is to be continued. Standard unfractionated heparin (UFH) and low-molecularweight heparin (LMWH) exert a prompt antithrombotic effect preventing thrombus growth, allowing the fibrinolytic system to act unopposed and more readily reduce the size of the thromboembolic burden [4]. Until recent years, patients with acute DVT were most commonly treated as inpatients with a bolus of UFH followed immediately by a continuous intravenous infusion of heparin. More recently, stable patients presenting with DVT with or without PE at many institutions are evaluated in the clinic or emergency department (ED) and, if they meet specific criteria, discharged and treated entirely in the outpatient arena. One institution s approach to outpatient DVT treatment is described in the primer that begins on page 64. CASE STUDY Initial Presentation A 66-year-old man with chronic obstructive pulmonary disease (COPD) presents to the ED for evaluation of pain and swelling in the left calf. History Five days ago, the patient developed an acute COPD flare with increased cough, sputum production, wheezing, and dyspnea. He was started on antibiotics and a steroid taper and sent home. He was much less mobile than at baseline, walking only from bed to bathroom and back for the next 3 days. On the fourth day, he noted the onset of pain and swelling in the left calf, which has increased over the past 24 hours. Physical Examination The patient is alert, oriented, and comfortable-appearing at rest. Heart rate is 88 bpm, respiratory rate is 18 breaths/min, and blood pressure is 140/78 mm Hg. The patient is afebrile. Lung examination reveals diffusely decreased breath sounds and a few rhonchi at both bases. Heart sounds are distant, as is consistent with COPD. Examination of the extremities reveals a tender, swollen left calf. Results from a complete blood count, chemistry panel, and coagulation studies are normal. From the Division of Pulmonary and Critical Care, Duke University Medical Center, Durham, NC. 62 JCOM December 2001 Vol. 8, No. 12

2 CASE-BASED REVIEW Diagnosis A compression ultrasound reveals DVT in the popliteal vein extending into the superficial femoral vein. What therapies are available for treatment of DVT? Unfractionated Heparin As mentioned, traditionally DVT is treated with UFH administered by continuous intravenous infusion. A secure continuous intravenous line is necessary for optimal delivery of UFH in the treatment setting and this may require replacement once or more during the 5- to 7-day course of UFH. The activated partial thromboplastin time (aptt) must be aggressively followed at 6-hour intervals until it is consistently in the therapeutic range of 1.5 to 2.0 times control values [4]. This range corresponds to a heparin level of 0.2 to 0.4 U/mL as measured by protamine sulfate titration. In general, heparin should be administered as an intravenous bolus of 5000 U followed by a maintenance dose of at least 30,000 to 40,000 U per 24 hours by continuous infusion [5]. The lower dose is administered if the patient is considered at high risk for bleeding. This aggressive approach decreases the risk of subtherapeutic anticoagulation and therefore of VTE recurrences, and although supratherapeutic levels are sometimes achieved initially, bleeding complications do not appear to be increased [6]. More recent data continues to support the principle that if UFH is to be used, it should be used aggressively. An alternative regimen consisting of a bolus of 80 U/kg followed by 18 U/kg/hr has been recommended [7]. Further adjusting of the heparin dose should also be weight-based. This weightadjusted approach is recommended in recent guidelines from the American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy [8]. Low-Molecular-Weight Heparins With the advent of LMWH preparations, treatment of acute DVT has been dramatically altered. While traditionally DVT is treated with UFH administered by continuous intravenous infusion, LMWH preparations allow for subcutaneous administration once or twice daily depending on the drug and the specific indication. The bioavailability of LMWH ensures a predictable dose response and eliminates the need for monitoring in most patients. (In patients with significant obesity, renal insufficiency, or weight less than 40 kg, monitoring is recommended via measurement of anti-factor Xa levels.) Additional advantages of using LMWH for the treatment of DVT are listed in Table 1. Table 1. Advantages of Low-Molecular-Weight Heparin Over Standard Unfractionated Heparin Superior bioavailability Superior or equivalent safety and efficacy Subcutaneous once- or twice-daily dosing No laboratory monitoring* Less phlebotomy (no monitoring/no intravenous line) Less thrombocytopenia Earlier/facilitated ambulation Ease of outpatient therapy Based on above, time saved for nursing staff Based on above, increased patient satisfaction *For treatment of established deep venous thrombosis ± pulmonary embolism, monitoring of anti-xa levels should be considered in massively obese patients, patients weighing less than 40 kg, and patients with renal insufficiency. Trials Comparing LMWH with UFH A number of clinical trials have compared LMWH preparations with UFH in patients with VTE [9 11]. In 1996, the results of 2 large (Canadian and European) trials were reported in the same issue of the New England Journal of Medicine [9,10]; the studies showed that out-of-hospital administration of LMWH to eligible patients with DVT was as effective and safe as UFH. In both studies, the 2 study groups did not demonstrate any statistically significant differences in clinical endpoints such as recurrent thromboembolic disease, major bleeding, or death. A number of other outpatient studies followed these 2 pivotal trials. Four meta-analyses examined the use of LMWH compared with unfractionated heparin for the initial treatment of acute proximal DVT [12 15]. While there was overlap with regard to the studies included in these analyses, they helped to confirm the efficacy and safety of LMWH for the treatment of established DVT. The most recent of these meta-analyses suggested a reduced total mortality in patients treated with LMWH, but the precise reason for this is not clear. [12]. Available Agents There are 2 LMWH preparations approved by the U.S. Food and Drug Administration (FDA) for use in patients presenting with DVT with or without acute PE. Enoxaparin is approved for both inpatient and outpatient use at a dose of 1 mg/kg subcutaneously every 12 hours or at 1.5 mg/kg once daily for inpatient use. The latter regimens were studied in a large randomized controlled trial of inpatients in which both doses proved as effective and safe as unfractionated heparin [16]. The second preparation, tinzaparin, is administered as 175 U once daily, with the FDA approval being based on clinical trials involving inpatients. Neither enoxaparin nor tinzaparin is approved for use in patients presenting with acute PE, although tinzaparin has proven effective in a large, randomized European trial of patients (continued on page 68) Vol. 8, No. 12 December 2001 JCOM 63

3 DEEP VENOUS THROMBOSIS (continued from page 63) with PE [17]. It would appear logical that since DVT and PE represent 2 manifestations of the same disease, LMWH would be as effective for acute PE as standard UFH. Steps outlining the use of LMWH as outpatient therapy for acute DVT derived from the Sixth ACCP Antithrombotic Therapy Consensus Statement are listed in Table 2 [8]. Currently, both subcutaneous LMWH and UFH by continuous intravenous infusion are utilized for the treatment of inpatients with established VTE. The advantages to using LMWH for acute DVT in the outpatient setting also apply when using it in the inpatient setting. Advantages, however, to using intravenous UFH over LMWH for treatment of acute DVT include UFH s short half-life (allowing necessary surgical procedures to be performed after only about 4 to 5 hours following infusion discontinuation) and lower cost, although data is accumulating indicating that even in the inpatient setting, overall cost may be lower with LMWH (see cost-effectiveness discussion below). Is this patient a candidate for outpatient treatment? It is important to carefully evaluate each patient with DVT prior to discharging on outpatient therapy. Patients should be stable, compliant, and have no signs of symptomatic PE. (Although outpatient therapy of symptomatic, stable PE patients with LMWH has been evaluated, it is not commonly practiced in the United States.) In addition to PE, there are several other risk factors that deem a patient not well-suited to outpatient care. For example, patients with very extensive, symptomatic proximal DVT or with unstable comorbid illness should be considered for inpatient therapy. The Lovelace Health Systems outpatient DVT treatment protocol described in the primer identifies a set of exclusionary criteria; these are listed in the Table on page 66. If teaching cannot be completed within a reasonable period of time in the emergency department, if clinical stability cannot be assured, or if another reason for admission is evident, the patient can be admitted for a 24- to 48-hour hospital stay and then discharged to complete therapy in the outpatient setting. Table 2. Outpatient Therapy for Acute Deep Venous Thrombosis with Low-Molecular-Weight Heparin (LMWH) Give LMWH (enoxaparin, tinzaparin)* Start warfarin on day 1 (5 mg) and adjust for INR Check platelet count on day 3 to 5 Stop LMWH after at least 4 to 5 days of combined therapy (INR > 2.0 for 2 consecutive days) Continue warfarin for 3 to 6 months with INR INR = international normalized ratio. (Adapted from Hirsh J, Dalen J, Guyatt G. The sixth [2000] ACCP guidelines for antithrombotic therapy for prevention and treatment of thrombosis. American College of Chest Physicians. Chest 2001;119[1 Suppl]:1S 370S.) *Both drugs are approved for treatment of acute DVT in the United States. The data leading to FDA approval of tinzaparin was based on treatment of inpatients, while approval for enoxaparin was based on both inpatient and outpatient studies. Initiation of Therapy There is no history of bleeding disorders, recent surgery, or other contraindications to anticoagulation. The patient s laboratory tests are normal. His acute obstructive lung disease flare has improved significantly and does not constitute a reason for admission. No invasive procedures are anticipated; in the setting of treatment of acute DVT, this would have favored the use of UFH. Based on evaluation by the ED physician and the nurse responsible for patient education, the patient is judged to be a good outpatient candidate. It is therefore elected to treat the patient on an outpatient basis. The patient is instructed on subcutaneous injection, begun on LMWH, and discharged to home. The patient is instructed to return to the anticoagulation clinic or ED for immediate evaluation if increased pain or swelling of the leg develops or any bleeding occurs. Oral warfarin is started the following day. The patient lives 15 miles from the hospital. He returns to the anticoagulation clinic for protime/international normalized ratio (PT/INR) testing 2 days later. What is follow-up care for patients receiving outpatient DVT therapy? Documented proximal DVT or PE should be treated for at least 3 months. Longer treatment is appropriate when significant risk factors persist or when patients have idiopathic DVT. Both short- and long-term anticoagulation guidelines are outlined in the ACCP consensus conference on antithrombotic therapy [8]. If pain and swelling are significant, minimizing ambulation may be appropriate. However, based on clinical trial data, bed rest in patients being treated for acute DVT probably does not reduce the incidence of acute PE [18]. How cost-effective is treatment of DVT with LMWH? Treatment of DVT with LMWH is more cost-effective than treatment with UFH. O Brien and colleagues [19] performed 68 JCOM December 2001 Vol. 8, No. 12

4 CASE-BASED REVIEW an economic analysis of the Levine et al outpatient DVT study [9] and determined that the cost of outpatient therapy compared with inpatient therapy with standard heparin was approximately $3000 less per patient (P < 0.001). Eliminating the need for hospitalization substantially reduces the cost of care. Overall cost in patients treated with LMWH in the inpatient setting also has proven lower than with intravenous UFH in several clinical trials. In a meta-analysis, Rodger and colleagues [20] compared the cost of inpatient UFH, inpatient LMWH, inpatients treated with UFH who were eligible for outpatient therapy, and outpatients treated with LMWH. While outpatients treated with LMWH incurred the lowest cost, it was determined that the cost of treating inpatients with LMWH was less than that for inpatients treated with UFH, although the latter difference was not significant. Gould et al [21] similarly determined that the cost of inpatient treatment of DVT was not statistically different in patients receiving UFH compared with LMWH. Finally, a retrospective analysis of the Merli study [16] of inpatient LMWH versus standard heparin also revealed similar costs among the 3 groups of patients (intravenous UFH and subcutaneous enoxaparin either once or twice daily) [22]. The additional cost of enoxaparin was offset by a lower hospital readmission rate and shorter readmission length of stay. Treatment Course On day 5 of LWMH therapy, the INR returns therapeutic (> 2.0) for a second consecutive day, and the therapy is discontinued. Warfarin is continued for 6 months with periodic INR checks. The patient experiences no complications. Corresponding author: Victor F. Tapson, MD, Division of Pulmonary and Critical Care, Box 31175, Room 351 Bell Building, DUMC, Durham, NC Financial disclosure: Dr. Tapson has a consulting relationship with Aventis Pharmaceuticals and has conducted lectures sponsored by Aventis and Dupont. References 1. Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to Br J Surg 1991;78: Anderson FA Jr, Wheeler HB. Venous thromboembolism. Risk factors and prophylaxis. Clin Chest Med 1995;16: Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis 1975;17: Hirsh J, Warkentin TE, Shaughnessy SG. Heparin and lowmolecular-weight heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety. Chest 2001;119(1 Suppl):64S 94S. 5. Hull RD, Raskob GE, Hirsh J, et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal-vein thrombosis. N Engl J Med 1986;315: Hull RD, Raskob GE, Rosenbloom D, et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med 1992;152: Raschke RA, Reilly BM, Guidry JR, et al. The weight-based heparin dosing nomogram compared with a standard care nomogram. Ann Intern Med 1993;119: Hirsh J, Dalen J, Guyatt G. The sixth (2000) ACCP guidelines for antithrombotic therapy for prevention and treatment of thrombosis. American College of Chest Physicians. Chest 2001;119(1 Suppl):1S 370S. 9. Levine M, Gent M, Hirsh J, et al. A comparison of lowmolecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep vein thrombosis. N Engl J Med 1996;334: Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med 1996;334: Tapson VF. Treatment of acute deep venous thrombosis and pulmonary embolism: use of low molecular weight heparin. Semin Respir Crit Care Med 2000;21: Dolovich LR, Ginsberg JS, Douketis JD, et al. A metaanalysis comparing low-molecular-weight heparins with unfractionated heparin in the treatment of venous thromboembolism: examining some unanswered questions regarding location of treatment, product type, and dosing frequency. Arch Intern Med 2000;160: Siragusa S, Cosmi B, Piovella F, et al. Low-molecular-weight heparins and unfractionated heparin in the treatment of patients with acute venous thromboembolism: results of a meta-analysis. Am J Med 1996;100: Lensing AW, Prins MH, Davidson BL, Hirsh J. Treatment of deep venous thrombosis with low-molecular-weight heparins. A meta-analysis. Arch Intern Med 1995;155: Leizorovicz A, Simonneau G, Decousus H, Boissel JP. Comparison of efficacy and safety of low molecular weight heparins and unfractionated heparin in initial treatment of deep venous thrombosis: a meta-analysis. BMJ 1994;309: Merli G, Spiro TE, Olsson CG, et al. Subcutaneous enoxaparin once or twice daily compared with intravenous unfractionated heparin for treatment of venous thromboembolic disease. Ann Intern Med 2001;134: Simmoneau G, Sors H, Charbonnier B, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l Embolie Pulmonaire. N Engl J Med 1997;337: Aschwanden M, Labs KH, Engel H, et al. Acute deep vein thrombosis: early mobilization does not increase the frequency of pulmonary embolism. Thromb Haemost 2001;85: O Brien B, Levine M, Willan A, et al. Economic evaluation of outpatient treatment with low-molecular-weight heparin Vol. 8, No. 12 December 2001 JCOM 69

5 DEEP VENOUS THROMBOSIS for proximal vein thrombosis. Arch Intern Med 1999;159: Rodger M, Bredeson C, Wells PS, et al. Cost-effectiveness of low-molecular-weight heparin and unfractionated heparin in treatment of deep vein thrombosis. CMAJ 1998;159: Gould MK, Dembitzer AD, Sanders GD, Garber AM. Lowmolecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A cost-effectiveness analysis. Ann Intern Med 1999;130: delissovoy G, Yusen RD, Spiro TE, et al. Cost for inpatient care of venous thrombosis: a trial of enoxaparin versus standard heparin. Arch Intern Med 2000;160: The Journal of Clinical Outcomes Management acknowledges DuPont Pharmaceuticals Company, who provided an unrestricted educational grant to support the development of this article. Copyright 2001 by Turner White Communications Inc., Wayne, PA. All rights reserved. 70 JCOM December 2001 Vol. 8, No. 12

6 JCOM CME EVALUATION FORM: Outpatient Management of Acute Deep Venous Thrombosis To receive 1 hour of AMA PRA Category 1 CME credit, read the article named above and mark your responses on this form. You must complete all parts to receive credit. Then return this form using the fax number or address appearing at the bottom of this page. A certificate awarding 1 hour of category 1 CME credit will be sent to you by fax or mail. This CME Evaluation Form must be fax marked or postmarked within 1 year of this JCOM issue date. Please allow up to 4 weeks for your certificate to arrive. Part 1. Please respond to each statement. Strongly Agree Strongly Disagree I was provided with new information pertinent to my practice I reaffirmed a specific skill or knowledge. This article will help with clinical decision making. Relevant clinical outcomes are addressed. The case is communicated in a manner that kept my interest. The case presentation is realistic and effective. I could easily interpret the tables and figures. My attitude about this topic changed in some way. Additional comments: Part 2. Please complete the following sentence. As a result of reading this case study, I... see no need to change my practice. will seek more information before modifying my practice. intend to change the following aspect(s) of my practice: (Briefly describe) Part 3. Statement of completion: I attest to having completed the CME activity. Signature: Date: Part 4. Identifying information: Please PRINT legibly or type the following: Name: Fax number Address: Telephone number Social Security number: (Required and confidential) Medical specialty: SEND THE COMPLETED CME EVALUATION FORM TO: BY FAX: BY MAIL: Wayne State University Division of CME 101 Alexandrine, Lower Level Detroit, MI Wayne State University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Wayne State University School of Medicine designates this CME activity for a maximum of 1 hour of category 1 credit toward the Physician s Recognition Award of the American Medical Association. Physicians should claim only those hours of credit actually spent in the educational activity. Vol. 8, No. 12 December 2001 JCOM 71

Outpatient Treatment of Deep Vein Thrombosis with Low Molecular Weight Heparin (LMWH) Clinical Practice Guideline August 2013

Outpatient Treatment of Deep Vein Thrombosis with Low Molecular Weight Heparin (LMWH) Clinical Practice Guideline August 2013 Outpatient Treatment of Deep Vein Thrombosis with Low Molecular Weight Heparin (LMWH) Clinical Practice Guideline August 2013 General Principles: There is compelling data in the medical literature to support

More information

To aid practitioners in prescribing unfractionated heparin and low-molecular-weight heparins to patients.

To aid practitioners in prescribing unfractionated heparin and low-molecular-weight heparins to patients. UNFRACTIONATED HEPARIN AND LOW-MOLECULAR-WEIGHT HEPARIN TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To aid practitioners in prescribing unfractionated heparin and low-molecular-weight

More information

Inpatient Anticoagulation Safety. To provide safe and effective anticoagulation therapy through a collaborative approach.

Inpatient Anticoagulation Safety. To provide safe and effective anticoagulation therapy through a collaborative approach. Inpatient Anticoagulation Safety Purpose: Policy: To provide safe and effective anticoagulation therapy through a collaborative approach. Upon the written order of a physician, Heparin, Low Molecular Weight

More information

Outpatient strategies in the management of deep

Outpatient strategies in the management of deep PRIMER: THE LOVELACE OUTPATIENT TREATMENT PROGRAM Alex C. Spyropoulos, MD Outpatient strategies in the management of deep venous thrombosis (DVT) are gaining acceptance in U.S. health care centers. Observational

More information

Disclosure. New Agents for Treatment of DVT. Prevalence of DVT VTE. Normal Hemostasis 7/17/2015. Mark Oliver, MD, RVT, RPVI,FSVU

Disclosure. New Agents for Treatment of DVT. Prevalence of DVT VTE. Normal Hemostasis 7/17/2015. Mark Oliver, MD, RVT, RPVI,FSVU New Agents for Treatment of DVT Disclosure PI Adopt and Amplify trials Mark Oliver, MD, RVT, RPVI,FSVU BMS and Pfizer Speaker VTE Venous Thromboembolism Recognized DVT s New : 170,000 Recurrent : 90,000

More information

DVT/PE Management with Rivaroxaban (Xarelto)

DVT/PE Management with Rivaroxaban (Xarelto) DVT/PE Management with Rivaroxaban (Xarelto) Rivaroxaban is FDA approved for the acute treatment of DVT and PE and reduction in risk of recurrence of DVT and PE. FDA approved indications: Non valvular

More information

To provide an evidenced-based approach to treatment of patients presenting with deep vein thrombosis.

To provide an evidenced-based approach to treatment of patients presenting with deep vein thrombosis. DEEP VEIN THROMBOSIS: TREATMENT TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To provide an evidenced-based approach to treatment of patients presenting with deep vein thrombosis.

More information

ABOUT XARELTO CLINICAL STUDIES

ABOUT XARELTO CLINICAL STUDIES ABOUT XARELTO CLINICAL STUDIES FAST FACTS Xarelto (rivaroxaban) is a novel, oral direct Factor Xa inhibitor. On September 30, 2008, the European Commission granted marketing approval for Xarelto for the

More information

Confirmed Deep Vein Thrombosis (DVT)

Confirmed Deep Vein Thrombosis (DVT) Confirmed Deep Vein Thrombosis (DVT) Information for patients What is deep vein thrombosis? Blood clotting provides us with essential protection against severe loss of blood from an injury to a vein or

More information

Anticoagulant therapy

Anticoagulant therapy Anticoagulation: The risks Anticoagulant therapy 1990 2002: 600 incidents reported 120 resulted in death of patient 92 deaths related to warfarin usage 28 reports related to heparin usage Incidents in

More information

0.9% Sodium Chloride injection may be used in most cases.

0.9% Sodium Chloride injection may be used in most cases. Table 2. Alternatives to Heparin Sodium in Selected Situations 12-14 Situation Alternative Dose Maintain patency of peripheral venous catheters* 21-26 0.9% Sodium Chloride injection may be used in most

More information

ACUTE DVT MANAGEMENT Richard J. DeMasi, MD April 26, 2014

ACUTE DVT MANAGEMENT Richard J. DeMasi, MD April 26, 2014 ACUTE DVT MANAGEMENT Richard J. DeMasi, MD April 26, 2014 Thromboembolism epidemiology 5 million DVT s 900,000 PE s 290,000 fatalities Heit J. Blood. 2005;106:910. 10 VTE events Since this talk began DVT

More information

Venous Thromboembolism: Long Term Anticoagulation. Dan Johnson, Pharm.D.

Venous Thromboembolism: Long Term Anticoagulation. Dan Johnson, Pharm.D. Venous Thromboembolism: Long Term Anticoagulation Dan Johnson, Pharm.D. Disclosures No financial relationships with products discussed Off-label use of drug therapy always discussed Objectives Review clinical

More information

Overview of the TJC/CMS VTE Core Measures

Overview of the TJC/CMS VTE Core Measures Overview of the TJC/CMS VTE Core Measures CMS Specification Manual 4.2 January 1, 2013 June 30, 2013 Victoria Agramonte, RN, MSN Project Manager, IPRO VTE Regional Learning Sessions NYS Partnership for

More information

Backgrounder. Current anticoagulant therapies

Backgrounder. Current anticoagulant therapies Backgrounder Bayer AG Investor Relations 51368 Leverkusen Germany www.investor.bayer.com Current anticoagulant therapies Anticoagulant drugs have significantly reduced the risk of thromboembolic events

More information

Venous Thromboembolic Treatment Guidelines

Venous Thromboembolic Treatment Guidelines Venous Thromboembolic Treatment Guidelines About the NYU Venous Thromboembolic Center (VTEC) The center s mission is to deliver advanced screening, detection, care, and management services for patients

More information

New Oral Anticoagulants. How safe are they outside the trials?

New Oral Anticoagulants. How safe are they outside the trials? New Oral Anticoagulants How safe are they outside the trials? Objectives The need for anticoagulant therapy Indications for anticoagulation Traditional anticoagulant therapies Properties of new oral anticoagulants

More information

Stroke/VTE Quality Measure Build for Meaningful Use Stage 1

Stroke/VTE Quality Measure Build for Meaningful Use Stage 1 Stroke/VTE Quality Measure Build for Meaningful Use Stage 1 Presented by Susan Haviland, BSN RN Senior Consult, Santa Rosa Consulting Meaningful Use Quality Measures Centers for Medicare and Medicaid Services

More information

Low Molecular Weight Heparin. All Wales Medicines Strategy Group (AWMSG) Recommendations and advice

Low Molecular Weight Heparin. All Wales Medicines Strategy Group (AWMSG) Recommendations and advice Low Molecular Weight Heparin All Wales Medicines Strategy Group (AWMSG) Recommendations and advice Starting Point Low Molecular Weight Heparin (LMWH): Inhibits factor Xa and factor IIa (thrombin) Small

More information

Thrombosis and Hemostasis

Thrombosis and Hemostasis Thrombosis and Hemostasis Wendy Lim, MD, MSc, FRCPC Associate Professor, Department of Medicine McMaster University, Hamilton, ON Overview To review the important developments in venous thromboembolism

More information

Clinical Study Synopsis

Clinical Study Synopsis Clinical Study Synopsis This Clinical Study Synopsis is provided for patients and healthcare professionals to increase the transparency of Bayer's clinical research. This document is not intended to replace

More information

Treatment of Venous Thromboembolism in Cancer Patients

Treatment of Venous Thromboembolism in Cancer Patients The role of low-molecular-weight heparin in cancer patients with acute venous thromboembolism and how it improves outcomes are discussed. Jacky Tiplady. Jersey Cottages. Photograph. Treatment of Venous

More information

Randomized, double-blind, parallel-group, multicenter, doubledummy

Randomized, double-blind, parallel-group, multicenter, doubledummy ABOUT RECORD STUDIES FAST FACTS RECORD is a global program of four trials in more than 12,500 patients, comparing Xarelto (rivaroxaban) and enoxaparin in the prevention of venous thromboembolism (VTE)

More information

CLINICAL PRACTICE GUIDELINE: MOBILITY WITH A DEEP VEIN THROMBOSIS (DVT) Page 1 of 10

CLINICAL PRACTICE GUIDELINE: MOBILITY WITH A DEEP VEIN THROMBOSIS (DVT) Page 1 of 10 Page 1 of 10 1.0 FOCUS: Mobilization with a Deep Vein Thrombosis (DVT). The purpose of this clinical practice guideline (CPG) is to ensure that new knowledge is integrated across Fraser Health and to standardize

More information

Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (AF) with one or more risk factors

Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (AF) with one or more risk factors News Release For use outside the US and UK only Bayer Pharma AG 13342 Berlin Germany Tel. +49 30 468-1111 www.bayerpharma.com Bayer s Xarelto Approved in the EU for the Prevention of Stroke in Patients

More information

Position Statement: The Use of VTED Prophylaxis in Foot and Ankle Surgery

Position Statement: The Use of VTED Prophylaxis in Foot and Ankle Surgery Position Statement: The Use of VTED Prophylaxis in Foot and Ankle Surgery Position Statement There is currently insufficient data for the (AOFAS) to recommend for or against routine VTED prophylaxis for

More information

XARELTO (rivaroxaban tablets) in Knee and Hip Replacement Surgery

XARELTO (rivaroxaban tablets) in Knee and Hip Replacement Surgery XARELTO (rivaroxaban tablets) in Knee and Hip Replacement Surgery Fast Facts: XARELTO is a novel, once-daily, oral anticoagulant recently approved in the United States for the prevention (prophylaxis)

More information

Investor News. Not intended for U.S. and UK media

Investor News. Not intended for U.S. and UK media Investor News Not intended for U.S. and UK media Bayer AG Investor Relations 51368 Leverkusen Germany www.investor.bayer.com Bayer s Xarelto (Rivaroxaban) Approved for the Treatment of Pulmonary Embolism

More information

Key words: deep vein thrombosis; enoxaparin; low-molecular-weight heparin; meta-analysis; noninferiority; pulmonary embolism; unfractionated heparin

Key words: deep vein thrombosis; enoxaparin; low-molecular-weight heparin; meta-analysis; noninferiority; pulmonary embolism; unfractionated heparin Enoxaparin in the Treatment of Deep Vein Thrombosis With or Without Pulmonary Embolism* An Individual Patient Data Meta-analysis Patrick Mismetti, MD, PhD; Sara Quenet, MS; Mark Levine, MD, MSc; Geno Merli,

More information

PRESCRIBING GUIDELINES FOR THE MANAGEMENT OF PATIENTS ANTICOAGULANT THERAPY

PRESCRIBING GUIDELINES FOR THE MANAGEMENT OF PATIENTS ANTICOAGULANT THERAPY PRESCRIBING GUIDELINES FOR THE MANAGEMENT OF PATIENTS ON ANTICOAGULANT THERAPY Prepared by: NPSA Anticoagulation Steering Group Approved by: Wirral Drug & Therapeutics Committee 14 th May 2008 Review:

More information

2. Background This indication of rivaroxaban had not previously been considered by the PBAC.

2. Background This indication of rivaroxaban had not previously been considered by the PBAC. PUBLIC SUMMARY DOCUMENT Product: Rivaroxaban, tablets, 15mg and 20mg, Xarelto Sponsor: Bayer Australia Ltd Date of PBAC Consideration: March 2013 1. Purpose of Application The application requested the

More information

UHS CLINICAL CARE COLLABORATION: Outpatient & Inpatient

UHS CLINICAL CARE COLLABORATION: Outpatient & Inpatient Guidelines for Anticoagulation Initiation and Management Y2014 UHS CLINICAL CARE COLLABORATION: Outpatient & Inpatient Topic Page Number MEDICATION FLOW AND PATIENT FLOW... 2 AND 3 PARENTERAL ANTICOAGULANTS...

More information

Review of the Stroke and VTE Measure Sets

Review of the Stroke and VTE Measure Sets Review of the Stroke and VTE Measure Sets Vicky Agramonte, RN, MSN IPRO Quality Data Reporting and Improvement Project Presentation to NYS Hospitals January 29, 2013 The QIO Program CMS Leads a national

More information

Pulmonary Embolism Treatment Update

Pulmonary Embolism Treatment Update UC SF Pulmonary Embolism Treatment Update Jeffrey Tabas, MD Professor UCSF School of Medicine Emergency Department San Francisco General Hospital sf g h Disclosure No Financial Relationships to Disclose

More information

Failure or significant adverse effects to all of the alternatives: Eliquis and Xarelto

Failure or significant adverse effects to all of the alternatives: Eliquis and Xarelto This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical practice standards, and approved by the IEHP Pharmacy and Therapeutics

More information

DATE: 06 May 2013 CONTEXT AND POLICY ISSUES

DATE: 06 May 2013 CONTEXT AND POLICY ISSUES TITLE: Low Molecular Weight Heparins versus New Oral Anticoagulants for Long-Term Thrombosis Prophylaxis and Long-Term Treatment of DVT and PE: A Review of the Clinical and Cost-Effectiveness DATE: 06

More information

rivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (755/12) Bayer PLC

rivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (755/12) Bayer PLC rivaroxaban 15 and 20mg film-coated tablets (Xarelto ) SMC No. (755/12) Bayer PLC 13 January 2012 The Scottish Medicines Consortium (SMC) has completed its assessment of the above product and advises NHS

More information

CDEC FINAL RECOMMENDATION

CDEC FINAL RECOMMENDATION CDEC FINAL RECOMMENDATION RIVAROXABAN (Xarelto Bayer Inc.) New Indication: Pulmonary Embolism Note: The Canadian Drug Expert Committee (CDEC) previously reviewed rivaroxaban for the treatment of deep vein

More information

Anticoagulation Initiation,Monitoring and Titration. Ng Heng Joo Department of Haematology Singapore General Hospital

Anticoagulation Initiation,Monitoring and Titration. Ng Heng Joo Department of Haematology Singapore General Hospital Anticoagulation Initiation,Monitoring and Titration Ng Heng Joo Department of Haematology Singapore General Hospital The 3 I s on the Anticoagulated Patient Indication? Intensity? Indefinite? Indications

More information

To define a diagnostic algorithm and treatment strategy for patients with acute pulmonary embolism.

To define a diagnostic algorithm and treatment strategy for patients with acute pulmonary embolism. PULMONARY EMBOLISM: DIAGNOSIS AND MANAGEMENT TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To define a diagnostic algorithm and treatment strategy for patients with acute pulmonary

More information

New Oral Anticoagulants

New Oral Anticoagulants New Oral Anticoagulants Tracy Minichiello, MD Associate Professor of Medicine Chief, San FranciscoVA Anticoagulation and Thrombosis Service Ansell, J. Hematology Copyright 2010 American Society of Hematology.

More information

Anticoagulation Dosing at UCDMC Indication Agent Standard Dose Comments and Dose Adjustments VTE Prophylaxis All Services UFH 5,000 units SC q 8 h

Anticoagulation Dosing at UCDMC Indication Agent Standard Dose Comments and Dose Adjustments VTE Prophylaxis All Services UFH 5,000 units SC q 8 h Indication Agent Standard Dose Comments and Dose Adjustments VTE Prophylaxis All Services UFH 5,000 units SC q 8 h See EMR adult VTE prophylaxis CI order set Enoxaparin See service specific dosing Assess

More information

THE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT

THE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT THE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT Stroke Prevention in Atrial Fibrillation Gregory Albers, M.D. Director Stanford Stroke Center Professor of Neurology and Neurological

More information

What Does Pregnancy Have to Do With Blood Clots in a Woman s Legs?

What Does Pregnancy Have to Do With Blood Clots in a Woman s Legs? Patient s Guide to Prevention of Blood Clots During Pregnancy: Use of Blood-Thinning A Patient s Guide to Prevention of Blood Clots During Pregnancy: Use of Blood-Thinning Drugs to Prevent Abnormal Blood

More information

APSR RESPIRATORY UPDATES

APSR RESPIRATORY UPDATES APSR RESPIRATORY UPDATES Volume 6, Issue 1 Newsletter Date: January 2014 APSR EDUCATION PUBLICATION Inside this issue: Venous thromboembolism Pulmonary embolism and deep vein thrombosis. 2 Outpatient versus

More information

Joseph A. Caprini, MD, MS, FACS, RVT

Joseph A. Caprini, MD, MS, FACS, RVT Joseph A. Caprini, MD, MS, FACS, RVT Louis W. Biegler Chair of Surgery NorthShore University HealthSystem, Evanston, IL Clinical Professor of Surgery University of Chicago Pritzker School of Medicine,

More information

Conserva)ve Treatment of PE/ DVT

Conserva)ve Treatment of PE/ DVT Conserva)ve Treatment of PE/ DVT Amir Kaki, MD FACC FSCAI Asst Prof of Medicine Wayne St SOM Medical Director Cardiac Catheteriza)on Lab Heart Hospital DMC Detroit, MI Incidence Acute pulmonary embolism

More information

Chronic Thromboembolic Disease. Chronic Thromboembolic Disease Definition. Diagnosis Prevention Treatment Surgical Nonsurgical

Chronic Thromboembolic Disease. Chronic Thromboembolic Disease Definition. Diagnosis Prevention Treatment Surgical Nonsurgical Chronic Thromboembolic Disease Diagnosis Prevention Treatment Surgical Nonsurgical Chronic Thromboembolic Disease Definition Pulmonary Hypertension due to chronic thromboembolism 6 months post acute PE:

More information

DVT and Pulmonary Embolism: Part II. Treatment and Prevention

DVT and Pulmonary Embolism: Part II. Treatment and Prevention PRACTICAL THERAPEUTICS DVT and Pulmonary Embolism: Part II. Treatment and Prevention DINO W. RAMZI, M.D., C.M., and KENNETH V. LEEPER, M.D. Emory University School of Medicine, Atlanta, Georgia Treatment

More information

Information for you Treatment of venous thrombosis in pregnancy and after birth. What are the symptoms of a DVT during pregnancy?

Information for you Treatment of venous thrombosis in pregnancy and after birth. What are the symptoms of a DVT during pregnancy? Information for you Treatment of venous thrombosis in pregnancy and after birth Published in September 2011 What is venous thrombosis? Thrombosis is a blood clot in a blood vessel (a vein or an artery).

More information

Enoxaparin for long term anticoagulation in patients unsuitable for oral anticoagulants

Enoxaparin for long term anticoagulation in patients unsuitable for oral anticoagulants Enoxaparin for long term anticoagulation in patients unsuitable for oral anticoagulants Traffic light classification- Amber 2 Information sheet for Primary Care Prescribers Relevant Licensed Indications

More information

National Patient Safety Goals Effective January 1, 2015

National Patient Safety Goals Effective January 1, 2015 National Patient Safety Goals Goal 1 Nursing are enter ccreditation Program Improve the accuracy of patient and resident identification. NPSG.01.01.01 Use at least two patient or resident identifiers when

More information

Time of Offset of Action The Trial

Time of Offset of Action The Trial New Antithrombotic Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant Amgen Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University What I am Talking About

More information

Novel Anticoagulation Agents DISCLOSURES. Objectives ATRIAL FIBRILLATION TRIALS. NOAC Comparison 6/12/2015

Novel Anticoagulation Agents DISCLOSURES. Objectives ATRIAL FIBRILLATION TRIALS. NOAC Comparison 6/12/2015 Novel Anticoagulation Agents DISCLOSURES James W. Haynes, MD Department of Family Medicine Univ of TN Health Science Center (Chattanooga) Objectives Understand mechanism of action behind the NOAC agents

More information

Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism ERRATUM

Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism ERRATUM Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism ERRATUM This report was commissioned by the NIHR HTA Programme as project number 12/78

More information

To Bridge or Not to Bridge. Periop Anticoagulation Management. Don Weinshenker, MD Ambulatory Care Denver VAMC

To Bridge or Not to Bridge. Periop Anticoagulation Management. Don Weinshenker, MD Ambulatory Care Denver VAMC To Bridge or Not to Bridge Periop Anticoagulation Management Don Weinshenker, MD Ambulatory Care Denver VAMC Financial Disclosure Information Nothing to report Periop AC Management Chronically anti-coagulated

More information

National Patient Safety Goals Effective January 1, 2015

National Patient Safety Goals Effective January 1, 2015 National Patient Safety Goals Effective January 1, 2015 Goal 1 Improve the accuracy of resident identification. NPSG.01.01.01 Long Term are ccreditation Program Medicare/Medicaid ertification-based Option

More information

Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012

Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012 Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012 Agenda Ideal anticoagulant. Drawbacks of warfarin. Rivaroxaban in clinical trails. Present

More information

CDEC RECORD OF ADVICE

CDEC RECORD OF ADVICE CDEC RECORD OF ADVICE RIVAROXABAN (Xarelto Bayer Inc.) Indication: Deep Vein Thrombosis Without Symptomatic Pulmonary Embolism This document summarizes the Canadian Drug Expert Committee (CDEC) response

More information

Published 2011 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018. AAOS Clinical Practice Guidelines Unit

Published 2011 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018. AAOS Clinical Practice Guidelines Unit Volume 4. AAOS Clinical Guideline on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty Comparison with Other Guidelines Disclaimer This clinical guideline

More information

Committee Approval Date: September 12, 2014 Next Review Date: September 2015

Committee Approval Date: September 12, 2014 Next Review Date: September 2015 Medication Policy Manual Policy No: dru361 Topic: Pradaxa, dabigatran Date of Origin: September 12, 2014 Committee Approval Date: September 12, 2014 Next Review Date: September 2015 Effective Date: November

More information

Clive Kearon, Susan R. Kahn, Giancarlo Agnelli, Samuel Goldhaber, Gary E. Raskob and Anthony J. Comerota. DOI 10.1378/chest.

Clive Kearon, Susan R. Kahn, Giancarlo Agnelli, Samuel Goldhaber, Gary E. Raskob and Anthony J. Comerota. DOI 10.1378/chest. Antithrombotic Therapy for Venous Thromboembolic Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Clive Kearon, Susan R. Kahn, Giancarlo Agnelli,

More information

CLINICAL QUALITY MEASURES FINALIZED FOR ELIGIBLE HOSPITALS AND CRITICAL ACCESS HOSPITALS BEGINNING WITH FY 2014

CLINICAL QUALITY MEASURES FINALIZED FOR ELIGIBLE HOSPITALS AND CRITICAL ACCESS HOSPITALS BEGINNING WITH FY 2014 CLINICAL QUALITY MEASURES FINALIZED FOR ELIGIBLE HOSPITALS AND CRITICAL ACCESS HOSPITALS BEGINNING WITH FY 2014 e 55 0495 2 Emergency Department (ED)- 1 Emergency Department Throughput Median time from

More information

Use of Antithrombotic Agents In The Presence Of Neuraxial Anesthesia

Use of Antithrombotic Agents In The Presence Of Neuraxial Anesthesia Use of Antithrombotic Agents In The Presence Of Neuraxial Anesthesia Insertion, removal or presence of a catheter in selected sites can place a patient who is antithrombotic agent at risk for a local bleeding

More information

The largest clinical study of Bayer's Xarelto (rivaroxaban) Wednesday, 14 November 2012 07:38

The largest clinical study of Bayer's Xarelto (rivaroxaban) Wednesday, 14 November 2012 07:38 Bayer HealthCare has announced the initiation of the COMPASS study, the largest clinical study of its oral anticoagulant Xarelto (rivaroxaban) to date, investigating the prevention of major adverse cardiac

More information

rivaroxaban 15mg and 20mg film-coated tablets (Xarelto ) SMC No. (852/13) Bayer plc

rivaroxaban 15mg and 20mg film-coated tablets (Xarelto ) SMC No. (852/13) Bayer plc rivaroxaban 15mg and 20mg film-coated tablets (Xarelto ) SMC No. (852/13) Bayer plc 08 February 2013 The Scottish Medicines Consortium (SMC) has completed its assessment of the above product and advises

More information

Pathway for the management of DVT in primary Care

Pathway for the management of DVT in primary Care Pathway for the management of DVT in primary Care Final Version: Approved by NHS DGS CCG: June 2015 This document aims to support practices in DGS CCG in the Management & Treatment of patients with suspected

More information

New Anticoagulants: When and Why Should I Use Them? Disclosures

New Anticoagulants: When and Why Should I Use Them? Disclosures Winship Cancer Institute of Emory University New Anticoagulants: When and Why Should I Use Them? Christine L. Kempton, MD, MSc Associate Professor of Pediatrics and Hematology and Medical Oncology Hemophilia

More information

How To Get A Dose Of Bayer Healthcare'S Oral Anticoagulant, Xarelto

How To Get A Dose Of Bayer Healthcare'S Oral Anticoagulant, Xarelto News Release FOR UK HEALTHCARE MEDIA ONLY Bayer HealthCare Bayer plc Bayer House Strawberry Hill Newbury Berkshire, RG14 1JA www.bayer.co.uk Bayer s Xarelto (rivaroxaban) Recommended by CHMP for EU Approval

More information

Common Drug Review Pharmacoeconomic Review Report

Common Drug Review Pharmacoeconomic Review Report Common Drug Review Pharmacoeconomic Review Report August 2015 Drug rivaroxaban (Xarelto) Indication Listing request Manufacturer Treatment of venous thromboembolic events (deep vein thrombosis [DVT], pulmonary

More information

Gruppo di lavoro: Malattie Tromboemboliche

Gruppo di lavoro: Malattie Tromboemboliche Gruppo di lavoro: Malattie Tromboemboliche 2381 Soluble Recombinant Thrombomodulin Ameliorates Hematological Malignancy-Induced Disseminated Intravascular Coagulation More Promptly Than Conventional Anticoagulant

More information

Paul G. Lee. 2 ND YEAR RESEARCH ELECTIVE RESIDENT S JOURNAL Volume III, 1998-1999. A. Objective

Paul G. Lee. 2 ND YEAR RESEARCH ELECTIVE RESIDENT S JOURNAL Volume III, 1998-1999. A. Objective A comparison of six months of anticoagulation with extended anticoagulation for a first episode of venous thromboembolism in patients with thrombophilia Paul G. Lee A. Objective a. To evaluate the risk

More information

Using CDS (Clinical Decision Support) for Quality Initiatives at a Community Hospital

Using CDS (Clinical Decision Support) for Quality Initiatives at a Community Hospital Using CDS (Clinical Decision Support) for Quality Initiatives at a Community Hospital Jonathan Sykes MD, CMIO Jacalyn Liebowitz RN, MBA,NEA-BCFACHE VP Care Continuum Allegiance Health - Jackson, MI DISCLAIMER:

More information

New Anticoagulants for the Treatment of Thromboembolism With a little subplot on superficial thrombophlebitis. Mark Crowther

New Anticoagulants for the Treatment of Thromboembolism With a little subplot on superficial thrombophlebitis. Mark Crowther New Anticoagulants for the Treatment of Thromboembolism With a little subplot on superficial thrombophlebitis Mark Crowther 1 Disclosures Advisory Boards in last 24 months Pfizer, Alexion, Bayer, CSL Behring,

More information

Traditional anticoagulants

Traditional anticoagulants TEGH Family Practice Clinic Day April 4, 03 Use of Anticoagulants in 03: What s New (and What Isn t) Bill Geerts, MD, FRCPC Director, Thromboembolism Program, Sunnybrook HSC Professor of Medicine, University

More information

NHS FIFE WIDE POLICY - HAEMATOLOGY MANAGEMENT OF ANTICOAGULATION THERAPY DURING MAJOR AND MINOR ELECTIVE SURGERY

NHS FIFE WIDE POLICY - HAEMATOLOGY MANAGEMENT OF ANTICOAGULATION THERAPY DURING MAJOR AND MINOR ELECTIVE SURGERY MANAGEMENT OF ANTICOAGULATION THERAPY DURING MAJOR AND MINOR ELECTIVE SURGERY The scope of this guideline is to simplify the management of patients on oral anticoagulation undergoing major and minor surgery.

More information

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012 The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era CCRN State of the Heart 2012 June 2, 2012 Disclosures I have I have been involved in trials of new anticoagulants and have received

More information

Preventing Blood Clots After Hip or Knee Replacement Surgery or Surgery for a Broken Hip. A Review of the Research for Adults

Preventing Blood Clots After Hip or Knee Replacement Surgery or Surgery for a Broken Hip. A Review of the Research for Adults Preventing Blood Clots After Hip or Knee Replacement Surgery or Surgery for a Broken Hip A Review of the Research for Adults Is This Information Right for Me? Yes, if: You are considering or planning to

More information

Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain

Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain Dr Alexander (Ander) Cohen Guy s and St Thomas Hospitals, King s College London, UK Pavia Spring Meeting 13 June 2014 Overview

More information

CHEST Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed Sarah Meyer, PharmD November 9, 2012

CHEST Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed Sarah Meyer, PharmD November 9, 2012 CHEST Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed Sarah Meyer, PharmD November 9, 2012 1. CHEST has made a few changes 1 a. For patients sufficiently healthy to be treated as outpatients,

More information

Prior Authorization Guideline

Prior Authorization Guideline Guideline Guideline Name Formulary Xarelto (rivaroxaban) UnitedHealthcare Community & State Approval Date 0/0/203 Revision Date 8//204 Technician Note: CPS Approval Date: /5/20; CPS Revision Date: 8/20/204

More information

University of Illinois at Chicago College of Pharmacy. Hospital Compliance with Proposed JCAHO Performance Measures for VTE

University of Illinois at Chicago College of Pharmacy. Hospital Compliance with Proposed JCAHO Performance Measures for VTE 1 Hospital Compliance with Proposed JCAHO Performance Measures for VTE Vikrant Vats, PhD Post Doc Research Associate Center of Pharmacoeconomic Research Background/Rationale Venous thromboembolism (VTE)

More information

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk Anticoagulation at the end of life Rhona Maclean Rhona.maclean@sth.nhs.uk Content Anticoagulant Therapies Indications for anticoagulation Venous thromboembolism (VTE) Atrial Fibrillation Mechnical Heart

More information

Antithrombotic therapy

Antithrombotic therapy Orthogeriatrics Clinical Summary Document Antithrombotic therapy Topics Preexisting anticoagulation and timing of surgery Reversal of anticoagulation Perioperative thromboprophylaxis When should we be

More information

Pharmacological prophylaxis for venous thromboembolism

Pharmacological prophylaxis for venous thromboembolism Pharmacological prophylaxis for venous thromboembolism Essence of this ArticleFor more than 20 years, routine preventive anticoagulant therapy has been the standard of care after major orthopaedic surgery.

More information

Guidelines for diagnosis and management of acute pulmonary embolism

Guidelines for diagnosis and management of acute pulmonary embolism Guidelines for diagnosis and management of acute pulmonary embolism By Dr. Ahmed Zaghloul M.D. Anesthesia & Critical Care 2014 Predisposing factors for VTE Predisposing factor Strong predisposing factors

More information

USE AND INTERPRETATION OF LABORATORY COAGULATION TESTS IN PATIENTS WHO ARE RECEIVING A NEW ORAL ANTICOAGULANT (DABIGATRAN, RIVAROXABAN, APIXABAN)

USE AND INTERPRETATION OF LABORATORY COAGULATION TESTS IN PATIENTS WHO ARE RECEIVING A NEW ORAL ANTICOAGULANT (DABIGATRAN, RIVAROXABAN, APIXABAN) USE AND INTERPRETATION OF LABORATORY COAGULATION TESTS IN PATIENTS WHO ARE RECEIVING A NEW ORAL ANTICOAGULANT (DABIGATRAN, RIVAROXABAN, APIXABAN) TARGET AUDIENCE: All Canadian health care professionals:

More information

PROTOCOL TITLE: Ambulatory Initiation and Management of Warfarin for Adults

PROTOCOL TITLE: Ambulatory Initiation and Management of Warfarin for Adults PROTOCOL NUMBER: 7 PROTOCOL TITLE: Ambulatory Initiation and Management of Warfarin for Adults THIS PROTOCOL APPLIES TO: UW Health Clinics: all adult outpatients with an active order for warfarin TARGET

More information

STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach

STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach Jeffrey I Weitz, MD, FRCP(C), FACP Professor of Medicine and Biochemistry McMaster University Canada Research Chair in Thrombosis

More information

Management for Deep Vein Thrombosis and New Agents

Management for Deep Vein Thrombosis and New Agents Management for Deep Vein Thrombosis and New Agents Mark Malesker, Pharm.D., FCCP, FCCP, FASHP, BCPS Professor of Pharmacy Practice and Medicine Creighton University 5 th Annual Creighton Cardiovascular

More information

Safety indicators for inpatient and outpatient oral anticoagulant care

Safety indicators for inpatient and outpatient oral anticoagulant care Safety indicators for inpatient and outpatient oral anticoagulant care 1 Recommendations from the British Committee for Standards in Haematology (BCSH) & National Patient Safety Agency (NPSA) Address for

More information

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below

HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below Name: generic (trade) Rivaroxaban (Xarelto ) HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) RIVAROXABAN RECOMMENDED see specific recommendations for licensed indications below What it is Indications

More information

Cost Effectiveness of Apixaban (Eliquis ) for the Prevention of Venous Thromboembolic Events in Adult Patients who have Undergone Elective Total Hip

Cost Effectiveness of Apixaban (Eliquis ) for the Prevention of Venous Thromboembolic Events in Adult Patients who have Undergone Elective Total Hip Cost Effectiveness of Apixaban (Eliquis ) for the Prevention of Venous Thromboembolic Events in Adult Patients who have Undergone Elective Total Hip Replacement or Total Knee Replacement National Centre

More information

2.5mg SC daily. INR target 2-3 30 mg SC q 12 hr or 40mg daily. 10 mg PO q day (CrCl 30 ml/min). Avoid if < 30 ml/min. 2.

2.5mg SC daily. INR target 2-3 30 mg SC q 12 hr or 40mg daily. 10 mg PO q day (CrCl 30 ml/min). Avoid if < 30 ml/min. 2. Anticoagulation dosing at UCDMC (SC=subcutaneously; CI=continuous infusion) Indication Agent Dose Comments Prophylaxis Any or No bleeding risk factors see adult heparin (VTE prophylaxis) IV infusion order

More information

Dabigatran (Pradaxa) Guidelines

Dabigatran (Pradaxa) Guidelines Dabigatran (Pradaxa) Guidelines Dabigatran is a new anticoagulant for reducing the risk of stroke in patients with atrial fibrillation. Dabigatran is a direct thrombin inhibitor, similar to warfarin, without

More information

Eliquis. Policy. covered: Eliquis is. indicated to. reduce the. therapy. Eliquis is. superior to. of 32 to. Eliquis is AMPLIFY. nonfatal. physicians.

Eliquis. Policy. covered: Eliquis is. indicated to. reduce the. therapy. Eliquis is. superior to. of 32 to. Eliquis is AMPLIFY. nonfatal. physicians. Eliquis (apixaban) Policy Number: 5.01.573 Origination: 06/2014 Last Review: 07/2015 Next Review: 07/2016 Policy BCBSKC will provide coverage for Eliquis when it is determined to be medically necessary

More information

Executive Summary. Motive for the request for advice

Executive Summary. Motive for the request for advice Executive Summary Motive for the request for advice Currently nearly 400,000 people in the Netherlands are being treated with anticoagulants of a type Vitamin K antagonists (VKAs). Although VKAs are very

More information

Oxford Anticoagulation & Thrombosis Service Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

Oxford Anticoagulation & Thrombosis Service Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Oxford University Hospitals NHS Trust Oxford Anticoagulation & Thrombosis Service Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Information for people with a blood clot (thrombus) What is this

More information

Prescriber Guide. 20mg. 15mg. Simply Protecting More Patients. Simply Protecting More Patients

Prescriber Guide. 20mg. 15mg. Simply Protecting More Patients. Simply Protecting More Patients Prescriber Guide 20mg Simply Protecting More Patients 15mg Simply Protecting More Patients 1 Dear Doctor, This prescriber guide was produced by Bayer Israel in cooperation with the Ministry of Health as

More information