1

Management of Management of
Anticoagulation for Venous Anticoagulation for Venous
Thromboembolism Thromboembolism
Sirada Maphanta, PharmD, MS, BCPS Sirada Maphanta, PharmD, MS, BCPS
Faculty of Pharmaceutical Sciences Faculty of Pharmaceutical Sciences
Naresuan University Naresuan University
Overview Overview
Introduction to Venous Thromboembolism (VTE) Introduction to Venous Thromboembolism (VTE)
Risk factors Risk factors
Pathophysiology Pathophysiology
DVT DVT
PE PE PE PE
Diagnosis Diagnosis
Complications Complications
Treatment Treatment
Acute Acute
Long term Long term
Approach for pharmacists at an anticoagulation clinic Approach for pharmacists at an anticoagulation clinic
Venous Venous
Thromboembolism (VTE) Thromboembolism (VTE)
VTE VTE
22
Deep vein thrombosis (DVT) Deep vein thrombosis (DVT)
Pulmonary embolism (PE) Pulmonary embolism (PE)
VTE VTE
USA: USA: 100 100//100 100,,000 000 population population
(TKA) (TKA)

Exponentially rise with age to Exponentially rise with age to 5 5//1000 1000/year at age > /year at age >80 80
thrombophillia thrombophillia

Caucacians ( Caucacians (104 104//100 100,,000 000) > Asians ( ) > Asians (21 21//100 100,,000 000))
VTE: VTE:
Asians Asians
Mannucci PM. J Thrombosis Haemostasis 2007;5 (suppl):68-72
VTE in VTE in
Thais Thais
61% venograms of TKA patients were positive for DVT
without prophylaxis
82.1% Calf vein
28% posterior tibia vein
65.6%in females VS 44.4%males
Chotanaphuti T. J Med Assoc Thai 2007;90(7):1342-7
65.6%in females VS 44.4%males
2
Virchows Triad Virchows Triad
Rudolf Virchow Rudolf Virchow
1821 18211902 1902
Venous Thrombus Venous Thrombus
Remain asymptomatic Remain asymptomatic
Spontaneously lyses Spontaneously lyses
Obstruct the venous Obstruct the venous
circulation circulation
Propagate into more proximal Propagate into more proximal
veins veins
Embolize Embolize
Combination of the above Combination of the above
Deep Vein Thrombosis Deep Vein Thrombosis
(DVT) (DVT)
Thrombus composed of cellular material Thrombus composed of cellular material
bound together with fibrin strands, formed bound together with fibrin strands, formed
in venous portion of vasculature in venous portion of vasculature
Can involve any vein in the body but usually Can involve any vein in the body but usually
occurs in the lower limb occurs in the lower limb
Complications Complications
Acute: embolization leading to PE, gangrene Acute: embolization leading to PE, gangrene
Long term: post Long term: post- -phlebitis or post phlebitis or post--thrombotic thrombotic
syndrome, chronic venous insufficiency syndrome, chronic venous insufficiency
Pulmonary Embolism (PE) Pulmonary Embolism (PE)
Thrombus or foreign substances arising Thrombus or foreign substances arising
from systemic circulation and lodges in from systemic circulation and lodges in
the pulmonary artery or one of its the pulmonary artery or one of its p y y p y y
branches causing complete or partial branches causing complete or partial
obstruction of pulmonary blood flow obstruction of pulmonary blood flow
50 50- -70% of PE cases originate from DVT 70% of PE cases originate from DVT
Fatal cases mostly resulting from mis Fatal cases mostly resulting from mis--
diagnosis diagnosis
VTE VTE
Nutcscu EA. Am J Health-Syst Pharm 2007;64:S5-13
DVT DVT
Nutcscu EA. Am J Health-Syst Pharm 2007;64:S5-13
3
VTE VTE 44--77
VTE VTE
VTE & Malignancy VTE & Malignancy
VTE VTE
11::200 200
Genetic Thrombophilia Genetic Thrombophilia
Antithrombin III deficiency Antithrombin III deficiency
Protein C deficiency Protein C deficiency
Protein S deficiency Protein S deficiency** Protein S deficiency Protein S deficiency**
Hyperprothrombinemia (Prothrombin Hyperprothrombinemia (Prothrombin
GG2021 2021A mutation) A mutation)
Factor V Leiden deficiency Factor V Leiden deficiency
*Most common genetic cause of DVT in Asians and Thais
*Found in 3.7% of healthy Thais
Acquired Thrombophilia Acquired Thrombophilia
Antiphospholipid antibody syndromes Antiphospholipid antibody syndromes
Malignancy Malignancy
Pregnancy Pregnancy
Therapy Therapy- -related hypercoagulable states related hypercoagulable states
Nephrotic syndrome Nephrotic syndrome
Inflammatory bowel syndrome Inflammatory bowel syndrome
Myeloproliferative syndromes Myeloproliferative syndromes
Clinical features of inherited Clinical features of inherited
deficiencies of AT, PC, PS deficiencies of AT, PC, PS
Venous thrombosis (> Venous thrombosis (>90 90%% of cases) of cases)
Deep vein thrombosis of the lower limbs (common) Deep vein thrombosis of the lower limbs (common)
Pulmonary embolism (common) Pulmonary embolism (common)
Superficial thrombophlebitis Superficial thrombophlebitis Superficial thrombophlebitis Superficial thrombophlebitis
Mesenteric vein thrombosis (rare but characteristic) Mesenteric vein thrombosis (rare but characteristic)
Cerebral vein thrombosis (rare but characteristic) Cerebral vein thrombosis (rare but characteristic)
Frequent family history of thrombosis Frequent family history of thrombosis
First thrombosis usually at young age (< First thrombosis usually at young age (<40 40yr*) yr*)
Frequent recurrences* Frequent recurrences*
Deep Vein Thrombosis Deep Vein Thrombosis
4
Location of Venous Thrombosis Location of Venous Thrombosis
DEFINITIONS DEFINITIONS
Proximal Proximal Clot: Popliteal vein or higher Clot: Popliteal vein or higher
Distal Distal: calf vein below trifurcation : calf vein below trifurcation
Superficial DVT Superficial DVT: in vein just below the : in vein just below the
skin skin
Idiopathic or Unprovoked Idiopathic or Unprovoked : No clear, : No clear,
reversible or transient risk factor; i.e. reversible or transient risk factor; i.e.
surgery surgery
Secondary: Secondary: Associated with transient risk Associated with transient risk
factor ie., surgery, pregnancy, trauma factor ie., surgery, pregnancy, trauma
Deep Vein Thrombosis Deep Vein Thrombosis
(DVT) (DVT)
Thrombus in DVT Thrombus in DVT
DVT DVT
Signs and symptoms Signs and symptoms
Leg pain, tenderness, swelling, warmth to Leg pain, tenderness, swelling, warmth to
touch and occasional discoloration touch and occasional discoloration
Complications Complications
Chronic venous disease Chronic venous disease
Post Post--thrombotic syndrome thrombotic syndrome
Chronic Venous Disease Chronic Venous Disease
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Chronic Venous Disease Chronic Venous Disease
Post Post- -thrombotic thrombotic
Syndrome Syndrome
Post thrombotic Post thrombotic
syndrome syndrome
50 50 - - 60 60% of cases % of cases
ith t ti ith t ti with symptomatic with symptomatic
DVT DVT
10 10% have severe, % have severe,
disabling symptoms disabling symptoms
Up to Up to 4 4% develop % develop
venous ulcers venous ulcers
Pathophysiolgy of
Chronic Venous Disease
Classification Classification
Submassive: < Submassive: < 50 50% of pulmonary vascular bed % of pulmonary vascular bed
is occluded is occluded
Massive: > Massive: > 50 50% of pulmonary vascular bed is % of pulmonary vascular bed is
Pulmonary Embolism Pulmonary Embolism
Massive: > Massive: > 50 50% of pulmonary vascular bed is % of pulmonary vascular bed is
occluded occluded
Signs and symptoms Signs and symptoms
Vary widely Vary widely
Sudden onset of dyspnea, cough, tachypnea, Sudden onset of dyspnea, cough, tachypnea,
pleuritic chest pain, anxiety, hemoptysis, right pleuritic chest pain, anxiety, hemoptysis, right
heart failure, syncope, shock heart failure, syncope, shock
6
Pulmonary Embolism Pulmonary Embolism
Three major clinical presentations: Three major clinical presentations:
11.. dyspnea with or without pleuritic chest dyspnea with or without pleuritic chest
pain and hemoptysis pain and hemoptysis
22.. hemodynamic instability and syncope hemodynamic instability and syncope
(usually associated with massive (usually associated with massive
pulmonary embolism) pulmonary embolism)
33.. mimicking indolent pneumonia or heart mimicking indolent pneumonia or heart
failure, especially in the elderly failure, especially in the elderly
Symptom list of PE Symptom list of PE
73 73% Dyspnea % Dyspnea
66 66% Pleuritic chest pain % Pleuritic chest pain
43 43% Cough % Cough
33 33% Leg Swelling % Leg Swelling
30 30% Leg Pain % Leg Pain
15 15% Hemoptysis % Hemoptysis
12 12% Palpitations % Palpitations
10 10% Wheezing % Wheezing
55% Angina % Angina- -Like pain Like pain
Complication of PE: Right Complication of PE: Right
Ventricular Dysfunction Ventricular Dysfunction
Progressive right heart failure is the Progressive right heart failure is the
usual immediate cause of PE death usual immediate cause of PE death
pulmonary vascular resistance pulmonary vascular resistance pulmonary vascular resistance pulmonary vascular resistance
right ventricular wall tension right ventricular wall tension
right ventricle dilation and dysfunction right ventricle dilation and dysfunction
CTPH CTPH
Chronic Thromboembolic Pulmonary Chronic Thromboembolic Pulmonary
Hypertension Hypertension
Result of recurrent or unresolved PE Result of recurrent or unresolved PE
Occurs in Occurs in 11% of patients with PE % of patients with PE
Sx: increasing dyspnea, exertion Sx: increasing dyspnea, exertion constant constant g y p , g y p ,
Diagnosis: Diagnosis:
diagnosis should be considered in any one with diagnosis should be considered in any one with
unexplained dyspnea on exercise unexplained dyspnea on exercise
V/Q scan shows multiple large defects V/Q scan shows multiple large defects
Diagnosis of VTE Diagnosis of VTE
History & Physical exam History & Physical exam
Non Non- -invasive invasive
Chest X Chest X--ray ray
DD- -dimer dimer
Duplex ultrasonography (Doppler scan) Duplex ultrasonography (Doppler scan)
Ventilation/perfusion scan (V/Q scan) Ventilation/perfusion scan (V/Q scan)
Spiral Computed Tomography (Spiral CT) Spiral Computed Tomography (Spiral CT)
Invasive Invasive
Pulmonary angiography Pulmonary angiography
Chest X Chest X- -ray of PE ray of PE
parenchymal density
prominent central pulmonary
arteries 2
nd
to pulmonary hypertension
7
Duplex Ultrasonography Duplex Ultrasonography
Ventilation/Perfusion Scan Ventilation/Perfusion Scan
(V/Q scan) (V/Q scan)
normal pulmonary embolism
Spiral Computed Spiral Computed
Tomography Tomography
Pulmonary Angiography Pulmonary Angiography
Estimating Clinical Estimating Clinical
Probability of DVT Probability of DVT
Wells PS. JAMA 2006;295:199-207
Estimating Clinical Estimating Clinical
Probability of PE Probability of PE
Southern Med J 2007;100(10):1015-21
8
Treatment Goals of VTE Treatment Goals of VTE
Arrest Thrombus Growth Arrest Thrombus Growth Arrest Thrombus Growth Arrest Thrombus Growth
Prevent Embolization Prevent Embolization
Prevent Death from PE Prevent Death from PE
Limit Complications Limit Complications
Prevent Recurrence Prevent Recurrence
While Minimizing Bleeding While Minimizing Bleeding
Treatment Treatment- -Acute Acute
Pain Relief Pain Relief
Supplemental Oxygen Supplemental Oxygen
Dobutamine for pts with right heart Dobutamine for pts with right heart
failure and cardiogenic shock failure and cardiogenic shock
Volume loading is not advised because Volume loading is not advised because
increased right ventricular dilation can increased right ventricular dilation can
lead to further reductions in left lead to further reductions in left
ventricular outflow ventricular outflow
Thrombolytics Thrombolytics
Treatment Strategies Treatment Strategies
Thrombolytics Thrombolytics
Anticoagulants Anticoagulants
Non Non pharmacotherapy pharmacotherapy Non Non--pharmacotherapy pharmacotherapy
Caval interruption Caval interruption
Greenfield filter: prevention of PE using filter Greenfield filter: prevention of PE using filter
placed in inferior venacava placed in inferior venacava
Surgical removal Surgical removal
Thrombectomy Thrombectomy
Thrombolytics Thrombolytics
Limited roles in treatment of VTE Limited roles in treatment of VTE
Selected group of patients may derive Selected group of patients may derive
benefit more than risk benefit more than risk benefit more than risk benefit more than risk
Hemodynamically unstable PE Hemodynamically unstable PE
Massive iliofemoral thrombosis Massive iliofemoral thrombosis
Thrombolytic Dosing Thrombolytic Dosing
Streptokinase Streptokinase
250 250,,000 000 units IV loading dose, then units IV loading dose, then
100 100,,000 000 units/hr x units/hr x 24 24- -72 72 hours hours
Urokinase Urokinase
44,,400 400 units/kg IV loading, then units/kg IV loading, then
22,,200 200units/kg x units/kg x 12 12 hours hours
Reteplase Reteplase
100 100 mg IV / mg IV / 2 2hours hours
Inferior Vena Caval Filters Inferior Vena Caval Filters
Patient with proximal DVT Patient with proximal DVT
who cannot receive anticoagulants who cannot receive anticoagulants
who has failed anticoagulants who has failed anticoagulants
Patient undergoing pulmonary embolectomy Patient undergoing pulmonary embolectomy Patient undergoing pulmonary embolectomy Patient undergoing pulmonary embolectomy
Patient undergoing pulmonary endarterectomy Patient undergoing pulmonary endarterectomy
for chronic thromboembolic pulmonary for chronic thromboembolic pulmonary
hypertension hypertension
Filters appear to prevent PE within the Filters appear to prevent PE within the
following following 2 2 wks but did not affect short or wks but did not affect short or
long long- -term mortality term mortality
9
Anticoagulant Therapy Anticoagulant Therapy
for VTE for VTE
Initial treatment with heparin for at least Initial treatment with heparin for at least 5 5--
77 days is recommended. ( days is recommended. (10 10 days for days for
massive PE or severe ileofemoral DVT) massive PE or severe ileofemoral DVT)
Optimal therapeutic range with warfarin is Optimal therapeutic range with warfarin is
General Principle of VTE General Principle of VTE
Treatment: Updated Treatment: Updated 2008 2008
Optimal therapeutic range with warfarin is Optimal therapeutic range with warfarin is
an INR of an INR of 2 2..0 0 -- 33..0 0
Chest Chest 2008 2008 approved low approved low- -intensity intensity
anticoagulation anticoagulation
Duration of treatment Duration of treatment
Evaluate at Evaluate at 3 3 months, then depends on patients months, then depends on patients
risk factors risk factors
Anticoagulants Anticoagulants
IV or SC Unfractunated Heparin (UFH) IV or SC Unfractunated Heparin (UFH)
IV UFH IV UFH
Monitored SC UFH Monitored SC UFH
Fi d d it d SC UFH Fi d d it d SC UFH Fixed dose unmonitored SC UFH Fixed dose unmonitored SC UFH
SC Low Molecular Weight Heparin (LMWH) SC Low Molecular Weight Heparin (LMWH)
Vitamin K antagonist (VKA) Vitamin K antagonist (VKA) Warfarin Warfarin
SC Fondaparinux SC Fondaparinux
8
th
ACCP anti-thrombotic guidelines - 2008; 133: 454-545
LMWH or UFH
5 to 7 days (until INR >2) Initial treatment
Treatment for VTE Treatment for VTE
Vitamin K antagonist (Warfarin)/LMWH/Fondaparinux
3 months Long-term therapy
8
th
ACCP anti-thrombotic guidelines - 2008; 133: 454-545
* 1
st
day of treatment
UFH in VTE UFH in VTE
Standard treatment of VTE for prior to Standard treatment of VTE for prior to
1990 1990s s
Reduce thrombus recurrence and extension Reduce thrombus recurrence and extension
Therapeutic range: Therapeutic range:
Plasma heparin level: Plasma heparin level: 0 0..3 3--0 0..7 7 IU/mL anti IU/mL anti
Xa activity Xa activity
Indirect monitoring: aPTT Indirect monitoring: aPTT 1 1..5 5 22..5 5 x x
control control
10
IV UFH IV UFH
Conventional dosing: Conventional dosing:
55,,000 000 units IV bolus + units IV bolus + 1 1,,300 300 u/hr continuous u/hr continuous
infusion infusion
hh b d ( f d) b d ( f d) Weight Weight--based (preferred): based (preferred):
80 80--100 100 u/kg bolus + u/kg bolus + 18 18 u/kg/hr continuous u/kg/hr continuous
infusion infusion
aPTT should be therapeutic within aPTT should be therapeutic within 24 24 hours hours
to minimize risk of recurrent VTE to minimize risk of recurrent VTE
High alert drug High alert drug
Heparin Protocol Heparin Protocol
Initial dosing: Loading Initial dosing: Loading 80 80 U/kg U/kg 18 18 U/kg/hg (APTT in U/kg/hg (APTT in 6 6 hrs) hrs)
APTT(s) APTT(s) Dose Change Dose Change Additional Additional Next APTT (h) Next APTT (h)
(x normal) (x normal) (U/kg/h) (U/kg/h) Action Action
<<35 35 ( (1 1..2 2 x) x) ++44 Rebolus Rebolus 80 80 U/kg U/kg 6 6
35 35--45 45 ( (1 1..2 2--11..5 5x) x) + +22 Rebolus Rebolus 40 40 U/kg U/kg 6 6
46 46--70 70 ( (1 1..5 5--22..3 3x) x) 0 0 00 66**
71 71--90 90 ( (2 2..3 3--33..0 0x) x) - -22 00 66
>>90 90 (< (<3 3x) x) --33 Stop infusion Stop infusion 1 1 hh 66
* During first 24 h, thereafter, once / day
Am J Respir Crit Care Med. Vol 159: 1-14; 1999
Heparin Protocol Heparin Protocol SC Heparin SC Heparin
With appropriate dosing, SC UFH With appropriate dosing, SC UFH
should be at least as effective and safe should be at least as effective and safe
as IV UFH as IV UFH
Monitored SC UFH Monitored SC UFH
Initial dose Initial dose 17 17,,500 500 units units SC SC 250 250 units/kg units/kg
SC BID SC BID aPTT aPTT
Fixed dose unmonitored SC UFH Fixed dose unmonitored SC UFH
Initial dose Initial dose 333 333 units/kg SC units/kg SC 250 250
units/kg SC BID units/kg SC BID
LMWH LMWH
New standard treatment of VTE New standard treatment of VTE
Weight Weight- -base dosing with no need to base dosing with no need to
monitor in most cases monitor in most cases
In patients who CrCl < In patients who CrCl < 30 30 ml, once daily ml, once daily
dosing should be used to decrease risk of dosing should be used to decrease risk of
bleeding bleeding
Monitor anti Monitor anti--factor Xa level factor Xa level
Chest Chest 2008 2008 suggest IV UFH over LMWH if suggest IV UFH over LMWH if
severe renal failure severe renal failure
Dosing of LMWH for VTE Dosing of LMWH for VTE
Treatment Treatment
Enoxaparin Enoxaparin
1 mg/kg SQ q 12 hr (1 mg = 1 mg/kg SQ q 12 hr (1 mg =
100 IU) 100 IU)
Clexane Clexane
40 mg/0.4 mL 40 mg/0.4 mL
Nadroparin Nadroparin
86 86 IU/kg SQ q IU/kg SQ q 12 12
Fraxiparine Fraxiparine
22,,850 850 IU/ IU/0 0..33 mL mL
33,,800 800 IU/ IU/0 0..44 mL mL
g/ g/
60 mg/0.6 mL 60 mg/0.6 mL
80 mg/0.8 mL 80 mg/0.8 mL
Tinzaparin Tinzaparin
175 IU/kg SQ OD 175 IU/kg SQ OD
Innohep Innohep
Syringe: 10,000 IU/mL 0.35 Syringe: 10,000 IU/mL 0.35
mL, 2 mL mL, 2 mL
Vial: 10,000 IU/mL 2 mL Vial: 10,000 IU/mL 2 mL
Vial: 20,000 IU/mL 2 mL Vial: 20,000 IU/mL 2 mL
55,,700 700 IU/ IU/0 0..66 mL mL
Fraxiparin Forte Fraxiparin Forte
11 11,,400 400 IU/ IU/0 0..66 mL mL
11
Selection of Heparins Selection of Heparins
LMWH is an attractive option if LMWH is an attractive option if not not
the followings the followings
Morbidly obese patients Morbidly obese patients y p y p
Pregnancy Pregnancy
LMWH for LMWH for
Outpatients Outpatients
Cancer Cancer
Acute nonmassive PE Acute nonmassive PE
Meta Meta- -Analysis Analysis
LMWH vs Heparin for Treatment of DVT LMWH vs Heparin for Treatment of DVT
Meta Meta- -Analysis Analysis
LMWH vs Heparin for Treatment of DVT LMWH vs Heparin for Treatment of DVT
Primary Studies:
Duroux, 1991
Hull, 1992
Prandoni, 1992
Lopaciuk, 1992
Simonneau, 1993
Recurrent Thromboembolism
(n=3566)
Levine, 1996
Koopman, 1996
Fiessinger, 1996
Luomanmaki, 1996
Columbus, 1997
All studies
(fixed-effect model)
Lindmarker, 1994
Gould et al, 1999
OR 0.85
(=0.28)
0.01 0.1 1 10 100
Favors
LMWH
Favors
UFH
Odds Ratio
(OR)
Fondaparinux Fondaparinux
Selective factor Xa Selective factor Xa
inhibitor inhibitor
100 100% bioavailability % bioavailability
with SC with SC
Equally safe and Equally safe and
effective as heparins effective as heparins
for DVT for DVT
(Enoxaparin) and PE (Enoxaparin) and PE
(UFH) (UFH)
Fondaparinux Dosing Fondaparinux Dosing
<< 50 50 kg : kg : 5 5 mg SC OD mg SC OD
50 50--100 100 kg : kg : 7 7..55 mg SC OD mg SC OD
>> 100 100 mg : mg : 10 10 mg SC OD mg SC OD >> 100 100 mg : mg : 10 10 mg SC OD mg SC OD
Warfarin Warfarin
Target INR Target INR 22..5 5 (rage (rage 22. .0 0--3 3..0 0))
Low intensity INR Low intensity INR
INR INR 11..5 5--1 1..9 9 with less frequent INR monitoring with less frequent INR monitoring
Recommended for patients with unprovoked Recommended for patients with unprovoked
DVT who have a strong preference for less DVT who have a strong preference for less
frequent INR testing to monitor the therapy frequent INR testing to monitor the therapy
After After 33 months of conventional intensity months of conventional intensity
Chest Chest 2008 2008 recommends against high recommends against high
intensity VKA therapy intensity VKA therapy
Duration of Treatment with Duration of Treatment with
Anticoagulant Therapy for DVT Anticoagulant Therapy for DVT
12
Prevention of VTE Prevention of VTE
Risk of DVT in Risk of DVT in
Hospitalized Patients Hospitalized Patients
Chest 2008;133:381-453
Prevention of VTE Prevention of VTE
Without Prophylaxis (%) Without Prophylaxis (%) Recommended Recommended With Prophylaxis (%) With Prophylaxis (%)
Risk Group Risk Group Prox DVT Prox DVT Fatal PE Fatal PE Prophylaxis Prophylaxis Prox DVT Prox DVT Fatal PE Fatal PE
Hip replacement Hip replacement 20 20- -30 30 2 2- -44 WAR, LMWH WAR, LMWH 55 00. .11- -00. .22
Knee replacement Knee replacement 20 20- -30 30 2 2- -44 WAR, LMWH, IPC WAR, LMWH, IPC 55 00. .11- -00. .22
Hip fracture Hip fracture 25 25- -35 35 2 2- -44 WAR, LMWH WAR, LMWH 10 10 0 0. .22- -00. .44
Major trauma Major trauma 20 20 00 55 11 00 LMWH IPC LMWH IPC 10 10 <<00 11 Major trauma Major trauma 20 20 00..55--11..00 LMWH, IPC LMWH, IPC 10 10 <<00..11
Abdominal or pelvic Abdominal or pelvic
cancer surgery cancer surgery 20 20 0 0. .55- -11. .00 LMWH, IPC, WAR LMWH, IPC, WAR 10 10 < <00. .11
Abdominal surgery, Abdominal surgery,
coronary artery coronary artery 5 5- -77 00. .55 UF, LMWH, IPC UF, LMWH, IPC <<11 <<00. .11
bypass graft bypass graft WAR, ES WAR, ES
Medical patients Medical patients
>>40 40, immobilize , immobilize 55 <<0 0. .55 UF, ES, LMWH UF, ES, LMWH <<11 <<00. .11
Am J Respir Crit Care Med. Vol 159: 1-14; 1999
ES = elastic stockings; lPC = intermittent pneumatic compression; UF = unfractionated heparin
Prevention of VTE Prevention of VTE
aspirin VTE
anticoagulants
Chest Chest 2008 2008: VTE : VTE
Prophylaxis Prophylaxis
A formal, active strategy that address A formal, active strategy that address
the prevention of VTE should be the prevention of VTE should be
developed developed pp
Written, institution Written, institution--wide wide
thromboprophylaxis policy thromboprophylaxis policy
Prevention of VTE Prevention of VTE
VTE VTE

28 28 28 28
Cancer surgery Cancer surgery
History of VTE History of VTE
13
Prevention of VTE Prevention of VTE
Approach for Approach for
Anticoagulant Pharmacists Anticoagulant Pharmacists
Pharmacist Assessment Pharmacist Assessment
Determine rational for anticoagulant Determine rational for anticoagulant
DVT treatment DVT treatment
DVT prophylaxis DVT prophylaxis
PE prophylaxis PE prophylaxis PE prophylaxis PE prophylaxis
Determine duration of therapy Determine duration of therapy
Agents for treatment Agents for treatment
LMWH LMWH
Warfarin Warfarin
UFH UFH
LMWH LMWH
Evidence of therapeutic interchange Evidence of therapeutic interchange
Determine appropriate dosing Determine appropriate dosing
OD OD if CrCl < if CrCl < 30 30 ml/min ml/min OD OD if CrCl < if CrCl < 30 30 ml/min ml/min
Monitoring for signs and symptoms of Monitoring for signs and symptoms of
clots and bleeding clots and bleeding
No need for routine monitoring of anti No need for routine monitoring of anti
Xa level Xa level
Warfarin Warfarin
Determine INR goals Determine INR goals
Low intensity Low intensity
Conventional intensity Conventional intensity
Determine INR history Determine INR historyyy
Determine factors related to INR control Determine factors related to INR control
Medication history Medication history
Behavior history Behavior history
Assess signs and symptoms of clots and bleeding Assess signs and symptoms of clots and bleeding
Determine appropriate warfarin dosing to keep the Determine appropriate warfarin dosing to keep the
patient in the INR goal patient in the INR goal
14
Documentation is Documentation is
Crucial!! Crucial!!
Summary Summary
VTE is a major disease leading to VTE is a major disease leading to
increase in morbidity and mortality increase in morbidity and mortality
Anticoagulation is the mainstay therapy Anticoagulation is the mainstay therapy Anticoagulation is the mainstay therapy Anticoagulation is the mainstay therapy
Fondaparinux, SC UFH have been Fondaparinux, SC UFH have been
included in the Chest included in the Chest 2008 2008
Low intensity VKA therapy is suggest if Low intensity VKA therapy is suggest if
low risk and less frequent INR low risk and less frequent INR
monitoring (after monitoring (after 3 3 months of months of
conventioanal) conventioanal)
Questions? Questions? QQ