Prevention of Venous Thromboembolism

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This was powerpoint was requested by an attending physician to be shared with the Psychiatric providers regarding DVT prophylaxis in patients who may have been on the unit. They include recommendations as outlined by the ACCP 2012 Guidelines for prevention of venous thromboembolism

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  • IPC = Intermittent pneumatic compression devicesVPF = Venous Foot PumpsGCS = Graduated Compression Stockings
  • In hospitalized patient, Graduated compression stockings increase risk of skin breaks/ulcers but had no effect on lower limb ischemia or amputation. If used, thigh high, rather than knee-high is recommended
  • Other outpatients:GCS for patients going long-distance travel if they are at increased risk for VTE. Not if no additional risk factors
  • Heparin potentiates the activities of antithrombin III. This inactivates Factor X and inhibits to conversion of thrombin to thrombin and prevents fibrin conversion to fibrinogen during active thrombosis.
  • Fondaparinux is an agent that selectively binds to antithrombin III and potentiates the neutralization of Factor Xa, inhibiting thrombin formation
  • Directly inhibits thrombin (Factor IIa). This prevents free and clot-bound thrombin and thrombin-induced platelet aggregation
  • Rivaroxaban selectively inhibits factor Xa without the need of a cofactor. In other words, it works like heparin, but does not need antithrombin III
  • Phenobarbital may be used for patients with sedation. It has a very long half life, and effects on medications may not be stabilized for 3 – 4 weeks.
  • Prevention of Venous Thromboembolism

    1. 1. Prevention of Venous Thromboembolism2012 CHEST GUIDELINES REVIEW PRESENTED BY: J O Y A . AW O N I Y I , P H A R M D . PGY1 PHARMACIST PRACTICE RESIDENT MIAMI VA HEALTHCARE SYSTEM
    2. 2. PRESENTATION OBJECTIVES 2 Provide a brief background regarding venous thromboembolism (VTE) Identify the risk factors for developing VTE Review the general principles for thromboprophylaxis Review CHEST Guideline VTE prophylaxis recommendations for  Medical Conditions  Orthopedic Surgery Review old and new suggested medications to be used for VTE prevention Describe potential drug-interactions related to patients who may be admitted to psychiatric services
    3. 3. VENOUS THROMBOEMBOLISM 3  Result of clot formation in venous circulation  Manifests as deep vein thrombosis (DVT) or pulmonary embolism (PE)  Develops as a result of three primary components known as Virchow’s triad  Venous Stasis  Vascular Injury  Hypercoagulability
    4. 4. DVT PROPHYLAXIS 4 Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries Consequences of unprevented VTE:  Symptomatic DVT or PE  Fatal PE  Increased spending for investigation symptomatic patients  Increased risk of recurrence  Chronic post-thrombotic syndrome DVT prophylaxis, has a desirable benefit-to-risk ratio
    5. 5. RISK FACTORS Strong Risk Factors Moderate Risk Factors Weak Risk Factors Odds Ratio > 10 Odds Ratio 2-9 Odds Ration <2• Hip or Leg Fracture • Athroscopic Knee Surgery • Bed rest>3 days• Hip or Knee Replacement • Central Venous Lines • Immobility due to sitting• Major General Surgery • Chemotherapy • Increasing Age• Major Trauma • CHF or Respiratory Failure • Laparoscopic Surgery• Spinal Cord Injury • Hormone Replacement • Obesity Therapy • Pregnancy/ Antepartum • Malignancy • Varicose Veins • Oral Contraceptive Therapy • Paralytic Stroke • Pregnancy/ Postpartum • Previous VTE • Thrombophilia 5
    6. 6. GENERAL THROMBOPROPHYLAXIS RECOMMENDATIONS Level of Risk Estimated DVT Risk Suggested ThromboprophylaxisLow Minor surgery in mobile patients <10% Early and aggressive ambulation Medical patients who are fully mobileModerate Medical pts, bed rest or sick LMWH, LDUH BID/TID or Most general, open gynecologic Fondaparinux or urologic surgery patients 10%-40% Moderate VTE + High bleeding Mechanical risk ThromboprophylaxisHigh Risk Hip or knee arthroplasty, Major Trauma, SCI LMWH 40% - 80% High VTE + High Bleeding risk Mechanical Thromboprophylaxis 6
    7. 7. PREVENTION OF VTE IN NONSURGICAL PATIENTS 7 ANTITHROMBOTIC THERAPY ANDP R E V E N T I O N O F T H R O M B O S I S , 9 TH E D ; A C C P GUIDELINES
    8. 8. CONSIDERATIONS 8 50 – 70% of symptomatic thromboembolic events and 70 – 80% of fatal PEs occur in non-surgical patients Additional risk factors for VTE in medical patients Stroke with Advanced age Previous VTE Cancer lower extremity weakness Congestive COPD Sepsis Bed Rest Heart Failure Exacerbation
    9. 9. Acutely Ill Hospitalized Medical Patients 9Recommended Recommended Against Low-Molecular Weight  The use of thromboprophylaxis Heparins, Low Dose beyond period of Unfractionated Heparin or immobilization or acute Fondaparinux for patients hospital stay with high risk for thrombosis Optimal use of mechanical thromboprophylaxis with GCS  The use of pharmacologic or IPC for patients with prophylaxis or mechanical contraindications to prophylaxis in patients at low anticoagulant thromboprophylaxis risk of thrombosis
    10. 10. Other Nonsurgical Patient Recommendations 10Critically-Ill Outpatients with Cancer  Recommend against routine Low-Molecular Weight prophylaxis with LMWH or Heparins or Low dose LDUH if no additional risk Unfractionated Heparin factors is suggested  Recommended for patients with solid tumors who have additional risk factors Mechanical prophylaxis with GCS or IPC for those who are at high  Recommend against use of risk for major bleeding vitamin K antagonists until bleeding risk (Warfarin) for prophylaxis decreases
    11. 11. PREVENTION OF VTE INORTHOPEDIC SURGERY PATIENTS 11 ANTITHROMBOTIC THERAPY AND P R E V E N T I O N O F T H R O M B O S I S , 9 TH E D ; A C C P GUIDELINES
    12. 12. Total Hip or Knee Arthroplasty 12Pharmacological Options Additional Remarks Low-Molecular Weight  LMWH Preferred Heparin Fondaparinux  Pharmacological therapy Apixaban should be continued for a minimum of 10-14 days Dabigatran Rivaroxaban  Intermittent pneumatic Low-Dose Unfractionated compression devices should Heparin be used with patients with Warfarin (INR 2-3) high bleeding risk  Goal is to achieve 18h daily Aspirin compliance
    13. 13. Hip Fracture Surgery 13Pharmacological Options Additional Remarks Low-Molecular Weight  LMWH Preferred Heparin Fondaparinux  Pharmacological therapy should be continued for a Apixaban minimum of 10-14 days Dabigatran Rivaroxaban  Intermittent pneumatic Low-Dose compression devices should Unfractionated Heparin be used with patients with high bleeding risk Warfarin (INR 2-3)  Goal is to achieve 18h daily Aspirin compliance
    14. 14. Additional Considerations 14 Low-Molecular Weight Heparins (Enoxaparin)  Start 12 or more hours preoperatively OR 12 hours or more postoperatively Guidelines suggest to extend prophylaxis in the outpatient period for up to 35 days from the date of surgery Guidelines Suggest using dual prophylaxis with an antithrombotic agent AND an IPCD during hospital stay Therapy is not recommended in patients undergoing knee arthroscopy
    15. 15. PHAMACOLOGICAL THERAPY FOR VTE PROPHYLAXIS 15
    16. 16. Unfractionated Heparin 16 VTE Prophylaxis Dosing  5000 Units subcutaneously every 8 – 12 hours  Knee or hip replacement: give 2 hours before surgery, resume at full dose after surgery for at least 7 days Renal adjustment not required Adverse Effects  Thrombocytopenia (up to 30%) – monitor platelets  Hemorrhage (5-10%), Increased ALT/AST
    17. 17. Enoxaparin (Lovenox®) 17 DVT Prophylaxis Dosing  Knee or Hip Replacement: 30 mg subcutaneous every 12 hours  Medical Patients: 40mg subcutaneously every 24 hours Dose Reduction is required in patients with CrCl less than 30 mL/min  Knee or Hip replacement: 30 mg every 24 hours  Medical patients: 30mg every 24 hours Adverse Effects  Hemorrhage (7%), AST/ALT elevation (6%), Fever (5%), Local Site reactions (2-5%)
    18. 18. Fondaparinux (Arixtra®) 18 VTE Prophylaxis Dosing (Patients >50kg)  2.5mg subcutaneously every 24 hours  Knee or Hip Replacement: Give 6-8 hours AFTER surgery No official dose adjustment recommendations  CrCl 20 – 50 mL/min: 1.5 mg every 24 hours has been used  Clearance is reduced 25-40% in patients with CrCl between 30 and 80 mL/min  CONTRAINDICATED if CrCl is less than 30mL/min Adverse Effects  Anemia (20%), Fever (14%), Nausea (11%), Rash (7.5%)
    19. 19. BLACK BOX WARNING!!! 19  Stop twice daily LMWH or UFH 8 – 12 hours prior to “Epidural or spinal spinal puncture hematomas, which mayresult in long-term paralysis, may occur in patients who  Stop once daily LMWH 18 are anticoagulated with hours prior to spinal LMWHs or heparinoids and puncture are receiving neuroaxial anesthesia or undergoing  Monitor such patients spinal puncture” frequently for neurological impairment
    20. 20. 20
    21. 21. Warfarin (Coumadin®) 21 INR target of 2.5 (Range between 2 – 3)  Dose adjust based on INR Results  Reversal with Vitamin K Many drug and food interactions  Metabolized primarily by CYP2c9 and CYP3A4  Works by inhibiting the formation of Vitamin-K dependent clotting factors Adverse Effects:  Alopecia, hemorrhage, tissue necrosis (rare)
    22. 22. Dabigatran (Pradaxa®) 22 Not FDA Approved for VTE prophylaxis  150mg by mouth twice daily  75mg by mouth if CrCl is less than 30 mL/min Surgical considerations  Discontinue 1-2 days prior to an invasive or elective surgical procedure  Discontinue 3-5 days prior to procedure if CrCl is less than 50  Reinitiate ASAP after procedures  Not reversible Adverse Effects  GI effects (6.1%), Bleeding (16.6%)
    23. 23. Rivaroxaban (Xarelto®) 23 VTE Prophylaxis Dosing  Knee or hip replacement surgery: 10mg by mouth daily  Begin 6 – 10 hours after surgery  Continue for 12 days after knee, 35 days after hip  Secondary DVT/PE Prophylaxis: 2omg by mouth daily  DISCONTINUE at least 24 hours prior to procedure Avoid if CrCl is less than 30 mL/min Adverse Effects  Bleeding (5.8%), Epidural hematoma Carries same Black box Warning as LMWHs
    24. 24. Apixaban (Eliquis®) 24 New reversible and selective active site inhibitor of factor Xa Dosing (European Medicines Agency-Approved dosing)  Knee replacement surgery: 2.5mg by mouth daily  Begin 12 – 24 hours after surgery  Continue 10 – 14 days  Hip replacement surgery: 2.5mg by mouth twice daily  Begin 12 – 24 hours after surgery  Continue 32 – 38 days  DISCONTINUE 24 - 48 hours prior to elective or invasive surgery procedures Dose adjusted for body weight, age, renal impairment, and CYP3A4 inhibitors
    25. 25. IMPORTANT DRUG INTERACTIONS 25 Medications that increase bleeding risk  SSRI’s and SNRIs  Medications for pain (NSAIDs, Willow Bark)  Kava Kava may impair blood clotting due to effects on the liver Medications that alter metabolism  Barbiturates, such as phenobarbital, may induce metabolism of heparins, decreasing effect  Carbamazepine/oxcarbamezapine and St. John’s Wort induce metabolism of warfarin and apixaban by inducing 3A4 and 2C9 Bad habits  Smoking induces metabolism  Alcohol increasing bleeding risk
    26. 26. QUESTIONS? 26

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