BGS Autumn Conference 2014
|
|
- Prudence Warner
- 8 years ago
- Views:
Transcription
1 Management of VTE Dr Raj Patel King s Thrombosis Centre, London
2 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% of symptomatic patients have confirmed acute DVT 2 Upper limb (10%) lines, malignancy,assisted conception Other sites Cerebral venous sinus Porto-spleno-mesenteric, Budd-Chiari 1. Stamatakis JD. Brit J Surg Kahn S. Thrombosis and Haemostasis. 1999
3 VTE: the burden of disease Acute VTE In-hospital mortality 6-15% after PE Recurrent VTE Post-thrombotic syndrome Pulmonary hypertension Risks of anticoagulation
4 Deep vein thrombosis Common femoral vein Thrombus Proximal Knee Distal
5 Presentation of deep vein thrombosis 75% patients presenting with DVT have other diagnoses Kind permission from Ola Dahl Cellulitis Congestive cardiac failure Gout Lymphangitis Post-thrombotic syndrome Ruptured Baker s cyst Superficial thrombophlebitis Varicose veins Trauma: Muscle strain/tear, haematoma Jowett 1999
6 NICE CG 144 Diagnosis Guidance Clinical history Physical examination Wells Score (2-level) Confirmatory tests Proximal leg vein ultrasound (US) ---whole leg? D-dimer test Autumn Conference 2014 BGS NICE Clinical Guidance 144. Venous thromboembolic diseases Last Accessed
7 NICE Clinical Guideline 144 Two-level DVT Wells score 1. NICE Clinical Guidance 144. Venous thromboembolic diseases: Appendix C Last Accessed Wells PS. New Eng J Med
8 NICE CG 144 Diagnosis of DVT Algorithm Autumn Conference 2014 NICE Clinical Guidance 144. Appendix C:Venous thromboembolic diseases Last Accessed BGS
9 NICE Clinical Guideline 144 Initial DVT treatment LMWH or Fondaparinux unless contraindicated: egfr under 30ml/min: UFH infusion with APTT monitoring Elevated bleeding risk: UFH infusion with APTT monitoring Rivaroxaban and Apixaban licensed Rivaroxaban NICE-approved
10 NICE Clinical Guideline 144 Ongoing DVT treatment LMWH / Fondaparinux / UFH : Continue for at least 5 days or until INR>2 for at least 24hrs (whichever longer) LMWH for 6 months in active cancer, reassess risk/benefit at 6 months VKA for 3 months in provoked proximal DVT VKA beyond 3 months in unprovoked proximal DVT if recurrence risk high and no additional bleeding risk. NOACs: all 3 now licensed Rivaroxaban NICE-approved
11 NICE s Incremental Costeffectiveness Ratios (ICER) Patient group ICER ( /QALY) Meaning 3 months anticoagulation RIV dominates RIV less costly, greater QALYs than LMWH/VKA 6 months anticoagulation 3200 RIV cost-effective 12 months anticoagulation 14,900 RIV cost-effective Cancer NA Long term 19,400 RIV cost-effective
12 Key features of rivaroxaban (1) o Oral o Once daily o Rapidly absorbed o Cmax 2-4 hours after taking tablet o Half-life 5-9hrs (young) 11-13hrs(elderly) o Anticoagulation effect for 24hrs o 1/3 is excreted unchanged by the kidneys o 2/3 is metabolized by the liver to inactive metabolites Xarelto SmPC June 2012 O O N N O H N O O Rivaroxaban S Cl
13 Key features of rivaroxaban (2) o Fixed dose (varies by indication) o No need for routine anticoagulation monitoring o 15 mg and 20mg tablets take with food Xarelto SmPC June 2012 O O N N O H N O O Rivaroxaban S Cl
14 Current dual-drug approach is effective but demanding NHS Choices. Treating deep vein thrombosis o Need for two drugs o Initial subcutaneous injections o Coagulation monitoring o Frequent dose adjustments o Many drug drug interactions o Dietary restrictions
15 Drug interactions with rivaroxaban o Rivaroxaban not recommended in combination with o Systemic azole-antimycotics (ketoconazole, itraconazole) o HIV protease inhibitors o Dronedarone (lack of information) o Use rivaroxaban with caution in combination with o Other anticoagulants o NSAIDS o Platelet inhibitors o Strong CYP3A4 inducers such as rifampicin or St John s Wort Xarelto SmPC June 2012 BGS Autumn Conference 2014
16 Rivaroxaban EINSTEIN phase III: study designs Confirmed acute symptomatic DVT without symptomatic PE N=3449 Confirmed acute symptomatic PE with or without symptomatic DVT Confirmed symptomatic DVT or PE completing 6 or 12 months of rivaroxaban or VKA R N=4833 EINSTEIN DVT 1 and EINSTEIN PE 2 (non-inferiority studies) Treatment period of 3, 6 or 12 months Rivaroxaban 15 mg bid Enoxaparin 1.0 mg/kg bid for at least 5 days, followed Day 1 Day 21 N=1197 R Day 1 Rivaroxaban 20 mg od by VKA to start 48 hours, target INR range EINSTEIN EXT 1 (superiority study) Treatment period of 6 or 12 months Rivaroxaban 20 mg od Placebo 1. The EINSTEIN Investigators. N Engl J Med 2010;363:2499; 2. The EINSTEIN PE Investigators. N Engl J Med 2012;366: day observation after treatment cessation 30-day observation after treatment cessation
17 EINSTEIN DVT and EINSTEIN PE pooled analysis: primary efficacy outcome* Rivaroxaban (N=4150) Enoxaparin/VKA (N=4131) n (%) n (%) First symptomatic recurrent VTE 86 (2.1) 95 (2.3) Recurrent DVT 32 (0.8) 45 (1.1) Recurrent DVT + PE 1 (<0.1) 2 (<0.1) Non-fatal PE 41 (1.0) 36 (0.9) Fatal PE/unexplained death where PE cannot be ruled out 15 (0.4) 13 (0.3) 0 Rivaroxaban superior p=0.41 for superiority (two-sided) ITT population Prins MH et al. Thromb J. 2013;11: HR Rivaroxaban non-inferior p<0.001 for non-inferiority (one-sided) 1.75 Rivaroxaban inferior
18 EINSTEIN DVT and EINSTEIN PE pooled analysis: major bleeding Cumulative event rate (%) Rivaroxaban n/n (%) 40/4130 (1.0) Enoxaparin/VKA n/n (%) 72/4116 (1.7) First major bleeding HR (95% CI) p-value 0.54 ( ) p=0.002 Enoxaparin/VKA N=4116 Rivaroxaban N= Time to event (days) Number of patients at risk Rivaroxaban Enoxaparin/VKA Safety population Prins MH et al. Thromb J. 2013;11:21
19 EINSTEIN DVT and EINSTEIN PE pooled analysis: types of major bleeding Outcome Rivaroxaban (N=4130) Enoxaparin/VKA (N=4116) n % n % Major bleeding* Fatal 3 < Retroperitoneal <0.1 Intracranial 2 <0.1 4 <0.1 Gastrointestinal/thorax 1 <0.1 3 <0.1 In a critical site Retroperitoneal 1 < Intracranial 3 < Intraocular 3 <0.1 3 <0.1 Pericardial <0.1 Intra-articular <0.1 Adrenal/pulmonary/abdominal 3 <0.1 2 <0.1 Fall in haemoglobin 2 g/dl and/or transfusions 2 units *Some patients had >1 event Prins MH et al. Thromb J. 2013;11:21 HR (95% CI) p-value 0.54 ( ) p=0.002
20 EINSTEIN DVT and EINSTEIN PE pooled analysis: outcomes in fragile patients* Outcome Recurrent VTE Rivaroxaban Enoxaparin/VKA HR (95% CI) n/n % n/n % Fragile 21/ / Non-fragile 65/ / Major bleeding Fragile 10/ / Non-fragile 30/ / *Age >75 years or CrCl <50 ml/min or body weight 50 kg Prins MH et al. Thromb J. 2013;11: ( ) 0.98 ( ) 0.27 ( ) 0.80 ( )
21 EINSTEIN DVT and EINSTEIN PE pooled analysis: clot size and recurrent VTE Limited ( 25% of vasculature of a single lobe, popliteal vein only) Rivaroxaban Enoxaparin/VKA n/n % n/n % 10/ / Intermediate 41/ / Extensive (multiple lobes and >25% of entire pulmonary vasculature; involving common femoral/ iliac vein) Prins MH et al. Thromb J. 2013;11:21 35/ /
22 EINSTEIN DVT and EINSTEIN PE pooled analysis: outcomes in patients with cancer Outcome Recurrent VTE Rivaroxaban Enoxaparin/VKA HR (95% CI) n/n % n/n % Cancer 16/ / No cancer 70/ / Major bleeding Cancer 9/ / No cancer 31/ / Prins MH et al. Thromb J. 2013;11: ( ) 0.93 ( ) 0.53 ( ) 0.53 ( )
23 DVT or SVT? Superficial veins: upper limb thrombophlebitis Brachial, ulna, radial, cephalic, basilic veins Superficial veins: lower limb thrombophlebitis Short saphenous vein (SSV) Long saphenous vein (LSV) (Varicose vein phlebitis)
24 SVT: isolated lower limb (LSV/SSV) phlebitis <3 cm from saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ) Treat as DVT >3 cm from SFJ or SPJ <5 cm long Symptomatic management e.g. NSAID Consider rescan if no improvement at 1 week or progressive symptoms >5 cm long If one of: knee involvement, severe symptoms, LSV, previous DVT/SVT, active cancer, recent surgery then prophylactic LMWH 6/52 (if not then treat as for <5 cm long) Recurrent unexplained SVT: Vascular Surgeon
25 NICE Clinical Guideline 144: IVC filters Offer temporary IVC filter Proximal DVT or PE where anticoagulation contraindicated Remove filter when eligible for anticoagulation Consider IVC filter in recurrent proximal DVT or PE despite adequate anticoagulation only after: Increased INR target 3 4 Switch to LMWH Filter removal strategy (earliest opportunity) NICE Clinical Guideline 144,
26 NICE Clinical Guideline 144 thrombolysis for DVT Consider catheter-directed thrombolysis Symptomatic ilio-femoral DVT and Symptom duration less than 14 days and Good functional status, life expectancy over 1 year and Low bleeding risk NICE Clinical Guideline 144,
27 NICE Clinical Guideline 144 Investigations for cancer Offer all patients diagnosed with unprovoked VTE (who are not already known to have cancer): a physical examination a chest X-ray full blood count, serum calcium and liver function tests Urinalysis Consider further investigations for cancer with an abdomino-pelvic CT scan (and a mammogram for women): all patients aged over 40 years with a first unprovoked VTE (who do not have signs or symptoms of cancer)
28 Clinic review Complications ECHO Massive PE or post-thrombolysis or RV strain at presentation Ongoing symptoms >6 weeks GCS post-dvt Daily wear of below-knee GCS on affected leg (daytime only) mmhg ankle pressure Renew 3 6 monthly (according to manufacturer) 2 years, extend duration if PTS Lower grade compression if not tolerated, assess barriers (e.g. application) Reassure: symptoms fluctuate, likely to stabilise/improve over time Emollient for dryness/itching (Doublebase, Epiderm ) Ulcers: tissue viability nurse review
29 Clinic review: PHT investigation Indications Massive PE, thrombolysis, RV strain at presentation Ongoing symptoms (SOB, syncope, chest pain) Tests ECHO, chest X-ray ECHO suggestive of PHT? Pulmonary arterial systolic pressure >40 mmhg Tricuspid regurgitation velocity m/s Lung function: spirometry, Sa0 2, CO transfer Refer to Chest Physician at KCH, then regional unit Long-term anticoagulation
30 Provoked and unprovoked VTE Transient/ reversible factors e.g. surgery or hospitalisation Provoked VTE Continuing/ irreversible factors e.g. cancer ACCP guidelines recommend at least 3 months anticoagulation therapy after provoked VTE or longer after unprovoked (idiopathic) VTE* *In the case of low to moderate bleeding risk Zhu T et al. Arterioscler Thromb Vasc Biol 2009;29;298; Gensini GF et al. Semin Thromb Hemost 1997;23:55; Kearon C et al. Chest. 2012;141:e419S No identifiable cause Unprovoked (idiopathic) VTE
31 Recurrence Risk C: unprovoked A: surgical D: non-surgical 1. Baglin et al. Lancet 2003; 362:523; 2. Prandoni et al. Haematologica 2007;92:199; 3. Kearon et al. Circulation 2004;110:I-10 Cambridge Cohort Study 1 (2-year cumulative recurrence rates) Unprovoked VTE 17% Surgical trigger 0% Non-surgical trigger 8% Highest recurrence risk 1st year after initial event 2 Recurrence risk at 8 years 46% Warfarin prevents 95% recurrences 3
32 Idiopathic VTE: duration 1st unprovoked VTE: 1000 patients, 5 years Warfarin: (low risk) 24 major bleeding events, 3 deaths (high risk) 98 major bleeding events, 11 deaths No warfarin : 264 VTE recurrences, 10 deaths Kearon C et al. Chest. 2012;141:e419S
33 Duration Duration: considerations Unprovoked PE more likely ( 3) to recur as PE than DVT 1 Risk of fatal PE more likely (>5-fold) in patients with symptomatic non-massive PE, compared with those with DVT without symptomatic PE 2 Unprovoked calf VTE has a lower risk of recurrence CTEPH more likely after recurrent PE Morbidity from PTS (common) vs ICH (rare) 1. Baglin T et al. J Thromb Haemost 2010;8:2436; 2. Laporte S et al. Circulation 2008;117:1177
34 Duration of anticoagulation therapy after an unprovoked VTE: guidance from the SSC of the ISTH Residual vein occlusion Does not predict a likelihood of recurrent DVT to a degree that is clinically useful PTS A prospective cohort study showed PTS associated with 2.6-fold increased rate of recurrent DVT Male gender 1.8-fold higher risk of recurrence after unprovoked VTE Baglin T et al. J Thromb Haemost 2012;10:698
35 D-dimer Abnormal D-dimer level 1 month after discontinuation of anticoagulation (~40%) 1 Significant incidence of recurrent VTE compared with normal D-dimer level (15% vs 6.2% after 1.4 years; adjusted HR 2.27) Negative predictive value of D-dimer % in subjects with an unprovoked qualifying event 1. Palareti G et al. N Engl J Med 2006;355:1780; 2. Wang Y et al. J Thromb Thrombolysis. 2011;32(4):410
36 Duration of anticoagulation therapy after an unprovoked VTE: guidance from the SSC of the ISTH Other factors to predict risk of recurrence: 1. D-dimer 2. Residual vein occlusion 3. PTS 4. Thrombophilia 5. Male gender 6. Mode of presentation Baglin T et al. J Thromb Haemost 2012;10:698
37 Five Decades of VTE Treatment o From nothing to heparin o From intravenous to subcutaneous heparin o From heparin to low-molecular-weight heparins (LMWH) o From immobilization to early mobilization o From inpatient treatment to outpatient treatment o From LMWH to synthetic, specific anticoagulants
38 Dr Raj Patel King s Thrombosis Centre King s College Hospital rajpatel@nhs.net
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 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 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 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 informationHome treatment of VTE
Home treatment of VTE Prof. Adel El-Etriby Ain-Shams University Venous Thromboembolism (VTE): The DVT and PE Continuum Migration Embolus Thrombus VTE refers to a continuum of disease that begins with DVT
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 informationrivaroxaban 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 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 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 informationACUTE 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 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 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 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 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 informationEINSTEIN PE Data Summary & Perspectives on XARELTO (rivaroxaban) in ORS & NVAF. Recorded Webcast Update for Analysts and Investors March 26, 2012
EINSTEIN PE Data Summary & Perspectives on XARELTO (rivaroxaban) in ORS & NVAF Recorded Webcast Update for Analysts and Investors March 26, 2012 1 Webcast Presentation Agenda EINSTEIN PE Clinical Trial
More informationBreadth of indications matters One drug for multiple indications
Breadth of indications matters One drug for multiple indications Sylvia Haas, MD, PhD Formerly of the Technical University of Munich Munich, Germany Disclosures: Sylvia Haas 1 Novel oral anticoagulants:
More informationXarelto (Rivaroxaban): Effective in a broad spectrum. Joep Hufman, MD Medical Scientific Liason
Xarelto (Rivaroxaban): Effective in a broad spectrum Joep Hufman, MD Medical Scientific Liason Xarelto : Effective in a broad spectrum Introduction Therapeutic areas SPAF VTE Prevention VTE treatment Practical
More informationrivaroxaban 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 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 informationVenous 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 informationInnovations in Treating VTE, Using the EDOU
Innovations in Treating VTE, Using the EDOU Disclosures No financial conflicts or disclosures Kelly Sawyer, MD, MS kelly.sawyer@beaumont.edu Observation Symposium 2013 Objectives Overview of VTE Treatment
More information2. 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 informationVenous Thrombo-Embolism (VTE) Therapy current challenges & opportunities
Venous Thrombo-Embolism (VTE) Therapy current challenges & opportunities Asher Winder M.D. Director, Department of Hematology Wolfson Medical Center כנס האיגוד הישראלי לפרמקולוגיה קלינית 2012 04-May-2012
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 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 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 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 informationFULL REVIEW. PBS listing. Rivaroxaban (Xarelto) NPS RADAR AUGUST 2013 KEY POINTS
1 FULL REVIEW for treatment of deep vein thrombosis and pulmonary embolism, and for prevention of venous thromboembolism recurrence (riv-ah-rocks-ah-ban) An alternative to parenteral anticoagulation with
More informationTime 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 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 informationHaematology for GP s Part 2. Anticoagulation in DVT and PE VTE. Introduction. DVT Principles of diagnosis. VTE in Bradford
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
More informationRivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary Issued: July 2012 guidance.nice.org.uk/ta NHS Evidence has accredited the process used
More informationNHS 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 informationThrombosis 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 informationRivaroxaban 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 informationAntithrombotic Therapy for VTE Disease
CHEST Supplement ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Antithrombotic Therapy for VTE Disease Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American
More informationRivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary Issued: July 2012 guidance.nice.org.uk/ta NICE has accredited the process used by the
More informationVolume 7; Number 19 November 2013
Greater East Midlands Commissioning Support Unit in association with Lincolnshire Clinical Commissioning Groups, Lincolnshire Community Health Services, United Lincolnshire Hospitals Trust and Lincolnshire
More informationAntithrombotic Therapy for VTE Disease
CHEST Supplement ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Antithrombotic Therapy for VTE Disease Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American
More informationManagement 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 informationObjectives. New and Emerging Anticoagulants. Objectives (continued) 2/18/2014. Development of New Anticoagulants
Objectives New and Emerging Anticoagulants Adraine Lyles, PharmD, BCPS Clinical Pharmacy Specialist VCU Medical Center Describe the pharmacology of the novel oral anticoagulants Discuss the clinical evidence
More informationTo 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 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 informationAnticoagulant Treatment for Deep Venous Thrombosis Direct Oral Anticoagulants (NOACs)
Anticoagulant Treatment for Deep Venous Thrombosis Direct Oral Anticoagulants (NOACs) Prof. P. HAINAUT Médecine Interne - Maladie Thromboembolique Cliniques Univ. Saint Luc - UCL Background Direct Oral
More informationAcute behandeling van longembolie. Peter Verhamme. Bloedings- en Vaatziekten UZ Leuven. Research support and/or honoraria:
Acute behandeling van longembolie Peter Verhamme Bloedings- en Vaatziekten UZ Leuven Disclosures Research support and/or honoraria: Bayer, Boehringer-Ingelheim, Daiichi-Sankyo, Pfizer, BMS, Sanofi, Leo-pharma
More informationCost 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 informationUpdate on the Diagnosis and Treatment of Venous Thromboembolism Daniel B. DiCola, MD and Paul Ament, Pharm.D Excela Heath, Latrobe, PA
Disclosures: Update on the Diagnosis and Treatment of Venous Thromboembolism Daniel B. DiCola, MD and Paul Ament, Pharm.D Excela Heath, Latrobe, PA Paul Ament discloses that he receives honorarium and
More informationABOUT 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 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 informationClive 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 informationVolume 7; Number 15 August 2013
Greater East Midlands Commissioning Support Unit in association with Lincolnshire Clinical Commissioning Groups, Lincolnshire Community Health Services, United Lincolnshire Hospitals Trust and Lincolnshire
More informationCDEC 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 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 informationAPSR 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 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 informationThe New Oral Anticoagulants. Yes
Improving Improving protection protection against against venous venous thromboembolism thromboembolism with new oral anticoagulants with new oral? anticoagulants? The New Oral Anticoagulants will replace
More informationCardiovascular Disease
Cardiovascular Disease 1 Cardiovascular Disease 1. More target specific oral anticoagulants (TSOAC) 2. Vorapaxar (Zonivity) 3. Continued noise about a polypill 4. WATCHMAN 3 1 2 3 4 Left Atrial Appendage
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 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 informationDirect Oral Anticoagulants (DOACs) Who Gets What?
Direct Oral Anticoagulants (DOACs) Who Gets What? Kathryn Hassell, MD Professor of Medicine, Division of Hematology University of Colorado Denver Disclosures No financial or commercial conflicts of interest
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 informationDabigatran 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 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 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 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 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 informationExperience matters: Practical management in your hospital
Experience matters: Practical management in your hospital Dr AGG Turpie McMaster University, Hamilton, ON, Canada Disclosures AGG Turpie has acted as a consultant for Bayer HealthCare, Janssen, Sanofi-Aventis,
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 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 informationVenous and Lymphatic Disorders
Venous and Lymphatic Disorders. ก. Venous and Lymphatic Disorders Varicose Veins Deep Vein Thrombosis (DVT) Lymphedema What Is Varicose Veins? Latin: Varicose = Varix = twisted Abnormal venous dilatation
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 informationFailure 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 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 informationGuidelines 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 informationPulmonary 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 informationRivaroxaban (Xarelto) in the management of stroke and DVT
Rivaroxaban (Xarelto) in the management of stroke and DVT Steve Chaplin MSc, MRPharmS, Victoria Haunton BM, DGM, MRCP, Thompson Robinson BMedSci, MD, FRCP and Catherine Bagot MD, FRCPath KEY POINTS is
More informationPosition 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 informationReview 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 informationXarelto and the New Orals
Xarelto and the New Orals in the ER Peter L. Gross MD M.D., MSc M.Sc., FRCP(c) Associate Professor Thrombosis and Atherosclerosis Research Institute McMaster University Thrombosis Clinic Director, Juravinski
More informationGruppo 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 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 informationDisclosure. 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 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 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 informationAnticoagulation 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 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 informationNEWER ANTICOAGULANTS: FOCUS ON STROKE PREVENTION IN ATRIAL FIBRILLATION AND DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM
NEWER ANTICOAGULANTS: FOCUS ON STROKE PREVENTION IN ATRIAL FIBRILLATION AND DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM Carol Lee, Pharm.D., Jessica C. Song, M.A., Pharm.D. INTRODUCTION For many years, warfarin
More informationPrevention 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 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 informationThe 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 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 informationClinical 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 informationRivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Final appraisal determination Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism This guidance was developed using
More information1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF
Objectives Atrial Fibrillation and Prevention of Thrombotic Complications: Therapeutic Update Andrea C. Flores Pharm.D Pharmacy Resident at the Miami VA Healthcare System Review the epidemiology, pathophysiology
More informationHow To Treat Aneuricaagulation
Speaker Introduction Jessica Wilhoite, PharmD, BCACP Doctor of Pharmacy: Purdue University Postgraduate Residency Training: PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent
More informationPublished 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 informationConserva)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 informationΔορυφορικό Συμπόσιο: Αντιμετωπίζοντας τη θρόμβωση με Rivaroxaban. Κλινικές μελέτες και πρακτική διαχείριση σε ασθενείς με Φλεβική Θρομβοεμβολική Νόσο
Δορυφορικό Συμπόσιο: Αντιμετωπίζοντας τη θρόμβωση με Rivaroxaban Κλινικές μελέτες και πρακτική διαχείριση σε ασθενείς με Φλεβική Θρομβοεμβολική Νόσο Μ. Ματσάγκας, MD, PhD, FEBVS Αναπληρωτής Καθηγητής Αγγειοχειρουργικής
More information