Prostate Assessment Pathway Prostate Biopsy Alerts Guidelines for the Management of Patient Preparation, Medications and Complications July 2015
Table of Contents Roles and Responsibilities. 1 SECTION 1 Patient Preparation......2 SECTION 2 Medications Anticoagulation Agents.....3 Antiplatelet Agents......4 SECTION 3 Special Considerations Prevention of Endocarditis.........6 MRSA.... 7 Antibiotic Prophylaxis.........8 SECTION 4 Complications & Accountability Management.......9 Roles & Responsibilities Pathway Step Accountability Management of Patient Preparation & Complications Referral to Pathway Pre-Biopsy Consult Biopsy (intra-hospital visit) Post-Biopsy (after discharge) Family Physician Nurse Navigator Nursing Units Radiologist Family Physician Emergency Physician/ Urologist Provide initial biopsy education Identify biopsy alerts Instruct patients regarding management of medications Instruct patients regarding preparation (e.g. fasting) Provide biopsy education Confirm patient has instructions for management of medications and fasting Pre-biopsy administer antibiotic prophylaxis according to medical directive Post-biopsy monitor for post-biopsy complications; provide discharge instructions Perform biopsy Post-biopsy manage immediate minor post-biopsy complications Manage patients for minor post-biopsy complications Manage major post-biopsy complication (e.g. infection, rectal bleeding or sepsis) 1
SECTION 1 - PATIENT PREPARATION There is no patient preparation required. Patients do NOT need to fast prior to a prostate biopsy and may eat their regular diet. 1 Guidelines to the Practice of Anesthesia (Canadian Journal of Anesthesia Revised Edition 2012) 2
SECTION 2 - MEDICATIONS Anticoagulation Agents 1 Warfarin is an oral medication that interferes with the synthesis of vitamin K dependent clotting factors and is prescribed to reduce the risk of, or treat, thromboembolic disease. New oral agents (dabigatran, rivaroxaban and apixaban) each inhibit one specific coagulation factor (either thrombin or factor Xa) to reduce the risk of, or treat, thromboembolic disease. All of these anticoagulants should be managed according to the pre-existing conditions they have been prescribed for. Anticoagulants Apixaban (Eliquis) Dabigatran (Pradax) Low Molecular Weight Heparin (LMWH) Tinzaparin (Innohep) Enoxaparin (Lovenox) Rivaroxaban (Xarelto) An coagulant Continues on Agents next page Apixaban (Eliquis) Management Patient Managed by Primary Care Practitioner Primary Care Praconer Issue Special Instruc on to Pa ent Discon nue at least 24 hours prior to Discon nue at least 48 hours prior to procedure if elderly, reduced renal func on or complete hemostasis is required. Dabigatran (Pradax) If CrCl greater than 50ml/min, discon nue 1 3 days prior to the If CrCl is 31 50ml/min discon nue 2 4 days prior to If CrCl is less than or equal to 30ml/min discon nue at least 5 6 days prior to Rivaroxaban (Xarelto), prescribed for DVT and PE [Note: It does not currently have the indica on for treatment of PE in Canada. This is likely coming soon] Discon nue at least 24 hours prior to Discon nue at least 48 hours prior to procedure if elderly, reduced renal func on or complete hemostasis is required Note: If pa ent is less than one month into treatment of a VTE they are at increased risk if clot extension/emboliza on if the drug is discon nued. Consider PT if worried about bleeding risk on day of procedure (does not quan fy an coagula on ac vity, but if normal, there is likely li le drug in the pa ent s system. Urology Nurse Navigator Ensure pa ent has received instruc on from Primary Care Praconer regarding when to discon nue an coagulant agent. Table continues on next page 1 Darcy Lamb (Pharmacist) January 2013, Dr. Ivan Norval (Radiologist) December 2012. Reference documents include the Canadian Urological Associa on Guidelines on Prostate Biopsy Methodology (2010), Consensus Guidelines for Periprocedural Management of Coagula on Status and Hemostasis Risk In Percutaneous Image guided Interven ons (Journal of Interven onal Radiology, 2009) and Home Low Molecular Weight Heparin Therapy Program Informa on for Health Care Professionals (last updated July 2012 form # 101909). 3
An coagulant Agents Warfarin (Coumadin) Low Molecular Weight Heparin Management Patient Managed by Primary Care Practitioner Primary Care Praconer Issue Special Instruc on to Pa ent Discon nue Warfarin 4 5 days prior to the All pa ents should have a PT/INR prior to Note: If pa ent is less than one month into procedure (INR below treatment of a VTE they are at increased 1.5 is acceptable prior risk if clot extension/emboliza on if the to procedure). drug is discon nued. Bridging therapy with low molecular weight heparin should be considered for some pa ents. See the Saskatoon Health Region Home Low Molecular Weight Heparin Therapy Program Informa on for Health Professionals document for guidance in determining if bridging therapy is recommended. Withhold LMWH for 24 hours prior to Urology Nurse Navigator Ensure pa ent has received instruc on from Primary Care Praconer regarding when to discon nue an coagulant agent. Ensure INR ordered prior to The indication for the anti-coagulant agent has to be reviewed with the patient, his primary care practitioner or cardiologist and only after that should the anti-coagulant agent be stopped (Canadian Urological Association recommendations). 4
Antiplatelet Agents 2 Antiplatelet agents interfere with platelet function and impair clot formation. Antiplatelet Agents ASA/NSAIDS Mesalamine (Asacol) Thienopyridines Clopidogrel (Plavix) Ticlodipine (Ticlid) Prasugrel (Effient) Ticagrelor (Brilinta) Management Pa ent Managed by Primary Care Praconer An platelet Agents Issue Special Instruc on to Pa ent Refer Pa ent to Specialist ASA Discon nue 7 days prior to Note: if stent or ACS less than 1 year ago, there is a high risk of re thrombosis if drug stopped. Consult the pa ent s cardiologist to determine safety of stopping. NSAIDS Discon nue 3 5 days prior to Mesalamine (Asacol) No need to stop mesalamine prior to Clopidogrel (Plavix) Discon nue for 7 days prior to Note: if stent or ACS less than 1 year ago, there is a Ticlodipine Discon nue 10 14 days prior to high risk of re thrombosis if drug stopped. Consult the Prasugrel Discon nue 5 7 days prior to pa ent s cardiologist to determine safety of Ticagrelor Discon nue 5 days prior to stopping. Urology Nurse Navigator 2 Darcy Lamb (Pharmacist) January 2013, Dr. Ivan Norval (Radiologist) Reference documents include the Canadian Urological Association Guidelines on Prostate Biopsy Methodology (2010), Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk In Percutaneous Image-guided Interventions (Journal of Interventional Radiology, 2009) and Home Low Molecular Weight Heparin Therapy Program Information for Health Care Professionals (last updated July 2012 form # 101909). 5
SECTION 3 - SPECIAL CONSIDERATIONS Prevention of Infective Endocarditis 3 Prophylaxis should be limited to the highest risk patients (listed below). Routine prophylaxis against infective endocarditis is not required for invasive procedures of the gastrointestinal or genitourinary tract. The exception is in enterococcal urinary tract infection or colonization which should be treated prior to the procedure OR an anti-enterococcal agent (e.g. amoxicillin or vancomycin) could be added to the surgical prophylaxis. Routine prophylaxis in the setting of cardiac devices is not recommended. Management Pa ent Management by Primary Care Praconer Issue Special Instruc on Primary Care Praconer Preven on of Infec ve Endocardi s to Pa ent Prosthe c Heart Valves Not Applicable Refer to urologist if history of Previous Infec ve Endocardi s enterococcal urinary Congenital Heart Disease with any of the tract infec on or following: coloniza on. Completely repaired cardiac defect using prosthe c material Par ally corrected but with residual defect near prosthe c material Uncorrected cyano c congenital heart disease Surgically constructed shunts and conduits Valvulopathy following Heart Transplant Urology Nurse Navigator Not Applicable Table continues on next page 3 Brenda Thiessen (Pharmacist) and Leah Heilman (Pharmacist) November 2012 6
MRSA 4 Known MRSA positive patients who do not undergo decolonization should receive IV vancomycin in addition to their surgical prophylaxis. (Vancomycin alone will not cover the gram negative pathogens which would be expected to be of concern with a prostate biopsy.) MRSA MRSA posi ve pa ents who do not undergo decoloniza on Issue Special Instruc on to Pa ent Inform pa ent he will require vancomycin prior to Primary Care Praconer Order vancomycin g IV X 1 dose prior to procedure Urology Nurse Navigator Ensure Primary Care Praconer ordered vancomycin Pa ents weighing less than 90kg require 1g Pa ents weighing 90kg or greater require 1.5g Fax order to pharmacy Instruct nursing unit vancomycin required prior to procedure 4 Brenda Thiessen (Pharmacist) and Leah Heilman (Pharmacist) November 2012 7
Antibiotic Prophylaxis 5 5 See SHR medical direc ves policy (7311 60 027) for approval process. Reference documents include Best Prac ce Policy Statement on Urologic Surgery An microbial Prophylaxis (updated September 2008), John Hopkins Medicine An bio c Guide (www.hopkinsguides.com), European Associa on of Urology Guidelines on Urological Infec ons (2009) and The Cochrane Collabora on An bio c Prophylaxis for Transrectal Prostate Biopsy. Contribu ons by Dr. Alice Wong, Brenda Thiessen (Pharmacist), Leah Heilman (Pharmacist) and Cheryl Kolbinson (Pharmacist). 8
SECTION 4 - COMPLICATIONS AND ACCOUNTABILITY FOR MANAGEMENT Radiologist will manage any minor complications independently. If a major complication arises in which the radiologist cannot manage the patient s care, the patient will be sent to the emergency department for further assessment. The emergency department will refer to specialist as required. 9