1) NOACs have significant drug interactions with some antiviral medications used to treat COVID-19, whereas low molecular weight heparin and unfractionated heparin do not interact.
2) For hospitalized COVID-19 patients, low molecular weight heparin is preferred over NOACs for those admitted to the ICU or who are critically ill. NOACs, low molecular weight heparin, or unfractionated heparin can be used for non-ICU patients.
3) After discharge, extended anticoagulation may be recommended for high-risk COVID-19 patients, with rivaroxaban, apixaban, betrixaban, or enoxapar
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
Co-Chairs, Alok A. Khorana, MD, FACP, FASCO, and Robert D. McBane, II, MD, along with Dana Angelini, MD, prepared useful Practice Aids pertaining to VTE for this CME/MOC/NCPD/CPE activity titled “Reducing the Global Burden of Cancer-Associated VTE: Applying Guideline-Concordant, Evidence-Based Care and Shared Decision-Making Strategies to Improve Patient Outcomes.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/3pxFR5t. CME/MOC/NCPD/CPE credit will be available until August 9, 2022.
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
Co-Chairs, Alok A. Khorana, MD, FACP, FASCO, and Robert D. McBane, II, MD, along with Dana Angelini, MD, prepared useful Practice Aids pertaining to VTE for this CME/MOC/NCPD/CPE activity titled “Reducing the Global Burden of Cancer-Associated VTE: Applying Guideline-Concordant, Evidence-Based Care and Shared Decision-Making Strategies to Improve Patient Outcomes.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/3pxFR5t. CME/MOC/NCPD/CPE credit will be available until August 9, 2022.
Rivaroxaban for thromboprophylaxis after Hospitalization for Medical IllnessShadab Ahmad
Anticoagulant prophylaxis reduces the risk of in-hospital venous thromboembolism by 50 to 60% but is rarely continued after discharge in accordance with current guidelines
In COVID-19 any antiviral is more effective when used early in first week of illness.
What should not be used in covid-19 is also discussed in presentation.
Rivaroxaban for thromboprophylaxis after Hospitalization for Medical IllnessShadab Ahmad
Anticoagulant prophylaxis reduces the risk of in-hospital venous thromboembolism by 50 to 60% but is rarely continued after discharge in accordance with current guidelines
In COVID-19 any antiviral is more effective when used early in first week of illness.
What should not be used in covid-19 is also discussed in presentation.
A cardiologists perspective to current scenario in light of corona pandemic in india and world wide. cardiac procedures , heart disease , aceinhibitors , arni , heart failure , troponin, nt probnp
Having more than two year experiences, presently anticoagulant is an essential component of management of COVID 19
Its role is recommended in moderate to severe to critically ill patients with different opinion in the dosage
Giving anticoagulants in asymptomatic or mild cases is still need to be validated though there are suggestions in favor.
There is recommendation for post discharge patients who had clinically suspected/established thromboembolism events
Origin of virus??
Transmission of virus??
First case in Wuhan?
Aerosol transmission? Fomites? Re- infection/ reactivation
Vaccine/ safety & efficacy/ antibody test/ community transmission?
Case definition?
Pathophysiology/ pathology
Cardiovascular manifestations/ risk?
ACS
Role of aspirin
Low platelet in covid-19
Anti-coagulants
ACEI/ARB/ARNI
Diuretics
Clinical features
High risk groups
Antibiotics
HCQ& Lopinavir, Ritonavir
Anti viral drugs- remdisivir/ favipiravir
Biological therapy- tocilizumab
Convalescent plasma therapy
Systemic steroids
Ivermectin
NSAIDs
Respiratory failure
Other management in covid 19- fluid/ nebulization
Chemoprophylaxis
Bronchial asthma
Anti diabetics
Mgh COVID-19 Treatment Guidance March 17, 2020Ken Yale
This document was developed by members of the ID division at MGH in conjunction with pharmacy, radiology, and other medicine divisions to provide guidance to frontline clinicians caring for patients with COVID-19. This document covers potential off-label and/or experimental use of medications and immunosuppression management for transplant patients as well as a suggested laboratory work up. It does NOT cover recommendations for infection control, PPE, management of hypoxemia or other complications in patients with COVID-19. This is a living document that will be updated in real time as more data emerge.
This Presentation contains an international directory of guidelines collection from many international sources and best practice recommendations documents for the care and management of COVID-19 .
Contents
1-anticoagulation in COVID-19.
2-Antivirals in COVID-19.
3-immunomodulators in COVID-19.
4-antifibrotic therapy in COVID-19.
5-Antibiotic in COVID-19.
6-Nebulization in COVID-19.
7-Systemic steroids in COVID-19.
8- supplement in COVID-19.
9-radiation therapy in COVID-19.
10-Convalescent plasma in COVID-19.
11- COVID-19 in Pregnancy
12-Acute Kidney Injury in COVID-19.
13- Cardiology in COVID -19.
14-Critical Care in COVID-19.
15-Nutrition in ICU Patients in COVID-19.
16 Hypoxemia Management in COVID-19.
17-Mechanical Ventilation in COVID-19.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Role of Noac (Newer oral aticoagulants) in covid 19 treatment Dr. Jaykishan
1. ROLE OF NOACs IN COVID-19 TREATMENT
B Y
D R . J AY K I S H A N S I N G H
N A R W A R I YA
R M O M E D I C I N E
M O D E R A T O R
D R .V. P. PA N D E Y
P R O F E S S O R A N D H E A D
D E P A R T M E N T O F M E D I C I N E
M G M M C & M Y H H O S P I T A L I N D O R E
2. • TOTAL CASES in world : 86,196,009
• CASES in India : 10,373,287
• Total deaths in World
1,867,481 (2.16%)
• Total deaths in India
150,106 (1.45%)
CURRENT STATUS
3. • Clinical spectrum range from asymptomatic to profound, rapid multiple
organ dysfunction syndrome and death.
• MULTISYSTEM DISORDER NOT JUST RESPIRATORY DISEASE
A. Acute respiratory failure
B. ARDS
C. Sepsis
D. Venous and arterial thromboembolism
• DIC is a strong predictor of mortality, with 71.4% of non-survivors
meeting criteria for disseminated intravascular coagulation.
COVID-19
E. DIC
F. Acute kidney injury
G. Acute liver failure
4. COVID-19 Hypercoagulability
• Is it the first virus which is associated with hypercoagulable states???
NO
• Viral infections are associated with increased risk of thrombosis.
• Coagulopathy was first reported in viral infection during
1918 influenza pandemic
• In 2004 SARS related macrovascular complication of stroke were
reported during Singapore SARS-CoV outbreak.
• AIDS, Dengue and Ebola virus disease- Thrombosis reported
6. COVID-19 and Hypercoagulability
• Among critically ill patients, incidence of was pulmonary thrombosis 30% in
COVID-19 patients as compared to 1.3% of non-Covid-19 patients.
• Other studies from France and the Netherlands have also suggested that
thrombosis occurs in 20-30% of critically ill covid-19 patients, even with
prophylaxis.
• An analysis of contrast-enhanced CT findings in a case series of ICU patients
showed the presence of pulmonary artery thrombosis in 20.6% of 107 patients
admitted to ICU with COVID-19, compared with 7.5% of 40 influenza patients
admitted during the previous year.
7. Pathogenesis of COVID-19 associated thrombosis
Two mechanisms
• 1ST : HIGH CYTOKINE PRODUCTION
- Increased fibrinogen production and subsequent thrombosis.
- Sepsis and cytokine mediated increased thrombosis (Decreased antithrombin, protein C, TFPI & Increased TF)
- eg. Fibrinogen in critically ill COVID patient – 10-14 g/L (Normal- 2-4g/L)
• 2ND : ENDOTHELIAL INJURY-
-High conc. of ACE2 receptors in respiratory mucosa, vascular endothelium, organs like kidney, heart,
intestinal tract.
-Direct vascular endothelial injury starts a chain of thrombosis.
-This explains why thrombosis can also be seen in patients without significant pneumonia.
8. Test for detecting thrombosis
• D-dimer: It is a fibrin degradation product and named as it contains 2 D- fragments of fibrin protein linked by a cross link.
Normal value:
Individuals with D-dimer >2000 ng/ml had highest risk of critical illness (66%), thrombotic events (58.3%),
death(47%).
D-dimer value alone should not be used to guide the clinical decision making in COVID-19.
• High clinical suspicion : If d dimer raises >5 times ULN within 48 hours.
If acute worsening of oxygenation.
• PT/aPTT: These are mildly deranged in COVID-19 induced thrombosis.
• DVT screening by doppler, CT pulmonary angiography
<0.5 mg/L
<0.5 microgram/ml
<500 ng/ml
9. Management of thrombosis associated with COVID-19
• Who should receive anticoagulants
1. Routine anticoagulant prophylaxis is NOT RECOMMENDED for COVID-19
patients who are not hospitalized.
2. ALL COVID-19 PATIENTS who require hospitalization should receive
anticoagulation prophylaxis unless contraindicated.
(The dose and type of anticoagulant has to be individualized on the basis of
clinical condition of the patient.)
(Reference latest 2020: Anticoagulation Forum,the American College of Chest Physicians, the American
Society of Hematology,the International Society of Thrombosis and Haemostasis (ISTH),the Italian Society
on Thrombosis and Haemostasis, the Royal College of Physicians, NIH maryland )
10. Contraindications to anticoagulation
1. Active bleeding within 3 months
2. Intracranial bleed within 1 year
3. Known potential bleed site (eg. Peptic ulcer, bronchiectasis)
4. Thrombocytopenia ( Platelet count < 50000/cumm)
5. Significant liver disease (INR >1.4)
6. Lumbar puncture/epidural/spinal anaesthesia within previous 4 hours or expected within next 12
hours
7. Uncontrolled systemic hypertension ( BP >230/120mmHg)
12. What is the status of NOAC in In-hospital management of
COVID-19
• NOACs have significant drug interaction with some antiviral medications.
13. What is the status of NOAC in In-hospital management of
COVID-19
• NOACs have significant drug interaction with some antiviral medications whereas LMWH/ UFH have
no interaction with antiviral drugs.
1. All patients who are admitted to ICU or are critically ill should receive LMWH (Preferred) / UFH.
(NOACs not given)
2. Patients who are not managed in ICU can be given either LMWH (Preferred)/ UFH/ NOAC.
3. Patients who develop DVT/ PE in hospital and it is hemodynamically stable, can be started on
NOAC/LMWH/UFH .
4. If PE is hemodynamically unstable (E.g. BP <90 systolic). LMWH/ UFH/ thrombolysis with tPA
should be used. (NOAC are not to be given in case of hemodynamic unstable PE)
5. Patient on chronic NOAC/ Warfarin for chronic indication contracts COVID-19
If managed in non-ICU - should continue NOAC/Warfarin.
ICU admission or if antiviral medication needed - Switch to LMWH (Preferred)/ UFH
14. POST-DISCHARGE EXTENDED ANTICOAGULATION
IN COVID-19
1. Post discharge anticoagulant prophylaxis is not indicated for all patients
2. It is given to selective patients with high risk of VTE.
a) D-dimer >2 times ULN at time of discharge
b) Stay in ICU/ CCU
c) Age >60 Years
d) Immobilized for at least 7 days
e) Prior venous thromboembolism
f) Diagnosed thrombophilia
g) Current lower limb paralysis
h) Current cancer
AGENT for Post discharge extended anticoagulation
1. Tab Rivaroxaban 10mg daily
2. Tab Apixaban 2.5mg BD
3. Tab Betrixaban 160mg on day 1 f/b 80mg OD
4. S/C Enoxaparin 40mg OD
DURATION for post discharge extended anticoagulation
Minimum 4 weeks
15. The study of thromboembolic and bleeding events 30 days post discharge COVID-
19 patients was conducted & published in American society of haematology in
September 2020.
• Dr. Lara Roberts, MD, Kings college hospital NHS foundation trust London
• Dr. Jeffrey Zwicker, MD, Beth Israel deaconess center in Boston
Risk of VTE following COVID-19 is not significantly higher than patients
without COVID-19.
• Thus recommending post discharge anticoagulant prophylaxis to be
individualized.
DILEMMA
16. 3. Patients on chronic anticoagulant and antiplatelet therapy: Should continue
taking their medication. Switching to NOACs from parenteral and VKAs should be
individualized.
4. Pregnant and lactating COVID-19 patients: The anticoagulant prophylaxis
indication are same as non-pregnant patient but the choice of anticoagulant should
be taken into account. Heparin, enoxaparin and warfarin are not secreted in breast
milk so these are recommended. NOACs are not recommended due to lack of safety
data.
17. Why is NOACs important in COVID-19 ERA
• COVID-19 pandemic and health crisis
Requires containment for hundreds and millions of people.
Restrictions on mobility
Reduces access to medical care, both general practitioners and hospitals
Reduces access to pharmacies, laboratories and nursing care.
Many hospitals are saturated and devote most of their resources to the
management of COVID-19 patients.
• Traditional anticoagulants have 2 major limitation
1. Narrow therapeutic window of adequate anticoagulation without bleeding
2. Highly variable dose response, requiring lab monitoring
18. Advantages of NOACs over warfarin
ADVANTAGE REAL WORLD IMPLICATION
Low risk of bleeding Less need for emergency access and blood
products
Rapid onset of action No need for bridging with IV heparin
Predictable anticoagulant effect No need for routine monitoring of INR
Specific coagulation enzyme is targeted Low risk of off-target adverse effects
Low food interaction Can eat greens and salads
Lower risk of drug interaction Few restriction in using other drugs
Lower adverse effects Skin necrosis in protein C and S deficiency
Risk of osteoporosis
THE ANTITHROMBOTIC EFFICACY OF NOACS IS SUPERIOR TO ANTICOAGULATION WITH VITAMIN K
ANTAGONISTS (VKAS)
19. THE COVID-19 CRISIS IS AN OPPORTUNITY FOR
For patients in whom oral anticoagulation must be started, it seems legitimate to
favor the use of NOACs.
For patients on long-term VKA, the current crisis is probably an opportunity to
switch them to a NOAC.
For patients who should imperatively be or remain on VKAs
1. Valvular atrial fibrillation
2. Mechanical cardiac valve
3. Antiphospholipid syndrome
4. Renal impairment depending on its severity
the use of point-of-care (POC) devices for measuring INR should be promoted.
20. Factors to consider before starting NOAC
1. Renal function
2. Concurrent medication intake especially CYP3A4 and P-gp
inhibitors
3. Food intake
4. Clinical condition of patient such as heart failure
5. Whether patient will be compliant.
21. Characteristic WARFARIN
DABIGATRAN
(Pradaxatm) 2015
RIVAROXABAN
(Xareltotm) 2011
APIXABAN
(Eliquistm) 2014
EDOXABAN
2014
Target
Vitamin K epoxide
reductase (VKOR)
Direct thrombin
(Factor IIa) inhibitor
Factor Xa Factor Xa Factor Xa
Onset of action
Slow onset
May take upto 5 or
more days
Rapid
2 hours
Rapid
2.5 to 4 hours
Administered with full
meal
Rapid
3 hours
Rapid
1 to 2 hours
Half-life (Hours) 20-60 12-14 7-13 8-13 9-11
Time to wear of
drug`s effect once
stopped
Usually 4 days 14-17 hours 9-13 hours 8-15 hours 10-14 hours
Elimination
Liver
Not excreted in
kidney
Kidney (80%) Kidney (33%) + Liver Kidney (27%) + Liver Kidney (35%) + Liver
Drug Interactions
CYP2C9
Agents which increase
bleeding risks
Rifampin, Quinidine,
Amiodarone, P-gp
inhibitors
CYP3A4 inhibitors
P-gp inhibitors
CYP3A4 inhibitors
CYP3A4 inhibitors
P-gp inhibitors
22. Yi-Hsin Chan et al, Efficacy and safety of apixaban, dabigatran, rivaroxaban and warfarin in Asians with nonvalvular Atrial fibrillation, Journal of American heart
association 7(8):e008150 (Year 2018)
AMERICAN
HEART
ASSOCIATION
23. Disadvantages of NOACs
• Very short half-lives, which will be hazardous if patient is not
compliant
• Lack of effect assay (We do not know if patient is compliant or not)
• Renal function needs to be monitored
• No reversal agent at present except (Idarucizumab is antidote for
Dabigatran Cost:3500$/5g).
24. References:
• Covid19 treatment guidelines, 17 Dec 2020, NIH Maryland
• Considerations on the Use of Anticoagulants in COVID-19 Patients, 10 June 2020, European
society of cardiology
• Anticoagulant Therapy for Patients with Coronavirus Disease 2019: Urgent Need for Enhanced
Awareness, 21 June 2020, JAPAN, European cardiology review
• icmanaesthesiacovid-19.org/ 24 Dec 2020
• Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019, CHEST
Guideline and Expert Panel Report
• Anticoagulation guidelines for COVID 19 patients Riverside Health System