VTE treatment and prophylaxis

when do we use antiplatelets?

for arterial clots from things such as: CAD, PAD, and strokes

when do we use anticoagulants?

for venous clots such as: DTV and PE

VTE prophylaxis treatment goals

Prevent VTE from occurring in patients at high risk (usually only hospitalized patients)

VTE prophylaxis treatment:

Low dose anticoagulant AND/OR mechanical prophylaxis

How is risk of VTE development determined/assessed in hospitalized patients?

With a PADUA score (looking at risk factors)

What does a PADUA score of < 4 mean?

Low risk of VTE - generally does not require thromboprophylaxis

What does a PADUA score of > 4 mean?

Thromboprophylaxis is recommended for non-pregnant patients without contraindications (major bleeding, low platelets) who are > 18 years

T/F: A PADUA risk score is only applicable to non-hospitalized patients

FALSE (only for inpatients)

What is the magic number for VTE prophylaxis from PADUA score?

4!!!

What things are listed as risk factors for a PADUA score?

active cancer, previous VTE, reduced mobility, known genetic hypercoagulable condition, recent trauma/surgery (within 1 month), >= 70 years, cardiac or respiratory failure, acute MI or ischemic stroke, acute infection or rheumatologic disorder, obesity (BMI >= 30), hormonal treatment

Non-pharmacological treatments for VTE prophylaxis

ambulation, graduated compression stockings, sequential compression devices (SCDs), Inferior Vena Cava Filter

heparin SQ dose for VTE prophylaxis

5,000 units Q8-12H

heparin SQ dose for VTE prophylaxis in patients with BMI >= 40 kg/m2?

consider 7,500 units every 8-12 hours

enoxaparin SQ dose for VTE prophylaxis

30 units BID or 40 units daily

fondaparinux SQ dose for VTE prophylaxis

2.5 mg daily

rivaroxaban oral dosing for VTE prophylaxis

10 mg daily

apixaban oral dosing for VTE prophylaxis

2.5 mg BID

dabigatran oral dosing for VTE prophylaxis

220 mg daily

which anticoagulants can be used for orthopedic surgery VTE prophylaxis?

rivaroxaban, apixaban, and dabigatran

T/F: routine pharmacologic thromboprophylaxis should be offered to all outpatients with cancer?

False

If a high-risk outpatient with cancer and a Khorana score >= 2, can they be offered prophylaxis treatment?

Yes, they may be offered thromboprophylaxis with apixaban, rivaroxaban, and LMWH, provided there are no significant risk factors for bleeding and no drug interactions

What can patients with multiple myeloma receiving thalidomide or lenalidomide-based regimens with chemotherapy and/or dexamethasone be offered for VTE prophylaxis?

should be offered pharmacologic thromboprophylaxis with either aspirin or LMWH for lower-risk patients and LMWH for higher-risk patients

treatment for patients with VTE and no cancer

dabigatran, rivaroxaban, apixaban, or edoxaban over vitamin K antagonist (VKA) therapy

treatment for patients with VTE, no cancer, and were not treated with dabigatran, rivaroxaban, apixaban, or dabigatran?

VKA therapy over LMWH

Treatment for patients with unprovoked proximal DVT or PE who are stopping anticoagulant therapy and do not have a contraindication to aspirin

give aspirin to prevent recurrent VTE

Duration of treatment for patients with proximal DVT or PE?

3 months of anticoagulant therapy

duration of treatment with an unprovoked VTE and a low-moderate bleeding risk

extended anticoagulant therapy (no scheduled stop date)

duration of treatment with an unprovoked VTE and a high bleeding risk

3 months of anticoagulant therapy

duration of treatment for patients with DVT of the leg or PE and active cancer

extended anticoagulant therapy (no scheduled stop date)

What is considered low bleed risk?

Patients that have 0 bleed risk factors (risk factors will be given to us!!)

what is considered moderate bleed risk?

Patients that have 1 bleed risk factor (risk factors will be given to us!!)

what is considered high bleed risk?

Patients that have >=2 bleed risk factors (risk factors will be given to us!!)

treatment for patients with acute isolated distal DVT of the leg?

Get distal imaging of the deep veins for 2 weeks, unless there are severe symptoms or risk factors for extension, then it is suggested to give an anticoagulant

treatment for patients with managed anticoagulation

recommended to use the same anticoagulation as for patients with acute proximal DVT

treatment for patients with acute isolated distal DVT of the leg who are managed with serial imaging

no anticoagulation if the thrombus does not extend - suggest anticoagulation if the thrombus extends

initial anticoagulation treatment in cancer patients with DVT

May involve LMWH, UFH, fondaparinux, rivaroxaban, or apixaban.

initial parenteral anticoagulation treatment in cancer patients with DVT

LMWH is preferred over UFH for the initial 5 to 10 days

long-term anticoagulation treatment for cancer patients with DVT

LMWH, edoxaban, or rivaroxaban for at least 6 months due to improved efficacy over VKAs (there is an increase in major bleeding risk with DOACs, particularly in GI and potentially genitourinary malignancies

can anticoagulation treatment be offered to cancer patients with VT past initial 6 months?

they should be offered to select patients with active cancer, such as those with metastatic disease or those receiving chemotherapy

PE acute treatment for low-risk classified patients?

therapeutic anticoagulation

PE acute treatment for intermediate-risk classified patients?

anticoagulation, thrombectomy or catheter-directed thrombolytics, then therapeutic anticoagulation

PE acute treatment for high-risk classified patients?

IV thrombolytics then therapeutic anticoagulation

T/F: some patients with PE and high-risk will get catheter directed thrombolytics and some patients with intermediate risk will get systemic thrombolytics

True

How do thrombolytics work?

they activate plasminogen into plasmin which degrades fibrin clots!

which thrombolytic is fibrin specific?

Tenecteplase (specific to clot bound fibrin)

which thrombolytic is non-specific ?

Alteplase

half-life of alteplase

5 minutes

Half-life of tenecteplase

90-130 minutes

dosing administration of alteplase

bolus followed by infusion

dosing administration of tenecteplase

1 bolus

What are catheter directed thrombolytics (CDT)?

A catheter is inserted into the clot and the holes in the catheter deliver medications that break up the clot

which medications are used in CDT?

heparin and alteplase

Types of CDT

Unifuse without ultrasound and EKOS with ultrasound

what does EKOS stand for

stands for EkoSonic Endovascular System

what is EKOS?

a device to deliver catheter directed thrombolytics + sound waves and may be more efficient at breaking up clots than CDT alone (without ultrasound)