Haematology for GP s Part 2. Anticoagulation in DVT and PE VTE. Introduction. DVT Principles of diagnosis. VTE in Bradford
|
|
- Miranda Bryant
- 8 years ago
- Views:
Transcription
1 Haematology for GP s Part 2 Anticoagulation in DVT and PE Introduction NICE guidelines DVT and PE diagnosis and treatment Warfarin New anticoagulants Cases VTE VTE is an important cause of morbidity and mortality in the UK >64,000 patients diagnosed with VTE per year Managing VTE costs the NHS 640 million/year VTE in Bradford DVT Principles of diagnosis Other 19% Mechanical heart valves DVT 8% PE 8% Recurrent DVT 4% Recurrent PE 2% Wells score D-dimer USS 9% AF 50% DVT 150 new patients per year PE 150 cases per year 1
2 Wells Score Clinical diagnosis is difficult Risk Factors can predict Wells score >/=3 points: high risk (53%); 1 to 2 points: moderate risk (17%); <1 point: low risk (5%). Profesor Philip Wells The Ottawa Hospital The original 1997 DVT Wells score used a three-level risk stratification system. D-Dimer The negative predictive value of D-dimer Different quality of D-dimer tests Used in conjunction with Wells Score If Low risk If Moderate risk If High risk negative d-dimer 99% no DVT 96% no DVT 84% no DVT The 2003 version (which is referred to in the literature as updated, modified, revised or two-level ) uses two levels of risk stratification US legs Compressive US Three point compression Above knee only US Positive for DVT US vein - Colour Flow Compression 2
3 What about the calf veins? US calf veins is less sensitive for detection of below knee DVT NICE CG144 DVT diagnosis Three calf veins are not always seen Takes longer to do If negative, still need repeat in high risk Score 1 or less DVT unlikely Score 2 or more DVT likely Diagnostic Referral form Bradford GP Pathway PE diagnosis unlikely Wells 3
4 PE likely on wells score Treating VTE Duration of anticoagulation therapy NICE guidance Idiopathic or provoked Risks for bleeding Previous thrombosis Severity and type of thrombosis Post thrombotic syndrome On going risk factors D-Dimer / FVIII levels Investigating Unprovoked VTE All patients with unprovoked DVT or PE : Full physical examination as directed by history Chest X-ray Urinalysis FBC, Ca2+, LFTs If first VTE and >40 years old: CT abdomen/pelvis Mammogram Thrombophilia Testing Do not do routinely Do not test if continuing anticoagulation long term Do not test if provoked VTE Do not test relatives of patients with VTE routinely Consider testing if Unprovoked VTE and 1 st degree relative has had a VTE Consider Antiphospholipid antibody screen if Unprovoked VTE and stopping anticoagulation 4
5 Patient Verbal and Written information What is a VTE? What caused the VTE? How is it treated? Does the clot disappear? Can it cause long term damage? Will it happen again? How can I reduce the chance of another one? What about my family? What about pregnancy? What contraception is OK? Can I fly? Post thrombotic syndrome Diagnosis complications Prevention - Class 2 Below knee graduated compression stockings on affected leg for 2 years Risk for recurrence of DVT What is warfarin? Warfarin Haemorrhaging cows in 1920 s due to eating sweet clover in hay (not fresh) Coumarin derivative synthesised 1948 Vitamin K antagonist inhibits vitamin K epoxide reductase Inhibits carboxylation of FII, FVII, FIX, FX, PC, PS PIVKA (proteins induced in vitamin K absence) accumulate but no function (can be measured) Warfarin 2 isomers S and R Takes 2-3 days to work (while previously activated forms degrade) FII takes longest to reduce PC also reduced so initial pro-thrombotic phase covered by LMWH Six weeks v six months warfarin 1 st event 5
6 3 months or longer for unprovoked DVT Six months or Long term for 2 nd VTE Recurrence risk VTE (next 12 months) Provoked surgical event 0.5% Provoked non-surgical 1-2% Unprovoked 8-10% Unprovoked and positive antiphospholipid antibodies 20-40% Risk of bleeding whilst on oral anticoagulation INR Bleedingevents per 100 patient years >7 200 ISCOAT study: Lancet 1996 Novel Oral Anticoagulants (NOAC) 6
7 1 Moderate to Severe bleeding: - reduction in Hb 2gd/L, transfusion of 2 units of red cells or symptomatic bleeding in critical area (i.e. requiring inotropic agents or bleeding requiring surgical intervention. Comparison Using Rivaroxaban what to watch out for Renal function CrCl<15 contraindicated CrCl caution (consider reduce dose to 15mg daily after 3 weeks) Liver function Coagulopathy or Child Pugh B/C contraindicated Drug interactions- CYP3A4 inhibitors - Eg Azoles, HIV protease inhibitors, (clarithromycin) CYP3A4 inducers Rifampicin, some antiepileptics Currently only Rivaroxaban licensed for treatment of DVT and PE Stop Antiplatelet drugs Stop NSAIDs if possible Rivaroxaban prior to surgery / procedures Reversal of rivaroxaban Bradford Teaching Hospitals NHS Trust Guideline for management of bleeding (and urgent reversal in case of need for emergency surgery) in patients on rivaroxaban Rivaroxaban is an oral factor Xa inhibitor with a half life of 7-11 hours and mostly renal 66% excretion. There is no licensed reversal agent for rivaroxaban. Rivaroxaban-related bleeding Or requirement for urgent reversal in case of need for emergency surgery Rivaroxaban (Xarelto ): Patients should be given instructions on when to take their last dose, dependent on the type of procedure and their usual dose of rivaroxaban. Major surgery or high bleeding risk or spinal/epidural anaesthesia on 15mg/20mg rivaroxaban OD STOP rivaroxaban Assess clinical bleeding 1,2 and resuscitate patient as appropriate. May need to act before lab results are back in emergency. Check: FBC, G&S, U&E and Clotting screen, PT, APTT, TT, Fibrinogen, d-dimer Rivaroxaban prolongs PT if PT is normal rivaroxaban levels are low. Consider rivaroxaban plasma level Indicate time of last rivaroxaban dose when requesting test and considering management options. Mild bleeding Moderate-Severe bleeding Life-threatening or site critical bleeding Delay next dose or discontinue treatment as appropriate. Discuss with haematologist on call Discuss with haematologist on call Minor procedure and low bleeding risk on 15mg or 20mg rivaroxaban OD With normal renal function level of riavaroxaban reduces rapidly in 24 hours Monitor clotting screen and PT Activate massive haemorrhage pathway Symptomatic treatment Consider tranexamic acid (avoid in DIC) Mechanical compression Surgical intervention Activated charcoal (if rivaroxaban ingestion < 2 hours before Fluid replacement and haemodynamic support- ensure good diuresis Consider Prothrombin complex concentrate (Octaplex) (50 units/kg), max 3000 units, IV infusion at 10ml/min blood product support as indicated consider role for interventional vascular radiology Manage as for Moderate- Severe bleeding Give Prothrombin complex concentrate (Octaplex) (50 units/kg), max 3000 units, IV infusion at 10ml/min Reassess clinically Repeat FBC, U&E, Clotting. PT and rivaroxaban level to be monitored intraocular, intracranial, intraspinal, intramuscular with compartment syndrome, retroperitoneal, intraarticular or pericardial bleeding). 2 Life-threatening bleeding: symptomatic intracranial bleed, reduction in Hb 5gd/L, transfusion of 4 units of red cells, hypotension Case 1 Cases 33 year old obese man has a DVT following a cholecystectomy He is a smoker but otherwise well He comes to see you as he is worried about his 2 daughters who are teenagers and whether they may be at risk of thrombosis No one else in his family has had a thrombosis 7
8 Yes I would do thrombophilia testing 1. Would you do thrombophilia testing? 2. What advice would you give him? 3. What advice would you give his children about COCP? Thrombophilia testing shows FV leiden Heterozygous 4. Does this affect what you do? 5. Who would you test in the family? He has 8 sisters 2 brothers and 17 nieces. Case 1 - discussion 1. thrombophilia testing He has 3 risk factors for thrombosis Obesity, surgery, smoking. He is young this is a provoked DVT Thrombophilia testing is not recommended Case 1 2. What advice would you give him. Stop smoking lose weight Class II BK graduated compression stockings for 1 2 years Always try and reverse risk factors for VTE Case 1 3. What advice for his daughters. RCOG recommends that women with a 1 st degree relative <45 years with VTE should avoid COCP Thrombophilia testing does not change this advice Case 1 Does FV leiden heterozygous change what you would do? NO It is common 1 in 20 in UK Only weak risk factor for VTE 2-4x polulation risk No effect on duration of anticoagulation Very slight increased risk of recurrence 8
9 Case 1 5. Who would you test in the family No one Thrombophilia result would not alter advice as FHx is more important i.e. If negative test in relative still have increased risk due to FHx Case 2 A 27 year old teacher comes to see you. She had a DVT aged 19 whilst on the COCP. She is normal weight and a non-smoker. She has 2 sisters who both have had DVT in pregnancy and are known to have PS deficiency. She wishes to become pregnant and asks for a thrombophilia test. 1. Would you do thrombophilia testing? YES I would test her Results shows normal thrombophilia screen Free PS = 0.9 (normal) 2. What is your advice to her now regarding the pregnancy? 3. Does she need LMWH prophylaxis? Case 2 Discussion 1. Would you do a thrombophilia test? She has had a hormone provoked VTE in the past and is already at high risk in pregnancy. Thrombophilia screen would not affect management Case 2 2. What advice regarding pregnancy She is at high risk and would need to start prophylactic LMWH once positive pregnancy test until 6 weeks post partum. She should be referred to the combined Obstetrics/Haematology clinic once pregnant LMWH is safe in pregnancy and for breast feeding. Case 3 A 28 year old taxi driver had a massive PE while out shopping and collapsed in the street. He was admitted to A&E where he was thrombolysed and then started on warfarin. He is previously fit and well. A non-smoker. No recent flights, surgery or immobility. He has no significant symptoms. He has an extensive family but no FHx of VTE. His parents are first cousins. He comes to see you as he is due to complete his 6 months of warfarin soon and is a bit concerned about stopping it. 1. Would you do a thrombophilia test? 2. Would you do any other tests? 3. Would you stop his warfarin? 9
10 YES I would do a thrombophilia test Thrombophilia test normal Case 3 - discussion 1. Would you do a thrombophilia test? 4. Does this effect what you do now? 5. He has 3 young children can you reassure him that at least they wont be effected? He is aged <40. The VTE is unprovoked and there are no obvious risk factors. No FHx so not NICE recommended Would be difficult to test while on anticoagulation Case 3 2. Would you do any other tests? Case 3 3. Would you stop the warfarin It is an unprovoked event and you need to find a cause. Consider rare causes Need to assess risk of recurrence: d-dimer and factor VIII NO It is unprovoked event Massive PE Tend to have similar recurrences ie if DVT first time DVT at recurrence Low bleeding risk Thrombophilia screen result has no impact on duration of anticoagulation Things may change over time if INR difficult to control, alcohol / drug issues etc.. Case 3 4. Does the negative thrombophilia screen change anything? May make you look harder for another cause 5. What would you till the family Increased risk of VTE Avoid COCP Case 4 60 year old man has a DVT following his total hip replacement. He had a thrombophilia screen while in hospital and it shows antithrombin III deficiency (0.56 iu/ml) He has never had a DVT in the past and is otherwise very well, nonsmoker and keen walker. There is a history of VTE in his sister after her knee replacement. His brother has had 2 DVT and is on long term warfarin. He comes to see you because he is not keen on stopping warfarin after 6 months. 1. Are there any questions or tests you may want? 2. Would you stop the warfarin? 3. His daughter is currently in her first pregnancy what advice do you have for her? Would you test ATIII levels? 10
11 Case 4 - Discussion 1. Any questions or tests? Case 4 2. Would you stop the warfarin Would want to know if any on-going risk factors that can be modified eg. Smoking / obesity / post thrombotic syndrome Could test d-dimer and factor VIII level YES - despite Strong family history Strong thrombophilia ATIII deficiency But was provoked event No evidence that positive thrombophilia should effect duration of anticoagulation Case 4 3. Pregnant daughter advice ATIII high thrombophilia risk Can test ATIII in pregnancy (PS and APCR are reduced in pregnancy false positive) I think in her ATIII testing would be useful as such a strong family history. (this is against NICE guidance) However even if negative may need LMWH prophylaxis depending on other risk factors as strong FHx Case 5 A 55 year old business woman is due to fly to Australia. She had a DVT 3 years ago after a hysterectomy. She comes to you for advice about the travel and whether she should take aspirin to prevent clots. 1. What risk factors may effect your advice? 2. What would you advise? Aspirin? LMWH? Other? Case 5 - Discussion 1. Risk Factors Are there any reversible risks: HRT Smoking Obesity Recent surgery Case 5 2. Advice for flight Aisle seat Flight stockings Ankle exercises Try and reduce these risks if possible and avoid flight for 6 weeks post surgery if possible Risk of flights is in fact quite low: 1:4656 risk asymptomatic DVT >4 hour flight Severe PE very rare in flight <8 hours, 5: flights >8 hours NO evidence alcohol / dehydration a risk factor Aspirin not recommended may be a role??? In very high risk consider LMWH (but in general this group on long term warfarin) 11
12 Case 6 40 year old crossword writer has an unprovoked DVT. He did smoke but has now stopped. There is no family history. He has no symptoms of disease and is well. Your colleague did a thrombophilia screen when he last came and he has come for the results prior to stopping his warfarin. Thrombophilia results: PT20210a - not detected FVL mutation not detected Chromogenic functional PC = 0.4 ( ) Free PS = 0.37 ( ) ATIII = 1.1 Lupus screen negative D-dimer <200 (normal) FVIII 97 iu/dl (55 150) Questions 1. What do you advise him about the results? 2. Should you stop the warfarin? Case 6 Discussion 1. The results PC and PS are vitamin K dependent so will be reduced on warfarin. As aged 40 and unprovoked CT to exclude malignancy Consider antiphospholipid antibody screen Case 6 2. Stop warfarin? VTE summary 1. History of thrombosis and risk factors most important YES He had a single unprovoked DVT but he did smoke and has now stopped. Risk recurrence provoked <1% v 5-8% unprovoked in 12 months It was not a life threatening event and was a DVT. His D-dimer is normal. Current advice is 6 months anticoagulation in unprovoked events 2. Reduce risk factors (like you would do in Ischemic heart disease) 3. Thrombophilia testing in general does not effect management (and can open a can of worms!) 4. Results of thrombophilia testing are difficult to interpret and can be effected by many factors 5. Provoked V Unprovoked 6. Role of NOAC in treatment 12
NHS FORTH VALLEY RIVAROXABAN AS TREATMENT FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM IN ADULTS
NHS FORTH VALLEY RIVAROXABAN AS TREATMENT FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM IN ADULTS Date of First Issue 01/12/ 2012 Approved 15/11/2012 Current Issue Date 29/10/2014 Review Date 29/10/2016
More informationEast Kent Prescribing Group
East Kent Prescribing Group Rivaroxaban (Xarelto ) Safety Information Approved by the East Kent Prescribing Group. Approved by: East Kent Prescribing Group (Representing Ashford CCG, Canterbury and Coastal
More informationClinical Guideline N/A. November 2013
State if the document is a Trust Policy/Procedure or a Clinical Guideline Clinical Guideline Document Title: Document Number 352 Version Number 1 Name and date and version number of previous document (if
More informationDVT/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 informationNew 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 informationTitle of Guideline. Thrombosis Pharmacist)
Title of Guideline Contact Name and Job Title (author) Guideline for patients receiving Rivaroxaban (Xarelto ) requiring Emergency Surgery or treatment for Haemorrhage Julian Holmes (Haemostasis and Thrombosis
More informationPrescriber 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 informationNHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation
NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation Date of First Issue 06/06/2012 Approved 06/06/2012 Current Issue Date 06/06/2012 Review Date 06/06/2014 Version 1.1 EQIA Yes /
More informationRivaroxaban: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF
Leeds Rivaroxaban: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF Amber Drug Level 3 (amber drug with monitoring requirements) We have started your
More informationThrombophilia. Steven R. Lentz, M.D. Ph.D. Carver College of Medicine The University of Iowa May 2003
Thrombophilia Steven R. Lentz, M.D. Ph.D. Carver College of Medicine The University of Iowa May 2003 Thrombophilia Hereditary and acquired risk factors for thrombosis Venous thromboembolism Arterial thromboembolism
More informationNHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation
NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation Date of First Issue 06/06/2012 Approved 06/06/2012 Current Issue Date 29/10/2014 Review Date 29/10/2016 Version 1.4 EQIA Yes 01/06/2012
More informationNational Guidance and New Protocols
National Guidance and New Protocols Dr Jane Strong Consultant Haematologist DVT clinical lead Acute VTE chair DAWN AC Twentieth User Group Meeting 8 th October 2012 Autumn dawn Restless geese take flight
More informationTraveller s Thrombosis. Dr. Peter Verhamme Vascular Medicine and Haemostasis UZ Leuven
Traveller s Thrombosis Dr. Peter Verhamme Vascular Medicine and Haemostasis UZ Leuven Case 1: To thromboprophylaxe or not Women, aged 49, BMI 29, Combined Oral Contraceptives. Family history of provoked
More informationWhat 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 informationRivaroxaban: Prescribing Guidance for the treatment of provoked venous thromboembolism (VTE)
Rivaroxaban: Prescribing Guidance for the treatment of provoked venous thromboembolism (VTE) Amber Drug Level 2 Leeds We have started your patient on rivaroxaban for the treatment of provoked VTE (deep
More informationRivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
Implementation of NICE TA 261 Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism Contents 1. Executive summary 2. Introduction
More informationNational Guidance and New Protocols
National Guidance and New Protocols Dr Jane Strong Consultant Haematologist DVT clinical lead Acute VTE chair DAWN AC Twentieth User Group Meeting 8 th October 2012 DVT patient pathway Assessment Diagnosis
More informationAnticoagulation 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 informationThe Prescribing pathway consists of a number of parts:
NHS EAST LANCASHIRE CCG & NHS BLACKBURN WITH DARWEN CCG DVT Primary Care Prescribing Pathway www.elmmb.nhs.uk Introduction www.elmmb.nhs.uk Version 1.2/January 2013 Introduction Blackburn with Darwen and
More informationNHS 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 informationNew Anticoagulants in treatment of DVT. Dr Neil Smith Consultant Haematologist Heart of England NHS Foundation Trust
New Anticoagulants in treatment of DVT Dr Neil Smith Consultant Haematologist Heart of England NHS Foundation Trust Venous thromboembolism UK: 90,000 DVT cases/year, 54,000 of them associated with PE 1
More informationUHS 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 informationINTRODUCTION Thrombophilia deep vein thrombosis DVT pulmonary embolism PE inherited thrombophilia
INTRODUCTION Thrombophilia (Hypercoagulability) is a condition in which a person forms blood clots more than normal. Blood clots may occur in the arms or legs (e.g., deep vein thrombosis DVT), the lungs
More informationVenous 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 informationDabigatran and Its Effect on Bleeding Risk
South West Essex Dabigatran Shared Care Guideline (SCG) Dabigatran SCG for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation Introduction Indication and Licensing
More informationTitle Use of rivaroxaban in suspected DVT in the Emergency Department Standard Operating Procedure. Author s job title. Pharmacist.
Document Control Title Use of rivaroxaban in suspected DVT in the Emergency Department Author Pharmacist Directorate Clinical Support Services Version Date Issued Status 0.1 Oct Draft 2015 1.0 Dec Final
More informationWhat is the appropriate duration of treatment for VTE? Any advances in predicting recurrence?
What is the appropriate duration of treatment for VTE? Any advances in predicting recurrence? Beverley Hunt Thrombosis & Haemostasis, King s College Guy s & St Thomas Trust Medical Director of Lifeblood:
More informationUncontrolled when printed. Version 1.1. Acute Sector. Lead Author/Co-ordinator: Mr Simon Barker Consultant Orthopaedic Surgeon Julie Fraser
Acute Sector NHS Grampian Staff Local Treatment Protocol For Venous Thromoboembolic Prophylaxis Using Rivaroxaban 10mg Tablets In Adult Patients Undergoing Elective Hip Or Knee Replacement Surgery. Lead
More informationPathway 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 informationImpact of new (direct) oral anticoagulants in patient blood management
Impact of new (direct) oral anticoagulants in patient blood management Yulia Lin, MD, FRCPC, CTBS Transfusion Medicine & Hematology, Sunnybrook Health Sciences Centre Dept of Laboratory Medicine & Pathobiology,
More informationNew 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 informationHERTFORDSHIRE 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 informationThe author has no disclosures
Mary Bradbury, PharmD, BCPS Clinical Pharmacy Specialist, Cardiac Surgery September 18, 2012 Mary.bradbury@inova.org This presentation will discuss unlabeled and investigational use of products The author
More information3/3/2015. Patrick Cobb, MD, FACP March 2015
Patrick Cobb, MD, FACP March 2015 I, Patrick Cobb, MD, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict
More informationINTRODUCTION Thrombophilia deep vein thrombosis DVT pulmonary embolism PE inherited thrombophilia
INTRODUCTION Thrombophilia (Hypercoagulability) is a condition in which a person forms blood clots more than normal. Blood clots may occur in the arms or legs (e.g., deep vein thrombosis DVT), the lungs
More informationLow 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 informationDabigatran (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 informationImplementation of NICE TAs 261 and 287
Corby Clinical Commissioning Group Kettering General Hospital NHS Trust Nene Clinical Commissioning Group Northampton General Hospital NHS Trust Northamptonshire Healthcare Foundation Trust Implementation
More informationA PATIENT S GUIDE TO PULMONARY EMBOLISM TREATMENT
A PATIENT S GUIDE TO PULMONARY EMBOLISM TREATMENT This medicine is subject to additional monitoring. This will allow quick identification of new safety information. If you get any side effects, talk to
More informationDr Gordon Royle Haematologist, Middlemore Hospital
The New Oral Anticoagulants (NOACs) Dr Gordon Royle Haematologist, Middlemore Hospital Disclaimers Boehringer-Ingelheim Bayer Sanofi Douglas Pharmaceuticals Preventing disasters: lessons learned A cautionary
More informationXabans Good for What Ails Ya? Brian Tiffany, MD, PhD, FACEP Dept of Emergency Medicine Chandler Regional Medical Center Mercy Gilbert Medical Center
Xabans Good for What Ails Ya? Brian Tiffany, MD, PhD, FACEP Dept of Emergency Medicine Chandler Regional Medical Center Mercy Gilbert Medical Center DISCLOSURES No relevant financial disclosures I will
More informationA PATIENT S GUIDE TO DEEP VEIN THROMBOSIS TREATMENT
A PATIENT S GUIDE TO DEEP VEIN THROMBOSIS TREATMENT This medicine is subject to additional monitoring. This will allow quick identification of new safety information. If you get any side effects, talk
More informationDr Gordon Royle Haematologist, Middlemore Hospital
The New Oral Anticoagulants (NOACs) Dr Gordon Royle Haematologist, Middlemore Hospital Disclaimers Boehringer-Ingelheim Bayer Sanofi Douglas Pharmaceuticals Preventing disasters: lessons learned A cautionary
More informationPaul 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 informationDabigatran: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF
Leeds Dabigatran: Amber Drug Guidance for the prevention of stroke and systemic embolism in patients with non-valvular AF Amber Drug Level 3 (amber drug with monitoring requirements) We have started your
More informationDrug name: RIVAROXABAN (Xarelto ) For the treatment of acute venous thromboembolism in adult patients.
Drug name: RIVAROXABAN (Xarelto ) For the treatment of acute venous thromboembolism in adult patients. DOCUMENT TO BE SCANNED INTO ELECTRONIC RECORDS AS AND FILED IN NOTES Patient Name : Date of Birth:
More informationComparison between New Oral Anticoagulants and Warfarin
Comparison between New Oral Anticoagulants and Warfarin Warfarin was the mainstay of oral anticoagulant therapy until the recent discovery of more precise targets for therapy. In recent years, several
More informationRivaroxaban for the treatment of Deep Vein Thrombosis in patients unsuitable for vitamin K antagonists
Rivaroxaban for the treatment of Deep Vein Thrombosis in patients unsuitable for vitamin K antagonists Traffic light classification- Amber 2 specialist initiation Information sheet for Primary Care Prescribers
More informationNew 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 informationInformation 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 informationTo assist clinicians in the management of minor, major, and/or life-threatening bleeding in patients receiving new oral anticoagulants (NOACs).
MANAGEMENT OF BLEEDING IN PATIENTS WHO ARE RECEIVING A NEW ORAL ANTICOAGULANT (DABIGATRAN, RIVAROXABAN, APIXABAN) TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To assist clinicians
More informationTrust Guideline for Thromboprophylaxis in Trauma and Orthopaedic Inpatients
A clinical guideline recommended for use In: By: For: Key words: Department of Orthopaedics, NNUHT Medical staff Trauma & Orthopaedic Inpatients Deep vein thrombosis, Thromboprophylaxis, Orthopaedic Surgery
More informationConfirmed 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 informationThe Role of the Newer Anticoagulants
The Role of the Newer Anticoagulants WARFARIN = Coumadin DAGIBATRAN = Pradaxa RIVAROXABAN = Xarelto APIXABAN = Eliquis INDICATION DABIGATRAN (Pradaxa) RIVAROXABAN (Xarelto) APIXABAN (Eliquis) Stroke prevention
More informationSpeaker Disclosure. Outline. Pharmacist Objectives. Patient Case. Outline 9/4/2014
Speaker Disclosure Matthew K. Pitlick, Pharm.D., BCPS St. Louis College of Pharmacy/VA St. Louis HCS mpitlick@stlcop.edu Matthew K. Pitlick, Pharm.D., BCPS declares no conflicts of interest, real or apparent,
More informationBirmingham, Sandwell and Solihull Cardiac and Stroke Network. Rivaroxaban or warfarin for treatment of Atrial Fibrillation: Position statement
Birmingham, Sandwell and Solihull Cardiac and Stroke Network Rivaroxaban or warfarin for treatment of Atrial Fibrillation: Position statement Introduction This guidance informs prescribers and commissioners
More informationWarfarin and Novel Anti-Coagulants: Management Before and After the Cath Lab
Warfarin and Novel Anti-Coagulants: Management Before and After the Cath Lab Drew Baldwin, MD Virginia Mason Seattle, Washington NCVH May 28, 2015 2:30 pm I have no disclosures. Stroke risk reduction in
More informationMCHENRY WESTERN LAKE COUNTY EMS SYSTEM OPTIONAL CE ADVANCED LEVEL (EMTP, PHRN, ECRN) August 2013. Anticoagulants
MCHENRY WESTERN LAKE COUNTY EMS SYSTEM OPTIONAL CE ADVANCED LEVEL (EMTP, PHRN, ECRN) August 2013 Anticoagulants Anticoagulants are agents that prevent the formation of blood clots. Before we can talk about
More informationTraditional 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 information5/21/2012. Perioperative Use Issues. On admission: During hospitalization:
Dabigatran and Rivaroxaban: Challenges in the Perioperative Setting Claudia Swenson, Pharm.D., CDE, BC-ADM, FASHP Central Washington Hospital Wenatchee, WA claudia.swenson@cwhs.com Dabigatran and Rivaroxaban:
More informationDiagnosis and Treatment of VTE in the ER
UHN ER Conference Nov 3, 2015 Diagnosis and Treatment of VTE in the ER Bill Geerts Thromboembolism Program, Sunnybrook HSC Professor of Medicine, University of Toronto National Lead, VTE Prevention, Canadian
More informationVenous thromboembolism: reducing the risk. Quick reference guide. Issue date: January 2010
Issue date: January 2010 Venous thromboembolism: reducing the risk Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital This guideline
More informationNORTH WEST LONDON GUIDANCE ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION
North West London CardioVascular & Stroke Network NORTH WEST LONDON GUIDANCE ON ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION Key Messages 1. Efforts should be made to identify patients with Atrial
More informationTo 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 informationDABIGATRAN ETEXILATE TARGET Vitamin K epoxide reductase WARFARIN RIVAROXABAN APIXABAN
TARGET SPECIFIC ORAL ANTICOAGULANTS (TSOACs) This document is intended as a guideline only and should not replace sound clinical judgment Please refer to UNMH formulary in Lexicomp for approved use(s)
More informationOutpatient 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 informationHypercoagulable States
Hypercoagulable States Daniel A. Forman, DO daniel.forman@readinghealth.org 610 509 5067 April 26, 2014 Risk Factors for Venous Thromboembolism (VTE) Hereditary thrombophilias How long to treat Newer agents
More informationAnticoagulation Essentials! Parenteral and Oral!
Anticoagulation Essentials! Parenteral and Oral! Anti-Xa and Anti-IIa! Parenteral Anticoagulants! Heparin family (indirect anti-xa and anti-iia):! UFH! LMWH (enoxaparin, fondaparinux)! Direct thrombin
More informationEnoxaparin 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 informationDirected to Dr. Carrier from NBRHC audience Q: In patients with GI Bleed history, would you suggest Apixaban for newly diagnosed patients
9 th Annual CBS/ORBCoN Transfusion Medicine Videoconference Symposium: April 9, 2014 Question and Answer Period Morning Session: Directed to Dr. Carrier from Dr. Bormanis Q: If the half lives are similar
More informationRivaroxaban shared care guidelines for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation.
South West Essex Rivaroxaban Shared Care Guideline (SCG) Rivaroxaban shared care guidelines for the prevention of stroke and embolism in adult patients with nonvalvular atrial fibrillation. Introduction
More informationORAL ANTICOAGULANTS RIVAROXABAN (XARELTO) FOR PULMONARY EMBOLISM (PE)
ORAL ANTICOAGULANTS RIVAROXABAN (XARELTO) FOR PULMONARY EMBOLISM (PE) Information Leaflet Your Health. Our Priority. Page 2 of 6 What Are Anticoagulants And What Do They Do? This information leaflet has
More informationThrombosis management: A time for change practical management with NOACs Dr Wala Elizabeth Medical Director, Bayer Healthcare
Thrombosis management: A time for change practical management with NOACs Dr Wala Elizabeth Medical Director, Bayer Healthcare Kenya Association of Physicians Conference 10 th May 2013 New anticoagulants:
More informationNOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST
NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST NGAIRE IS 70 YEARS OLD AND IN AF. SHE HAS NO MURMURS, NORMAL BLOOD PRESSURE, EGFR OF 65ML/MIN AND NO SIGNIFICANT PAST MEDICAL HISTORY. REGARDING
More informationNew 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 informationNovel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations
Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations Dardo E. Ferrara MD Cardiac Electrophysiology North Cascade Cardiology PeaceHealth Medical Group Which anticoagulant
More informationCOMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals.
COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS AND PHYSICIANS TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVES: To provide a comparison of the new
More information6/19/2012. Update on Venous Thromboembolism Prophylaxis. Disclosure. Learning Objectives. No conflicts of interest to declare
Update on Venous Thromboembolism Prophylaxis Disclosure No conflicts of interest to declare Learning Objectives After completion of this presentation, participants should be able to: Define venous thromboembolism,
More informationMore information for patients and caregivers can be accessed at http://www.xarelto-us.com/.
Janssen Research & Development Submits Application to U.S. FDA for XARELTO (rivaroxaban) to Reduce Secondary Cardiovascular Events in Patients with Acute Coronary Syndrome RARITAN, DECEMBER 29, 2011 -
More informationSTARTING, 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 informationCritical Bleeding Reversal Protocol
Critical Bleeding Reversal Protocol Coagulopathy, either drug related or multifactorial, is a major contributing factor to bleeding related mortality in a variety of clinical settings. Standard therapy
More informationDISCLOSURES CONFLICT CATEGORY. No conflict of interest to disclose
DISCLOSURES CATEGORY Employment Research support Scientific advisory board Consultancy Speakers bureau Major stockholder Patents Honoraria Travel support Other CONFLICT No conflict of interest to disclose
More informationXarelto (Rivaroxaban)
Xarelto (Rivaroxaban) Hightly selective, reversible, direct oral FXa inhibitor Maxium concentratiion after 2 to 4 hrs High bioavailability(66%),increase with food ( suggest with food) 1/3 from renal excretion,
More informationTSOAC Initiation Checklist
Task Establish appropriate dose based on anticoagulant selected, indication and patient factors such as renal function. Evaluate for medication interactions that may necessitate TSOAC dose adjustment.
More informationXARELTO (RIVAROXABAN) EDUCATIONAL PACK FOR 15MG AND 20MG DOSING
XARELTO (RIVAROXABAN) EDUCATIONAL PACK FOR 15MG AND 20MG DOSING NOW UPDATED A N D I N C L U D E S A NEW INDICATION Prevention of stroke and systemic embolism in eligible adult patients with non-valvular
More informationNew Anticoagulants: What to Use What to Avoid
New Anticoagulants: What to Use What to Avoid Bruce Davidson, MD, MPH Clinical Professor of Medicine Pulmonary and Critical Care Medicine Division University of Washington School of Medicine Seattle USA
More informationDorset Cardiac Centre
P a g e 1 Dorset Cardiac Centre Patients with Atrial Fibrillation/Flutter undergoing DC Cardioversion or Ablation procedures- Guidelines for Novel Oral Anti-coagulants (NOACS) licensed for this use February
More informationNovel Oral Anticoagulants (NOACs) Prescriber Update 2013
Novel Oral Anticoagulants (NOACs) Prescriber Update 2013 Indications/Contraindications Indications Orthopedic VTE Prophylaxis VTE Treatment Stroke Prevention for non-valvular AF Contraindications 150 mg
More informationBGS Autumn Conference 2014
Management of VTE Dr Raj Patel King s Thrombosis Centre, London Acute DVT Originate in the deep veins of the lower extremities >90% originate in the calves 1 Signs and symptoms are non-specific Only ~30%
More informationDisclosure. Warfarin
Disclosure No conflicts of interest to disclose Reversal Strategies for Novel Oral Anticoagulants Noelle de Leon, PharmD, BCPS Critical Care Pharmacist, Department of Pharmaceutical Services Assistant
More informationProvided by the American Venous Forum: veinforum.org
CHAPTER 3 CLOTTING DISORDERS Original authors: Edith A. Nutescu, Jessica B. Michaud, Joseph A. Caprini, Louis W. Biegler, and Robert R. McCormick Abstracted by Kellie R. Brown Introduction The normal balance
More informationThree new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008:
Key Points to consider when prescribing NOACs Introduction Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008: Dabigatran Etexilate (Pradaxa ) 75mg, 110mg, 150mg. Rivaroxaban
More informationHypercoagulability How to Expect the Unexpected. Beth Saft, DO VOMA Conference 2012
Hypercoagulability How to Expect the Unexpected Beth Saft, DO VOMA Conference 2012 Who is at Risk Most Common Hypercoagulability Objectives + When to Test What to do with the Test Results Who gets a DVT
More informationSession 3 Topics. Argatroban. Argatroban. Drug Use and Adverse Effects. Laboratory Monitoring of Anticoagulant Therapy
~~Marshfield Labs Presents~~ Laboratory Monitoring of Anticoagulant Therapy Session 3 of 4 Michael J. Sanfelippo, M.S. Technical Director, Coagulation Services Session 3 Topics Direct Thrombin Inhibitors:
More informationGuideline for managing patients on a factor Xa inhibitor Apixaban (Eliquis ) or Rivaroxaban (Xarelto )
Guideline [Optional heading here. Change font size to suit] Document Number # QH-GDL-950:2014-2 Guideline for managing patients on a factor Xa inhibitor Apixaban (Eliquis ) or Rivaroxaban (Xarelto ) 1.
More informationDevang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical
Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical Center A.Fib affects 2.2 million Americans. The lifetime
More informationUse 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