Updates in Pharmacotherapy for Peri-Operative Anticoagulation Management

Transcription

1 Updates in Pharmacotherapy for Peri-Operative Anticoagulation Management

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4 RN [7]1 TL1

5 Slide 4 RN [7]1 Somewhere in your introduction I would also like you to address the CHADS-VASC score, what this is, how it is calculated and what it helps us to determine. Rachel Naida, 5/1/2017 TL1 Done. See next slide Trinh Le, 5/1/2017

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7 Only for patients with atrial fibrillation Eur Heart J. 2010;31(19):

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9 RN [2]1 Factor Xa inhibitors rivaroxaban(xarelto ) apixaban(eliquis ) edoxaban(savaysa ) Direct Thrombin Inhibitors dabigatran(pradaxa )

10 Slide 8 RN [2]1 I would like you to make a few separate slides here VKA, 2 - Novel agents 3- LMWH. Also i would like you to briefly talk about each of them and why knowing the pharmacokinetics of each is important to understanding how/why we bridge. Example warfarin half life etc. Rachel Naida, 5/1/2017

11 UFH Heparin LMWH Medication Dosing t ½ Onset of action Clearance Enoxaparin (Lovenox ) Varies mins 1-2 hrs 1 mg/kg SQ q12h 1.5mg/kg SQ q24h Dalteparin(Fragmin ) 100 units/kg SQ q12h 200 units/kg SQ q24h Vitamin-K antagonists (VKA) Warfarin(Coumadin ) hrs Enzymatic degradation 3-5 hrs Renal Individualized hrs hrs Renal

12 Medication A. Fib Dosing t 1/2 Onset of action Clearance Direct oral anticoagulants (DOAC) FactorXa Inhibitors Apixaban(Eliquis ) Rivaroxaban(Xarelto ) Edoxaban(SAVAYSA ) Direct thrombin inhibitors 5mg BID or 2.5 mg BID if 2 of the following: Age 80 years, weight 60 kg, or serum creatinine 1.5 mg/dl 20mg daily w/ meals ~12 hrs 3-4 hrs Renal 5-9 hrs 2-4 hrs Renal 60 mg daily hrs 1-2 hrs Renal Dabigatran(Pradaxa ) 150 mg BID hrs 1 hr Renal DOAC black box warning: use in setting of neuraxialanesthesia raises risk of spinal or epidural hematoma RN2 RN3 RN4

13 Slide 10 RN2 I have deleted argatroban and bivalirudin because they are not DOACs (direct-acting-oral-anticoagulants). They are both iv admin. They are however DTIs as you mentioned. but we do not use them for routine anticoagulation maintenance. Rachel Naida, 5/3/2017 RN3 I have also deleted fodaparinux because it is also not oral. Rachel Naida, 5/3/2017 RN4 You are missing one DOAC!!! (hint it is a Xa inhibitor too! and is new) make sure you find this and include! Rachel Naida, 5/3/2017

14 RN1 TL [2] ACC Expert Consensus Decision Pathway for PeriproceduralManagement of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation (NVAF)

15 Slide 11 RN1 Please put the title of the new guidelines on this slide Rachel Naida, 5/1/2017 TL [2]1 check Trinh Le, 5/1/2017

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17 HAS-BLED Hypertension(>160 mmhg)* 1 Abnormal renal function 1 Abnormal liver function 1 Prior stroke/ TIA 1 Hx or predisposition of bleeding 1 Labile INR* 1 Elderly (>65 years) 1 Concomitant use of antiplatelet or NSAID * 1 Alcohol or drug use ( 8 drinks/week)* 1 RN [3]1 RN [4]1 TL [3]1 N EnglJ Med 2015; 373:

18 Slide 13 RN [3]1 Please indicate somewhere on this slide that this is the HAS-BLED Score Rachel Naida, 5/1/2017 RN [4]1 Please also make two seperate slides from this - 1. HAS-BLED (on the left) 2. Other risk factors (on the right). Rachel Naida, 5/1/2017 TL [3]1 check Trinh Le, 5/2/2017 RN5 great job highlighting the correctable factors Rachel Naida, 5/3/2017

19 Other Risk Factors Prior bleeding event within 3 months (includes intracranial hemorrhagic) Quantitativeand qualitative platelet abnormality INR aboverange at time of procedure Bleedinghxfrom previous bridging Bleeding hxwithsimilar procedure RN6 N EnglJ Med 2015; 373:

20 Slide 14 RN6 Make sure you understand what is considered a platelet abnormality! What is the quantitive value at which PLT count is likely too low to consider bridging? Rachel Naida, 5/3/2017

21 RN7 Rose Anne et al. Periproceduraland Regional Anesthesia Management with Antithrombotic Therapy Adult Inpatient and Ambulatory Clinical Practice Guideline; University of Wisconsin: 0-13; Aug. 2015

22 Slide 15 RN7 what is considered a simple dental extraction? what would be considered more complex? I think the main point here is that even if we believe the surgery to be considered a "minor" bleed risk we should still be contacting the performing surgeon as well as the provider to get their opinion on surgerys bleed risk. Surgical technique and other factors can also influence bleed risk. Rachel Naida, 5/3/2017

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24 No ProcedureNo clinicallyimportant or low bleed risk AND no patient related bleed risk factors Yes Procedure with intermediate or high bleed risk Procedure with uncertain risk and presence of patient related risk factors Consider Procedure with no clinicallyimportant or low bleed risk AND presence of patient related risk factors Procedure with uncertain risk ANDabsence of patient related risk factors N EnglJ Med 2015; 373:

25 RN [6]1 Procedural Bleed Risk No clinically important risk Low bleed risk Uncertain,Intermediate, or High bleed risk Whether to Interrupt Time surgery at DOAC interval trough Interrupt Interrupt N EnglJ Med 2015; 373:

26 Slide 18 RN [6]1 Make sure you type this out first (Direct Acting Anticoagulant) before you use the abbreviation. Rachel Naida, 5/1/2017

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28 RN [5]1 TL [4]1 INR Discontinue prior procedure (days) >3 At least5 N EnglJ Med 2015; 373:

29 Slide 20 RN [5]1 Make sure you can explain why here! Why do we need to measure the INR 5-7 days before? Help the nurses understand the reasoning behind these recommendations rather than just stating the recommendation. Rachel Naida, 5/1/2017 TL [4]1 see notes Trinh Le, 5/2/2017

30 John U. Doherty et al. JACC 2017;69:

31 Timing of last dose before surgery/procedure base on bleed risk and renal function Renal Function RIVAROXABAN t½= 5-9hr (11-13hr for elderly) DABIGATRAN t½= 12-17hr (14-17hr for elderly) APIXAPAN t½= ~12hr (CrCl, ml/min) # Low Risk High Risk Low Risk High Risk Low Risk High Risk >80 >24 h >48 h >24 h >48 h >24 h >48 h >24 h >48 h >36 h >72 h >24 h >48 h >24 h >48 h >48 h >4 days >24 h >48 h <30 Not indicated Not indicated Not indicated Not indicated >36 h * >48h * # CrCl calculated using the Cockcroft-Gault equation with ACTUAL body weight * Apixaban not indicated if CrCl <25 ml/min Post-Op: All agents should be resumed hours after procedure StangierJ, RathgenK, StähleH, Mazur D: Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate: An open-label, parallel-group, single-centre study. Clin Pharmacokinet 2010; 49:259 68

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33 RN [8]1 John U. Doherty et al. JACC 2017;69:

34 Slide 24 RN [8]1 make sure you explain why bridging with LMWH is NOT needed for DOAC patients Rachel Naida, 5/1/2017

35 John U. Doherty et al. JACC 2017;69:

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37 Medication Dosing Heparin Varies Enoxaparin (Lovenox ) Dalteparin (Fragmin ) Tinzaparin (Innohep ) 1 mg/kg SQ q12h 1.5mg/kg SQ q24h 100 units/kg SQ q12h 200 units/kg SQ q24h 175 IU/kg once daily

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40 BridgeAnticoag American College of Cardiology

41 RN10 RN9 PMH: A. fib T2DM Hypogonadism Glaucoma Macular degeneration Esophagitis CKD OSA COPD Lung cancer Obesity Hypercholesterolemia Prior stroke Erosive gastritis Peripheral Vascular Disease

42 Slide 31 RN9 When was pre-procedure INR drawn in relation to when procedure was performed? Rachel Naida, 5/3/2017 RN10 Another question - when should ASA be stopped before a surgery?!!!!! I see ASA on his list here! Rachel Naida, 5/3/2017

43 Patient Case #1 Aspirin 81 mg tablet Lantus Solostar 100u/mL Allopurinol 100 mg tablet Gabapentin 300 mg capsule Furosemide 40 mg tablet Januvia 50 mg tablet Levothyroxine 25 mcg tablet Spiriva 18 mcg capsule Nitroglycerin 0.4 mg tablet Multivitamin Medications Warfarin 5 mg tablet Omeprazole 40 mg DR capsule Glipizide 5 mg tablet Rosuvastatin 40 mg tablet Celexa 40 mg tablet Co-enzyme Q mg capsule Diltiazem 120 mg ER capsule Aldactone 25 mg tablet Valsartan 40 mg tablet KrillOil

44 Height Weight BP 66 Inches 262 pounds(lbs), 191 kg 106/40 SrC CrCl HAS-BLED Procedural Bleeding risk CHAD-VASc INR prior surgery Intermediate 6 7 days: days: 4.2 Day of: 2.7 Lab Value Normal White blood cell count (x1000/ul) Red Blood Cell Count (mil/ul) Hemoglobin (gm/dL) Hematocrit (%) Neutrophils (%) Platelet Count (x1000/uL) Lymphocytes (%)

45 HAS-BLED Hypertension(>160 mmhg)* 1 Patients Factors Abnormal renal function 1 1 Abnormal liver function 1 Prior stroke/ TIA 1 1 Hx or predisposition of bleeding 1 Labile INR* 1 Elderly (>65 years) 1 1 Concomitant use of antiplatelet or NSAID * 1 1 Alcohol or drug use ( 8 drinks/week)* 1 Total Score 4 CHADVASc CHF 1 HTN 1 Patient Factors Age Diabetes 1 1 Stroke/ TIA Hx 2 2 Vascular disease Age Sex (female) Total Score 6

46 HAS-BLED score: 4 Intermediate (colonoscopy) Yes ~5 days before (if INR therapeutic) Likely YES LMWH Consult with proceduralist, likely hours post

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49 Patient case #2 Hydrochlorothiazide 12.5mg cap Toprol XL 200mg Multivitamin Lisinopril 40mg Aspirin81mg Warfarin 3mg Medications Paxil 10mg, 20mg Trazodone 50mg Furosemide 40mg Vitamin D3 2,000 IU Fish Oil Lipitor 80mg

50 Height Weight BP 59.5 Inches 148 pounds(lbs), 67 kg 144/68 SrC CrCl HAS-BLED Procedural Bleeding risk CHAD-VASc INR prior surgery Intermediate 6 Lab Value Normal White blood cell count (x1000/ul) Red Blood Cell Count (mil/ul) Hemoglobin (gm/dL) Hematocrit (%) Neutrophils (%) Platelet Count (x1000/uL) Lymphocytes (%)

51 HAS-BLED Patients Factors Hypertension(>160 mmhg)* 1 1 Abnormal renal function 1 Abnormal liver function 1 Prior stroke/ TIA 1 Hx or predisposition of bleeding 1 Labile INR* 1 Elderly (>65 years) 1 1 Concomitant use of antiplatelet or NSAID * 1 1 Alcohol or drug use ( 8 drinks/week)* 1 Total Score 3 CHADVASc Patient Factors CHF 1 1 HTN 1 1 Age Diabetes 1 Stroke/ TIA Hx 2 Vascular disease Age Sex (female) 1 1 Total Score 6

52 HAS-BLED score: 3 Intermediate (colonoscopy) Yes ~5 days before (if INR therapeutic) Likely NO

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54 Patient Case #3 Meclizine12.5 mg Proscar 5mg Norvasc 2.5mg Coumadin 5mg Lisinopril 40mg Hytrin5mg Prevacid Medications Actos15mg Celexa 20mg Simvastatin 10mg Osteo- bi flex tablet Saw palmetto Fish oil Ocuvite

55 Height Weight BP 70.5 Inches pounds(lbs), 84 kg 138/70 SrC CrCl HAS-BLED Procedural Bleeding risk CHAD-VASc INR prior surgery Intermediate 4 Lab Value Normal White blood cell count (x1000/ul) Red Blood Cell Count (mil/ul) Hemoglobin (gm/dL) Hematocrit (%) Neutrophils (%) Platelet Count (x1000/uL) Lymphocytes (%)

56 HAS-BLED Patients Factors Hypertension(>160 mmhg)* 1 1 Abnormal renal function 1 Abnormal liver function 1 Prior stroke/ TIA 1 Hx or predisposition of bleeding 1 Labile INR* 1 Elderly (>65 years) 1 1 Concomitant use of antiplatelet or NSAID * 1 Alcohol or drug use ( 8 drinks/week)* 1 Total Score 2 CHADVASc CHF 1 Patient Factors HTN 1 1 Age Diabetes 1 1 Stroke/ TIA Hx 2 Vascular disease 1 Age Sex (female) 1 Total Score 4

57 HAS-BLED score: 3 Intermediate (colonoscopy) Yes ~5 days before (if INR therapeutic) NO

58 PMH: A. Fib TIA Hyperlipidemia GOUT Abnormal liver function HTN PVD Polyneuropathy CAD T2DM CKD Diabetic foot ulcer Obesity CHF

59 Patient case #4 Metoprolol tartrate 100mg Apixaban 5 mg BID Omeprazole 40mg DR Losartan 100mg Furosemide 20mg Allopurinol 300mg Lipitor 80mg Medications Diltiazem 240 mg Er Metformin 500mg ER Aspirin 81mg Docusate sodium 100mg Vitamin B mcg Tylenol 325mg Amlactin 12% cream

60 Height Weight BP 69.5 Inches pounds(lbs), 119 kg 132/60 SrC CrCl HAS-BLED Procedural Bleeding risk CHAD-VASc INR prior surgery Low 8 Lab Value Normal White blood cell count (x1000/ul) Red Blood Cell Count (mil/ul) Hemoglobin (gm/dL) Hematocrit (%) Neutrophils (%) Platelet Count (x1000/uL) Lymphocytes (%)

61 HAS-BLED Patients Factors Hypertension(>160 mmhg)* 1 1 Abnormal renal function 1 1 Abnormal liver function 1 1 Prior stroke/ TIA 1 1 Hx or predisposition of bleeding 1 Labile INR* 1 Elderly (>65 years) 1 1 Concomitant use of antiplatelet or NSAID * 1 1 Alcohol or drug use ( 8 drinks/week)* 1 Total Score 6 CHADVASc Patient Factors CHF 1 1 HTN 1 1 Age Diabetes 1 1 Stroke/ TIA Hx 2 2 Vascular disease Age Sex (female) Total Score 8

62 HAS-BLED score: 6 Low (skin biopsy) Yes 24 hours before procedure NO

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