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Thromboembolic Disease - clinical pearls

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jwendi4's version from 2016-11-27 23:14

Section 1

Question Answer
Acutely ill - hospitalized pt with increased risk of thrombosisLMWH, LDUH BID, LDUH TID, or fondaparinux
THA or TKAuse LMWH preferred over all other agents
LMWHendoxaparin (Lovenox)
THR, TKR, HFSRecommend at least 10 days up to 35 days after surgery
Warfarinbaseline PT/INR
WarfarinFactors VII, IX, X, and II (prothrombin) fall inthis order over 6 to 96 hours
Warfarinloading doses do not markedly shorten the time to achieve a full therapeutic effect
WarfarinPregnancy test before medicine (Cat X except very small defined time)
Increases PT/INR (increase warfarin effect)Fluoroquinolones, Metronidazole, TMP-SMX, Amiodarone
Decrease PT/INR (decrease warfarin effect)Barbiturates, Carbamazepine, Rifampin
hyperthyroidism/feverlonger PT/INR
hypothyroidismshorter PT/INR
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Section 2

Question Answer
Fondaparinuxprophylaxis and treatment of DVT/PE
DOACinhibit IIa (dabigatran) or Xa (rivaroxaban, apixaban, edoxaban)
DOACnot expected to require routine anticoag monitoring
Pradaxa (dabigatran)150 mg bid after 5-10 days of parenteral anticoagulation for DVT/PE (6 mo)
Xarelto(rivaroxaban)DVT or PE 15mg bid X 21 days - then 20 mg qd, continuation of therapy 20 mg qd (3, 6, 12 mo)
Eliquis (apixaban)10mg (2 x 5mg) bid X 7 days; 5 mg bid following day 7 for DVT/PE (6 mo)
Sayvasa (edoxaban)for DVT/Pe after 5-12d parenteral therapy for CrCl>50 dose is 60 mg Qd, for CrCl15-50 and certain Pgp drugs dose is 30mg Qd (3, 6, 12 mo)
VTE - no cancerDOAG recommended
VTE - cancerLMWH
DVT/PELMWH (over IV UFH)
IV UFH80 unit/kg bolus then 18 unit/kg/h
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Section 3

Question Answer
acute DVT with LMWHno need to monitor with anti-factor Xa measurements
unprovoked DVTtx for at least 3 months, then reevaluate
acute PEtx with LMWH, UFH, or fondaparinux at least 5 days AND INR is >= 2.0 at least 24 h
therapeutic aPTT55-85 s is about equal to antiXa of 0.3-0.7
aPTTat 6 h want 0.3-0.7 u/ml
enoxaparin (Lovenox)1.5 mg/kg wq q24 h for 5-7 d or until INR >2
memorize