University:
West Coast University
Course:
PHAR 740 | IPC Cardiopulmonary and Renal III
Academic year:

2024
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396

Pages:

54
Author:

Asal A.

formsinvein clot Bigod me Venous Thromboembolism Part I Catherine Van, PharmD, BCPS Assistant Professor, Pharmacy Practice 1 OBJECTIVES (PART I & II)  Identify risk factors for venous thromboembolism (VTE)  Recognize clinical presentation of VTE  Understand the diagnosis of VTE  Examine treatment strategies for VTE  Non-pharmacological  Pharmacological prophylaxis  Pharmacological treatment  Drug dosing  Drug-drug interactions  Follow up and monitoring parameters  Major patient counseling  Antidotes  Review associated risk versus benefits of different treatment options  Discuss VTE treatment and prophylaxis in special populations 2  Given a patient case, defend a care plan for the patient PATIENT CASE  CC: “My right leg is swollen and hurts a lot.”  ML is a 24 year old Asian female that presents to the ER with pain in her right leg. She stated that she has not done anything to hurt it. She just got back from Japan 2 days ago.  PMH: No significant PMH, healthy young female estrogen progestone  Medications: Recently started Yaz contraceptive Caacombined  SH: smoker (1 pack/day), social drinker (3 drinks/weekend) 5 VTE Introduction • • • • • • Definitions Epidemiology Etiology Clinical Presentation Complications Diagnosis 6 VTE DEFINITION  Clot formation within the venous circulation  Manifested as: Deep vein thrombosis (DVT)  Rarely fatal Pulmonary embolism (PE)  Can result in death within minutes of symptom onset, before effective treatment is given DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 7 VENOUS CIRCULATION AND DVT a prod nearest pistol FAM• Upper extremity DVT et myaz Proximal – Axillary or more proximal veins Catheter-associated • Lower extremity DVT Backofthe Proximal – Popliteal or res more proximal veins Distal – Calf veins DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGrawHill Education, 2017. Overview of the treatment of lower extremity deep vein thrombosis (DVT). Access through UpToDate. Primary (spontaneous) upper extremity deep vein thrombosis. Access through UpToDate. Catheter-related upper extremity venous thrombosis. Access through UpToDate. 8 T YPES OF PE Massive Don'thaveenoughpressure mpg inthesystemtokeep PE causing hemodynamic compromise bloodflowing low Bpj Sustained hypotension (systolic blood pressure < 90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE) Pulselessness OR Persistent profound bradycardia (heart rate 40 bpm with signs or symptoms of shock) Jaff, MR., et al. Management of Massive and Submassive PE, Iliofemoral DVT, and CTPH: AHA Scientific Statement. Circulation. 2011:123:1788-1830. 9 T YPES OF PE 2 Submassive PE causing right ventricular dysfunction (RV) demonstrable by echocardiography, computed tomography or elevated cardiac biomarkers Non-massive or low-risk PE without evidence of RV dysfunction or hemodynamic compromise Aggarwal, V., et al. Acute Management of Pulmonary Embolism. American College of Cardiology (Latest in Cardiology). 2017. 10 VTE EPIDEMIOLOGY H'm  Associated with major global disease burden  Little public awareness of the life-threatening nature of DVT and PE  The incidence rate of symptomatic first VTE:  Estimated at 1.32 per 1,000 patient-years  Occurs more frequently in women (55.6%)  When standardized by age, Asians appear to have the lowest VTE incidence (1.22 per 1,000 patient -years) followed by whites (1.91) and blacks (2.03) DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 11 VTE EPIDEMIOLOGY on  Rate of recurrent VTE: important  Highest in the 180 days following the initial event  Declines slowly over the next 4 to 10 years to a relatively constant rate  The 10-year cumulative risk of recurrent VTE is approximately 25.0% DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 12 AAA ETIOLOGY OF VTE h 3 important Virchow’s Triad 2 13 BokOF VTE goETIOLOGY Eton Wjw  Arise from the synergistic effects of multiple risk factors Abnormal bloodflow Éoncer is slow a pt redbloodeens produce DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 14 Thromboembolism. New York: McGraw-Hill Education, 2017. Back 90ETIOLOGY OF VTE East  Hypercoagulability 5  Inherited thrombophilia  Other acquired factors  Factor V Leiden  Malignancy É  Prothrombin (G20210A) gene 7  Pregnancy/postpartum mutation  Antithrombin, protein C or A Antiphospholipid antibodies protein S deficiency Aps a  COVID-19 infection autoimmune Drug therapy: do A real  Estrogen-containing contraceptives ofplognik blood  Estrogen replacement therapy offibrinogenin DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. Abou-Ismail, MY, et al. Thromb Res. 2020 Oct; 194: 101–115  Selective estrogen receptor modulators (e.g. tamoxifen, raloxifene)  Cancer therapy  Heparin-induced thrombocytopenia (HIT) 15 ETIOLOGY OF VTE Additional risk factors In Long-distance travelers Every additional 2 hours of travel confers an 18% increase in risk Risk greatest for prolonged flights > 6 hours a Smoking Fy Risk of developing VTE greater for current smokers than for former smokers Synergistic effect on VTE risk for smoking and oral contraceptive use. Pomp et al. reported the OR of developing VTE for oral contraceptive users was 3.90, but increased to 8.79 when current smoking was added Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. Cheng, YJ., et al. Current and Former Smoking and Risk for VTE: A Systematic Review and Meta-Analysis. PLoS Med. 2013; 10(9):e1001515. 16 CLINICAL PRESENTATION OF DVT Fyi  DVT Symptoms  Unilateral  Swelling, pain, or warmth  Nonspecific and objective testing must be performed to establish the diagnosis  DVT Signs  Superficial veins may be dilated  A palpable cord may be felt in affected area  Homan’s sign may be present  Pain in back of knee when examiner dorsiflexes the foot of the affected leg DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 17 Thromboembolism. New York: McGraw-Hill Education, 2017. CLINICAL PRESENTATION OF PE Fye  PE Symptoms  Cough, chest pain, chest tightness, shortness of breath, or palpitation at  Patient may spit or cough up blood (hemoptysis)  When PE is massive, patient may complain of dizziness or light headedness  PE Signs Sagat  May have tachypnea, tachycardia, and appear diaphoretic  Neck veins may be distended  In massive PE, patient may appear cyanotic and become hypotensive  In the worse cases, patient may go into cardiogenic shock and die within minutes heartcon't pumptheblood DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 18 Thromboembolism. New York: McGraw-Hill Education, 2017. COMPLICATIONS OF VTE I  Post-thrombotic syndrome  Long-term complication of DVT caused by damage to the venous valves  Chronic thromboembolic pulmonary hypertension (CTPH) Is  Result of one or more episodes of PE  Elevated pulmonary vascular pressures and increased pulmonary vascular resistance  Can lead to right heart failure and death DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. Madani, M, Ogo, T, Simonneau, G. The Changing Landscape of CTPH Management. Eur Respir Rev. 2017; 26:170105. 19 LABORATORY TESTS D-dimer serum concentration By-product of fibrin degradation, is nearly always elevated Values less than 500 ng/mL (mcg/L) combined with clinical decision rules are useful in ruling out the diagnosis of VTE Does not rule in diagnosis DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 20 Thromboembolism. New York: McGraw-Hill Education, 2017. DVT CLINICAL DECISION RULE EXAMPLE (FYI) • *Score ≥ 2 points: DVT likely • *Score < 2 points: DVT unlikely • Mostly validated in outpatient setting Wells, P.S., et al. Diagnosis of Venous Thromboembolism: 20 Years of Progress. Ann Intern Med. 2018;168:131-140. 21 DVT CLINICAL DECISION RULE EXAMPLE (FYI) DVT suspected DVT unlikely (Wells score < 2) D-dimer negative D-dimer positive DVT ruled out Diagnostic tests DVT likely (Wells score ≥ 2) Diagnostic tests DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 22 Thromboembolism. New York: McGraw-Hill Education, 2017. DIAGNOSTIC TESTS FOR DVT A  Compression ultrasound  Most commonly used test to diagnose DVT  Noninvasive test that can visualize clot formation in veins of the legs  Cannot reliably detect small blood clots in calf veins  Coupled with a careful clinical assessment, it can rule in or out the diagnosis in the majority of cases 2  Venography  Gold standard for the diagnosis of DVT  Invasive test that involves injection of radiopaque contrast on dye into a foot vein  Expensive  Can cause anaphylaxis and nephrotoxicity ft allergican DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 23 Thromboembolism. New York: McGraw-Hill Education, 2017. DIAGNOSTIC TESTS FOR PE  Computerized tomography pulmonary angiography (CTPA)  Most commonly used test to diagnose PE  Some centers still use the ventilation –perfusion (V/Q) scan  A V/Q scan measures the distribution of blood and airflow in the lungs  When there is a large mismatch between blood and airflow in one area of the lung, there is a high probability that the patient has a PE s blog  Pulmonary angiography (conventional)  Gold standard for the diagnosis of PE  Invasive test that involves injection of radiopaque contrast dye into the pulmonary artery  Expensive and associated with a significant risk of mortality DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 24 Thromboembolism. New York: McGraw-Hill Education, 2017. BACK TO ML  CC: “My right leg is swollen and hurts a lot.”  ML is a 24 year old Asian female that presents to the ER with pain in her right leg. She stated that she has not done anything to hurt it. She just got back from Japan 2 days ago.  PMH: No significant PMH, healthy young female  Medications: Recently started Yaz contraceptive so  SH: smoker (1 pack/day), social drinker (3 drinks/weekend) 25 PATIENT CASE  Subjective findings:  Onset of symptoms: 24 hours prior to ER visit  Right leg pain 7/10; no other symptoms  Objective findings:      Ht: 60” Wt: 100 lbs normal thatswhy don'thave All we HR, BP, RR, T, O2 saturation: All WNL Allergies: NKDA PE reveals right lower extremity is erythematous, swollen, tender and warm to touch  Imaging: Ultrasound detected occlusive thrombus in right posterior tibial vein  D-dimer: 600 ng/mL  SCr, CrCl, and all other labs WNL pt 26 PATIENT CASE What are ML risk factors for her DVT? Birthcontrol combined longdistanttraveling smoking pain imaging physicalexamresult Ddimeris elevated resat What subjective and objective findings support the diagnosis of a lower extremity DVT? 27 MEDICATIONS FOR VTE Pharmacological Options Unfractionated heparin Low molecular weight heparin (LMWH) (Lovenox®) Activity Drug Class or Mechanism of Action? Fondaparinux (Arixtra®) Warfarin (Coumadin®) Knowing Brand names are required Dabigatran (Pradaxa®) Rivaroxaban (Xarelto®) Apixaban (Eliquis®) Edoxaban (Savaysa®) New/Direct Oral Anticoagulants (NOAC/DOAC) Betrixaban (Bevyxxa®) 28 sit VTE Prophylaxis • VTE risk assessment model • Nonsurgical patients • Surgical patients • Bleeding risk assessment model • Non-pharmacological options • Pharmacological option overview • Nonsurgical patients • Surgical patients • Orthopedic • Chronically immobilized patients • Persons traveling long-distance 30 VTE RISK ASSESSMENT MODEL • There are many risk assessment models for VTE • See AHRQ publication for discussion of different models • Preventing Hospital-Associated VTE: A Guide for Effective Quality Improvement 31 3,151 VTE RISK ASSESSMENT MODEL a Nonsurgical patients • ACCP guideline 9 th edition recommends: •Padua Prediction Score risk assessment model • Used to assess VTE risk in hospitalized medical patients (non-critically and critically ill) • High risk VTE: cumulative score ≥ 4 points • Low risk VTE: cumulative score < 4 points Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 32 VTE RISK ASSESSMENT MODEL Fyi Padua Prediction Score Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 33 VTE RISK ASSESSMENT MODEL Surgical patients  Caprini Score Jonbtusig important  Used to estimate VTE risk after general surgery  VTE risk categorized as:  Very low (0 to 1 point)  Low (2 points)  Moderate (3 to 4 points)  High (more than or equal to 5 points) need Dont toknow  Estimating surgical bleeding risk is challenging.  Wide variety of surgery types  Effect of surgical technique  Lack of a validated bleeding predication rule DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous 34 Thromboembolism. New York: McGraw-Hill Education, 2017. BLEEDING RISK ASSESSMENT MODEL Sok 56600 Know the first 3 bleeding risk factors Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 36 BLEEDING RISK ASSESSMENT MODEL High bleeding risk  One of the three risk factors below (see table in previous slide)  Active gastroduodenal ulcer  Bleeding in 3 months before admission  Platelet count less than 50 × 10 9 /L OR  Two or more of the remaining 8 risk factors (see table in previous slide) Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 37 PATIENT CASE  AF is a 75 years old Caucasian male who was admitted to regular inpatient unit for management of his pneumonia.  PMH: active gastroduodenal cancer with metastases, HTN, DM, ESRD on HD  Allergy: NKDA  VS: WNL points  Labs: Na 140, K 5.5, Mg 3.4, Scr 4.7 Activecancer 3 elderly o infection point 1) Determine AF’s VTE risk using Padua Risk Score points E 2) Determine AF’s bleeding risk bleedingrisk the so mtsuIr poin y 1st If 3 high 38 NON-PHARMACOLOGICAL PROPHYLAXIS sÉ OPTIONS Mechanical thromboprophylaxis 1) Intermittent pneumatic compression (IPC) devices  Prevent VTE by increasing the velocity of venous blood flow through graded pressure application  Utilize a series of cuffs wrapped around the patient ’s legs that inflate in continuous 1- to 2-minute cycles from the ankles to the thighs  Worn at least 18 hours/day for optimal effectiveness  Reduces risk of VTE by more than 60% following general surgery, neurosurgery, and orthopedic surgery DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 39 NON-PHARMACOLOGICAL PROPHYLAXIS OPTIONS 2) Graduated compression stockings  Do not reliably reduce VTE in medically ill patients  Reduce the incidence of VTE by approximately 65% when used after orthopedic surgery, cardiac surgery, gynecologic surgery, or neurosurgery DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 40 RISKS VS. BENEFITS Mechanical thromboprophylaxis Benefit  Do not increase bleeding risk  Can be used in patients with contraindications to pharmacologic therapies Risks  Can cause discomfort, skin breakdown and ulceration DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 41 INFERIOR VENA CAVA (IVC) FILTERS  Provide short-term protection against PE in veryhigh-risk patients  Block embolization of thrombus formed below the filter  Insertion is minimally invasive  Unproven mortality benefit  Limited nonrandomized data support effectiveness and long-term safety for VTE prevention DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 42 INFERIOR VENA CAVA (IVC) FILTERS  Frequently “retrievable” IVC filters are never retrieved Increased risk for long-term complications such as DVT, filter migration, IVC occlusion, and insertion site thrombosis  Reserved for patients at highest VTE risk in whom other prophylactic strategies cannot be used  Removed when VTE risk has passed or when anticoagulation is no longer contraindicated DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 43 INFERIOR VENA CAVA (IVC) FILTERS 44 PHARMACOLOGICAL PROPHYLAXIS OPTIONS (NON-SURGICAL) Patient Population VTE risk Bleeding Risk Options Hospitalized noncritically ill Low N/A No prophylaxis Hospitalized noncritically ill Increased risk (i.e. high risk) Not high risk Low molecular weight heparin (LMWH) longing Low-dose unfractionated heparin (LDUH) BID or TID Fondaparinux (all Grade 1B) Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 45 PHARMACOLOGICAL PROPHYLAXIS OPTIONS (NON-SURGICAL) Patient Population Hospitalized noncritically ill VTE risk Increased risk (i.e. high risk) Bleeding Risk Bleeding or at high risk for major bleeding Options Mechanical thromboprophylaxis: Graduated compression stockings or IPC (Grade 2C) Consider pharmacologic thromboprophylaxis when bleeding risk decreases and if VTE risk persists (Grade 2B) Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 46 PHARMACOLOGICAL PROPHYLAXIS OPTIONS (NON-SURGICAL) Patient Population Ptin KU Bleeding Risk Options Hospitalized critically ill Not high risk LMWH or LDUH (Grade 2C) Hospitalized critically ill Bleeding or at high risk Mechanical for major bleeding thromboprophylaxis: Graduated compression stockings or IPC (Grade 2C) I Consider pharmacologic thromboprophylaxis when bleeding risk decreases (Grade 2C) Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 47 PATIENT CASE  AF is a 75 years old Caucasian male who was admitted to regular inpatient unit for management of his pneumonia.  PMH: active gastroduodenal cancer with metastases, HTN, DM, ESRD on HD pthadPyTE andbleeding  Allergy: NKDA  VS: WNL IF KO PUTEbleeds LMWH or Low  Labs: Na 140, K 5.5, Mg 3.4, Scr 4.7 EH Based on previously calculated VTE and bleeding risk scores, what would you recommend for AF? POTE notPbleeds mechanical Bal p t havehigh risk loanthat unfracted hephinBID TOD Fonda paring 48 ADDITIONAL ACCP RECOMMENDATION FOR PROPHYLAXIS (NON-SURGICAL) For hospitalized non-critically ill patients who receive an initial course of thromboprophylaxis, limit duration of thromboprophylaxis to the period of patient immobilization or acute hospital stay (Grade 2B). DO In chronically immobilized persons residing at home or at a nursing home, the routine use of thromboprophylaxis is NOT recommended (Grade 2C). Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 49 ADDITIONAL ACCP RECOMMENDATION FOR PROPHYLAXIS (NON-SURGICAL) For long-distance travelers at increased risk of VTE:  Frequent ambulation, calf muscle exercise, or sitting in an aisle seat if feasible is recommended (Grade 2C)  Use of properly fitted, below-knee GCS providing 15 to 30 mm Hg of pressure at the ankle during travel is recommended (Grade2C) For long-distance travelers, the use of aspirin or anticoagulants to prevent VTE is NOT recommended (Grade 2C) Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 50 PHARMACOLOGICAL PROPHYLAXIS OPTIONS (ORTHOPEDIC SURGICAL) Patient Population Options Duration Major orthopedic LMWH preferred (Grade 2C) surgeries: Lowenax 1) Total hip arthroplasty (THA) 2) Total knee arthroplasty (TKA) 3) Hip fracture surgery (HFS) Minimum of 10-14 days and extend in the outpatient period for up to 35 days t (Grade 2B) Major orthopedic surgeries During the hospital stay (Grade 2C) Dual prophylaxis with an antithrombotic agent and IPC Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 51 PHARMACOLOGICAL PROPHYLAXIS OPTIONS (ORTHOPEDIC SURGICAL) Patient Population Options Duration THA and TKA Alternative to LMWH: fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH, adjusted-dose warfarin, aspirin (all Grade 1B) Minimum of 10-14 days and extend in the outpatient period for up to 35 days (Grade 2B) HFS Alternative to LMWH: fondaparinux, LDUH, adjusted-dose warfarin, aspirin (all Grade 1B) Minimum of 10-14 days and extend in the outpatient period for up to 35 days (Grade 2B) Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 52 PHARMACOLOGICAL PROPHYLAXIS OPTIONS (ORTHOPEDIC SURGICAL) Patient Population Major orthopedic surgeries and decline injections Options apixaban or dabigatran (if not available, can use rivaroxaban or adjusted-dose warfarin) (all Grade 1B) I Duration Minimum of 10-14 days and extend in the outpatient period for up to 35 days (Grade 2B) Antithrombotic Therapy and Prevention of Thrombosis, 9th ED: ACC Guidelines. CHEST 2012;141(2)(Suppl):7S-47S. 53 VTE Treatments • Goals • Non-pharmacological options 54 VTE TREATMENT GOALS Preventing thrombus extension and embolization Reducing recurrence risk Preventing long-term complications such as the post-thrombotic syndrome and CTPH DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 55 MANAGING VTE  General principles  Confirm diagnosis prior to initiating therapy  DVT and PE require similar treatments  Prophylaxis doses differ from treatment doses for most of the anticoagulant agents  Treatment doses > prophylaxis doses  Proper treatment  complications & recurrences  Observe duration of therapy recommendations  Monitor for bleeding signs and symptoms 56 NON-PHARMACOLOGICAL TREATMENT Ambulation in conjunction with graduated compression stockings  Faster reduction in pain and swelling  No apparent increase in embolization rate Patients should be encouraged to ambulate as much as symptoms permit If ambulation increases pain and swelling, have patient lie down and elevate the affected leg until symptoms subside DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 57 NON-PHARMACOLOGICAL TREATMENT IVC filters have a limited role in the management of acute VTE  Only used when anticoagulants are contraindicated due to active bleeding  As soon as the bleeding risk resolves:  Patients should receive a conventional course of anticoagulant therapy AND  Have the filter removed within 90 to 120 days of implantation DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e., Ch19: Venous Thromboembolism. New York: McGraw-Hill Education, 2017. 58

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