Evaluation of Patients with Suspected Pulmonary Embolism; and NOAC Therapy for VTE

Transcription

1 Evaluation of Patients with Suspected Pulmonary Embolism; and NOAC Therapy for VTE Matthew Rice, M.D., M.B.A. Hospitalist Fellow, Womack Army Medical Center

2 Objectives Know how to safely and effectively exclude and diagnose pulmonary embolism Understand appropriate use of pre-test probability assessments, laboratory evaluation, and radiologic evaluation in patients with suspected pulmonary embolism Understand the indications and contraindications of NOAC s, and considerations when choosing anticoagulants for patients with VTE Review for the ABFM exam

3 Case #1 43 year old obese female, 2 weeks postpartum, with family history notable for mother with DVT/PE presents to ED with 5 hours of chest pain and dyspnea. Yesterday she flew from LAX to FAY after visiting her parents. While in CA, she fractured her L 5 th MT during a minor fall, and is ambulating in a CAM walker. She has no history of VTE. She has no history of cancer. She takes no medications. She has no hemoptysis or leg pain or swelling. Vital signs are normal with the exception of hypertension (P 70, BP 143/94, R 14, SPO2, 95%, T 100.1F. Exam is unrevealing. Chest x-ray is normal with exception of possible LLL atelectasis. ECG shows NSR with non-specific TW abnormalities. What is your next step? She does not have PE. Look for other causes of her symptoms Order D-dimer Order BLE duplex U/S Order CT-PA?Other

4 Gestalt: The general quality or character of something. True or False: If the physician evaluating the patient thinks that she has a high likelihood of pulmonary embolism, the physician should proceed directly to CT- PA.

5 Why is this so hard?

6 Do Clinicians Apply the Evidence? Substantial proportions of lowintermediate risk patients do not have D- dimer levels drawn; or do have CT-PA done despite normal D-dimer levels. Many patients with elevated D-dimer levels do not have CT-PA done. Why this significant variance and nonadherence to evidence-based guidelines?

7 Pre-test Probability

8 PERC Rule

9 Summary Wells or Geneva Score (pre-test probability) Low Intermediate High Pos PERC D- dimer Pos Neg Pos Neg Neg

10 Board Review #1 Which validated clinical prediction rule should clinicians use to estimate pre-test probability of PE? a. Wells b. Simplified Wells c. Geneva d. Simplified Geneva e. Any of the above

11 Board Review #2 A patient being evaluated for PE has a low probability Geneva score and negative PERC score. Should you obtain a D- dimer? a. Yes b. No

12 Board Review #3 What is an acceptable miss rate for PE in the ED? Why? a. 1% b. 2% c. 5% d. 7%

13 Board Review #4 Which of the following portend greater risk of mortality in PE patients? a. Elevated troponin b. Elevated BNP c. Hypotension d. TTE with RV dysfunction e. A & C f. All of the above g. None of the above

14 Board Review #5 Mr. Jones, a 57 y/o male has an intermediate likelihood of PE based on the Geneva score (5). You order a plasma D- dimer level and it results 530 ug/l. You decide to: a. Stop the work-up b. Order a CT-PA

15 Board Review #6 Mrs. Smith, 66 y/o, has a Geneva score of 7 (high probability). Her points are for age, previous PE, diagnosis of breast cancer 6 months ago, and left sided leg pain. You should: a. Order a D-dimer b. Order a CT-PA c. Apply the PERC rule d. Stop the work up e. Order an ultrasound of her legs

16 Board Review #7 Warfarin was patented in the 1940 s as a rodent control agent, and the name is derived from: a. Wharf Anti-Rat Formula b. Wisconsin Alumni Research Foundation

17 Board Review #8 You are treating a hospitalized patient for severe community acquired pneumonia, and suspect a P.E. Your initial evaluation is: a. Application of Wells or Geneva scores b. D-dimer c. LE duplex U/S d. CT-PA e. c or d.

18 NOAC s in VTE Disease New Oral Anticoagulants Novel Oral Anticoagulants Direct Anticoagulants Target Specific Oral Anticoagulants

19 Which are factor Xa inhibitors? Eliquis? Xarelto? Savaysa? Pradaxa? ApiXaban? RivaroXaban? EdoXaban? Dabigatran?

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21 Indications (FDA) To reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation. For the treatment of DVT and PE, and for the reduction in the risk of recurrent DVT and PE following initial therapy. For the prophylaxis of DVT in patients who have undergone hip or knee replacement surgery. ApiXaban (Eliquis) X X X RivaroXaban (Xarelto) X X X EdoXaban (Savaysa) X X Dabigatran (Pradaxa) X X

22 Contraindications Renal insufficiency (CrCL<30ml/min) Significant liver disease Drug-drug interactions Increased NOAC effect: e.g. ketoconazole, anti-retrovirals Reduced NOAC effect: e.g. rifampin, St. John s Wort, carbamazepine, phenytoin Recent significant bleeding with high likelihood of recurrence Patients with malignancy Pregnancy/Breastfeeding Extremes of weight and age: consult with your PharmD

23 Efficacy & Safety RivaroXaban (Xarelto) ApiXaban (Eliquis) EdoXaban (Savaysa) Dabigatran (Pradaxa) Warfarin (Coumadin) Efficacy 2.1% 2.3% 3.2% 2.1% % Safety % 4.3% 8.5% % % Efficacy = percentage of patients having recurrent VTE or VTErelated death. Safety = percentage of patients having clinically relevant bleeding (e.g. death, critical organ involvement, Hgb drop of 2g/dl; hospital admission, medical or surgical treatment, change in therapy). Dabigatran is associated with % annual absolute risk increase in ACS (vs. Coumadin). There are no NOAC head-to-head trials for direct comparison.

24 Treatment Initiation &Transition Initiation Transitioning from Coumadin RivaroXaban (Xarelto) 15mg B.I.D. x 21D; then 20mg daily ApiXaban (Eliquis) 10mg B.I.D. x7d; then 5mg B.I.D. EdoXaban (Savaysa) 60mg daily after 7 days of standard treatment (e.g. lovenox) Start when INR <3 Start when INR <2 Start when INR <2.5 Dabigatran (Pradaxa) 150mg B.I.D. after 7 days of standard treatment (e.g. lovenox) Start when INR <2 Transitioning to Coumadin Transitioning from one NOAC to another Impending surgical interventions * * * * Stop NOAC and begin new NOAC at time the next scheduled dose of original NOAC was due. Stop NOAC >/=24H prior to procedure Reference Lexicomp or consult PharmD. Stop NOAC and begin new NOAC at time the next scheduled dose of original NOAC was due. Stop NOAC >/=24H prior to procedure Stop NOAC and begin new NOAC at time the next scheduled dose of original NOAC was due. Stop NOAC >/=24H prior to procedure Stop NOAC and begin new NOAC at time the next scheduled dose of original NOAC was due. Stop NOAC >/=24H prior to procedure

25 Monitoring & Reversal RivaroXaban (Xarelto) ApiXaban (Eliquis) EdoXaban (Savaysa) Dabigatran (Pradaxa) Monitoring Renal function Renal function Renal function Renal function Half-life 5-9 hours 12 hours 8-10 hours hours Reversal Prothrombin complex concentrate (PCC), tranexamic acid, activated charcoal Prothrombin complex concentrate (PCC), tranexamic acid, activated charcoal Prothrombin complex concentrate (PCC), tranexamic acid, activated charcoal Praxbind (idarucizumab); dialysis All patients on anticoagulatants should be monitored for adherence, signs/syptoms of bleeding, recurrence of thrombolembolic events and other adverse events.

26 The Conversation What factors will you discuss with patients when considering NOAC vs warfarin? When considering NOAC 1 vs. NOAC 2? I have a history of a GI bleed, but definitely do not want to die of a PE. My memory isn t what it used to be. I have mild chronic kidney disease. I m trying to improve my diet by eating more salads I take medications for epilepsy. What about all those litigation ads on TV? I had a heart attack in My dad died of a bleeding ulcer. My priority is safety. I don t have time for frequent visits to the lab. I have mitral valve stenosis (or a prosthetic heart valve). My coumadin level is always too high or too low, it seems.

27 References Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians Review of the clinical trials The New Oral Anticoagulants for the Treatment of Venous Thromboembolism : VA TSOAC criteria for use, & algorithm: ulants_target_specific_oral_tsoac_cfu_and_algorithm_for_ve nous_thromboembolism_vte_treatment.pdf