Guide to Perioperative Medication Bleed and Thromboembolism Management Considerations
|
|
- Chloe Hood
- 5 years ago
- Views:
Transcription
1 Guide to Perioperative Medication Bleed and Thromboembolism Management Considerations Start Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step days prior to Perform Medication Reconciliation Table 1: Risk Assessment 1,2 Assess risk for ATE or VTE Instructions 1. Perform patient anticoagulation assessment 7+ days prior to s. 2. Categorize -related bleeding risk using columns to the right. 3. Categorize underlying thrombosis risk using rows below. 4. View suggestions for anticoagulant interruption and bridging in cell where row and column intersect. 5. View specific guidance for novel oral anticoagulant (NOAC) users in Table View specific guidance for warfarin users in Table View specific guidance for antiplatelet users in Table 4. Assess risk for bleeding If on anticoagulant determine whether interruption and/or bridging is suggested Assess for Meds to hold/timing Anticoagulants Anti-platelets NSAIDs Others Determine timing for resumption of held meds Table 1 Table 1 Tables 1 and 3 Tables 2 5 Tables 2 and 3 High Bleeding Risk Procedures (2 day risk of major bleeds 2%) Major surgery with extensive tissue injury Cancer surgery Major orthopedic surgery Reconstructive plastic surgery Urologic or Gastrointestinal surgery Transurethral prostate resection, bladder resection or tumor ablation Nephrectomy, kidney biopsy Colonic polyp resection Bowel resection Percutaneous endoscopic gastrotomy (PEG) placement, endoscopic retrograde cholangiopancreatography (ERCP) Other Cardiac, intracranial, or spinal surgery Surgery in highly vascular organs (kidneys, liver, spleen) Multiple tooth extractions Any major operation ( duration >45 minutes) Pacemaker or cardioverter-defibrillator device implantation* Low Bleeding Risk Procedures (2 day risk of major bleeds 0% - 2%) Minor dental s (simple dental extractions, restorations, prosthetic, endodontics) Cutaneous/lymph node biopsies Shoulder/foot/hand surgery Coronary angiography Gastrointestinal endoscopy +/- biopsy Colonscopy +/- biopsy Abdominal hysterectomy Laparoscopic cholecystectomy Abdominal hernia repair Hemorrhoidal surgery Bronchoscopy +/- biopsy Epidural injections with INR <1.2 Pacemaker battery change Arthroscopy Monitor post up to at least 7 10 days post Minimal Bleeding Risk Procedures Minor dermatologic s (excision of basal and squamous cell skin cancers, actinic keratosis, and premalignant or cancerous skin nevi) Cataract s Dental cleanings, fillings Underlying Thromboembolic Risk A B C HIGH ( > 10%/yr. risk of arterial thromboembolism [ATE] or >10%/month risk of venous thromboembolism [VTE]) Bridging with low molecular weight heparin (LMWH) NOT suggested for NOACs (see table Consider interrupting NOAC using clinical judgment. Bridging with LMWH NOT suggested 2); for NOACs (see table 2); Any mechanical mitral valve Caged ball or tilting disk valve in mitral/aortic position Stroke or transient ischemic attack (TIA) within last 6 months in patients with a mechanical valve Atrial fibrillation (AF) with CHADS2 score of 5 or 6 Stroke or TIA within past 3 months in patients with AF Rheumatic valvular heart disease VTE within past 3 months Severe thrombophilia Deficiency of protein C, protein S or antithrombin Antiphospholipid antibodies Multiple thrombophilias MEDIUM (4 10%/yr. risk of ATE or 4 10%/month risk of VTE) Bileaflet aortic valve replacement (AVR) WITH major risk factors for stroke AF with CHADS2 score of 3 or 4 VTE within past 3 12 months Recurrent VTE Non-severe thrombophilia Active cancer LOW (<4%/yr. risk of ATE or <4%/month risk of VTE) Bileaflet AVR WITHOUT major risk factors for stroke AF with CHADS2 score of 0-2 (and no prior stroke or TIA) VTE more than 12 months ago Warfarin (Coumadin, Jantoven) users: Interrupt warfarin and bridge with LMWH suggested (see table 3) Bridging with LMWH NOT suggested for NOACs (see table 2); Interrupt warfarin and consider bridging with LMWH suggested (see table 3) Warfarin (Coumadin, Jantoven) users: Consider interrupting warfarin using clinical judgment. Bridging with LMWH suggested if warfarin interrupted (see table 3) Consider interrupting NOAC using clinical judgment. Bridging with LMWH NOT suggested for NOACs (see table 2); Do NOT interrupt anticoagulants Do NOT interrupt anticoagulants A2 B2 C2 Consider interrupting warfarin with or without LMWH bridging based on clinician judgment (see table 3) Bridging with LMWH NOT suggested for NOACs (see table 2); Bridging with LMWH NOT suggested for NOACs (see table 2); A1 B1 C1 Do NOT interrupt anticoagulants A3 B2 C3 Interrupt warfarin. Bridging with LMWH NOT necessary (see table 3) Interrupt warfarin. Bridging with LMWH NOT necessary (see table 3)
2 Table 2: Novel Oral Anticoagulant (NOAC) Interruption Suggestions. Note: Bridging with LMWH NOT suggested 1,4 Drug Patient Low Bleeding Risk ** High Bleeding Risk Resumption of Therapy Renal Function Surgery (2 or 3 drug half-lives between last dose and surgery) Surgery (4 or 5 drug half-lives between last dose and surgery) Low Bleeding Risk Surgery High Bleeding Risk Surgery Dabigatran (Pradaxa) t½ = hours CrCl > 50 ml/min Last dose: 2 days t½ = hours CrCl ml/min Rivaroxaban (Xarelto) CrCl > 50 ml/min Last dose: 2 days t½ = 8 9 hours t½ = 9 hours CrCl ml/min Last dose: 2 days t½ = 9 hours CrCl ml/min Apixaban (Eliquis) CrCl > 50 ml/min Last dose: 2 days t½ = 7 8 hours t½ = hours CrCl ml/min Edoxaban (Savaysa) CrCl > 50 ml/min Last dose: 2 days t½ = 6 11 hours Last dose: 4 5 days Last dose: 4 days Last dose: 4 days Table 3: Warfarin (Coumadin, Jantoven) Interruption and Bridging Suggestions use table 1 to determine if bridging is suggested 1,2 Day Warfarin Dose LMWH Bridge INR Monitoring -7 to -10 Maintenance Dose Assess for perioperative bridging anticoagulation; classify as undergoing high or low bleeding risk s Check baseline labs (hemoglobin, platelet count, serum creatinine, INR) -6 or -5 Begin to hold warfarin day 5 or 6 No LMWH None -4 No Warfarin No LMWH None -3 No Warfarin Start LMWH None -2 No Warfarin Continue LMWH None -1 No Warfarin ½ total day dose at least 24 hours prior to If INR < 1.5, proceed with surgery If INR >1.5 and <1.8, consider low dose vitamin K (1-2.5 mg) 0 or +1 Resume maintenance dose of None None warfarin on evening of or morning after +1 Maintenance Dose Low Bleed Risk: restart LMWH Per clinical judgment High Bleed Risk: none +2 or +3 Maintenance Dose Low Bleed Risk: continue LMWH Per clinical judgment High Bleed Risk: restart LMWH +4 Maintenance Dose Low Bleed Risk: INR testing (discontinue if INR > 1.9) INR High Bleed Risk: INR testing (discontinue if INR > 1.9) +7 to +10 Maintenance Dose INR Table 4: Peri-Procedural Use of Antiplatelets 3 Patient Population on Antiplatelet On aspirin for secondary prevention of cerebrovascular disease (CVD) and is having minor dental or dermatologic, or cataract surgery On aspirin with moderate to high risk for cardiovascular events and requires non-cardiac surgery On aspirin with low risk for cardiovascular events and requires noncardiac surgery On aspirin and requires coronary artery bypass grafting (CABG) surgery On dual antiplatelet (aspirin plus another agent) drug therapy and requires CABG surgery On dual antiplatelet drug therapy and requires surgery within 6 weeks of bare-metal stent or within 6 months of drug-eluting stent and cannot wait the suggested time periods before surgery. Action Continue aspirin Continue aspirin Stop aspirin 7 to 10 days Continue aspirin Continue aspirin; Stop clopidogrel (Plavix) or ticagrelor (Brilinta) 5 days before surgery; Stop prasugrel (Effient) 7 days before surgery Stop ticlodipine (Ticlid) 10 days before to surgery Stop cilostazol (Pletal) 4 days before surgery Stop dipyridamole (Persantine) 2 days before surgery [Note: Aggrenox contains aspirin/dipyridamole] Continue dual antiplatelet drug therapy if surgery cannot be deferred until after those time periods (6 weeks for bare-metal stent/6 months for drug-eluting stent)
3 All Non-steroidal Anti-inflammatory Drugs (NSAIDs) can inhibit platelet aggregation and may prolong bleeding time. However, unlike aspirin, NSAIDs reversibly inhibit platelet aggregation with the effect lasting only as long as the drug remains in the circulation. As a rule of thumb NSAIDs are considered to be cleared from the body within five (5) half-lives; although, it should be noted that extendedreleased products may pose a prolonged bleeding risk due to their drug delivery system. Therefore, prior to surgery or an invasive patients should stop taking a medication appearing on this list for a period of time equivalent to five (5) half-lives. While an effort has been made to comprehensively identify medications in each of these drug classes, this list should not be a substitute for good clinical judgment. Additionally, other drugs not appearing on this list that are known to pose a potential bleeding risk should be considered in this same regard. Table 5: Recommendations for Holding NSAIDS Before Surgery or Invasive Procedure 5-12 Drug Brand name Half life Five Half-lives Approximate Notes Days Prior Celecoxib Celebrex No antiplatelet activity Consider Continuation, may provide postoperative pain relief Diclofenac (delayed-release, extended-release, topical gel/cream) Arthrotec, Cambia, Cataflam, Voltaren, and others 2 hours 10 hours Half day Diclofenac patch Flector 12 hours 60 hours 2 3 days Prolonged action may result from depot formed in skin due to drug delivery system Diflunisal Dolobid 8 12 hours hours 2 3 days Half-life in anephric patients reported to range from hours Etodolac Lodine 5 8 hours hours 1 2 days Half-life is extended to ~12 hours in children under 16 yrs Fenoprofen Nalfon Half 1 day hours hours Flurbiprofen Ansaid 5.7 hours 28.5 hours 1 day Ibuprofen Motrin, Advil, 2 4 hours hours Half 1 day Caldolor, Vicoprofen, and others Indomethacin Indocin 4.5 hours 22.5 hours 1 day Half-life may be prolonged and highly variable in neonates Ketoprofen (immediaterelease) Orudis, Actron, and others 2 4 hours hours Half 1 day Half-life is 5 9 hours for a CrCl <30 ml/min; half-life is prolonged 26% in geriatrics Ketoprofen (extended-release) Oruvail hours hours) 1 2 days No studies connected to renal impairment; half-life prolonged 54% in geriatrics Ketorolac Toradol 4 6 hours hours 1 2 days Half-life may be prolonged to 10 hours in renal impairment (SCr >1.9) Meclofenamate Meclomen 1 2 hours 5 10 hours Half day Lesser active metabolite has half-live of hours Mefenamic acid Ponstel 2 hours 10 hours Half day Meloxicam Mobic days hours hours Nabumetone Relafen 24 hours 120 hours 4 days Half-life increased by ~50% in patients with CrCl <50 ml/min Naproxen Aleve, Anaprox, Naprosyn, Naprelan, Treximet, and others hours hours 3 days Oxaprozin Daypro days hours hours Piroxicam Feldene 50 hours 250 hours 10 days Half-life reported to range from hours in health adults Sulindac Clinoril 7.8 hours 39 hours 2 days Half-life of active metabolites Tolmetin Tolectin 1 5 hours 5 25 hours Half 1 day This tool was adapted from IPRO s Management of Anticoagulation in the Peri-Procedural Period: A Tool For Clinicians 5/1/2014 and a tool from The Pharmacist s Letter. Full references and notes are below:
4 DISCLAIMER: Anticoagulation prescribing is highly complex, and should be conducted with the greatest care on a case by case basis, considering the complete patient medical profile. The information presented is for general guidance only. Prescribers are encouraged to consult the most current medical evidence and organizational policies and s. References: 1. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S. 2. Spyropoulus AC, Douketis JD. How I Treat Anticoagulated Patients Undergoing an Elective Procedure or Surgery. Blood. 2012; DOI /blood Baron TH, Kamath PS, McBane RD. Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures. NEJM. 2013; 368: Tun NM, Oo TH. Prevention and Treatment of Venous Thromboembolism with New Orgal Anticoagulants: A Practical Update for Clinicians. Thrombosis. 2013; 2013: AHFS Drug Information, DailyMed Product Labeling ( Accessed: 10/15/12 7. LexiComp Online 8. Micromedex DrugDex 9. Drug Facts Comparisons, Wilner KD, Rushing M, Walden C, Adler R, Eskra J, Noveck R, Vargas R. Celecoxib does not affect the antiplatelet activity of aspirin in healthy volunteers. J Clin Pharmacol. 2002;42(9): Leese PT, Hubbard RC, Karim A, Isakson PC, Yu SS, Geis GS. Effects of Celecoxib, a Novel Cyclooxygenase-2 Inhibitor, on Platelet Function in Healthy Adults: A Randomized, Controlled Trial. The Journal of Clinical Pharmacology (2); Roswell Park Cancer Institute. Anesthesia Perioperative Evaluation Center. Perioperative Medication Management: Analgesics. Viewed Dec Notes: * Recent evidence suggests that interruption of anticoagulation for ICD and pacemaker-related s is not necessary. See Birnie DH et al. NEJM 368(22): Also: Weitz JI, Healey MD, Skanes AC, Verma AV. Periprocedural Management of Oral Anticoagulants in Patients Undergoing Atrial Fibrillation Ablation. Circulation. 2014;129: Therapeutic LMWH regimens include enoxaparin 1.5 mg/kg once daily or 1.0 mg/kg twice daily subcutaneously; dalteparin 200 IU/kg once daily or 100 IU/kg twice daily subcutaneously. Intermediate dose LMWH (i.e., enoxaparin 40 mg twice daily subq) has been less studied in this situation. Estimated t1/2 based on renal clearance. CrCl calculated using Cockcroft-Gault method. ** Aiming for mild to moderate residual anticoagulant effect at surgery (12%-25%). Aiming for no or minimal residual anticoagulant effect (3% - 6%) at surgery. For patients at high risk for thromboembolism and high bleeding risk after surgery, consider administering a reduced dose of dabigatran (75 mg twice daily), rivaroxaban (10 mg once daily), or apixaban (2.5 mg twice daily) on the evening after surgery and on the following day (first postoperative day) after surgery. Value for patients receiving rivaroxaban, 15 mg once daily.
5 Case Example: How to Use the Tool Start Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step days prior to Perform Medication Reconciliation Assess risk for ATE or VTE Assess risk for bleeding If on anticoagulant determine whether interruption and/or bridging is suggested Assess for Meds to hold/timing Anticoagulants Anti-platelets NSAIDs Others Determine timing for resumption of held meds Table 1 Table 1 Tables 1 and 3 Tables 2 5 Tables 2 and 3 Monitor post up to at least 7 10 days post Patient AZ 67 yr old male with chronic afib and a CHADS2 score of 4, currently managed with Xarelto (rivaroxaban) 20 mg once daily. He is to undergo a total knee replacement 2 weeks from today. 1. Begin assessment 7 10 days before the anticipated 2. Perform medication reconciliation. Upon med history review and reconciliation it is also discovered that the patient takes ASA 81 mg every morning over-the-counter (OTC). 3. Use table 1 to assess VTE/ATE risk, a. Here because he has AF with CHADS2 score of 4 his risk is considered medium. 4. Use table 1 to assess bleed risk level from anticipated a. Here because he is undergoing total knee (considered major orthopedic surgery) his bleed risk is considered high 5. Since on anticoagulant, here Xarelto (rivaroxaban), determine whether interruption and/or bridging is needed using table 1. a. Here we see that the thromboembolic risk and bleed risk intersect at box A2, which states that interruption of the NOAC (Xarelto[rivaroxaban]) is suggested and to refer to table 2. b. It is also noted that bridging is NOT suggested for NOACs, stated on table 2 as well. 6. Assess for meds to hold. Using table 2 you see that Xarelto (rivaroxaban) has different recommendations based upon high or low bleed risk as well as renal function status. If current serum creatinine (SCr) has not already been obtained it is recommended to obtain one for appropriate assessment. This patient s SCr was obtained and is current and using cockroft-gault method the creatinine clearance (CrCl) is estimated at 75 ml/min. We have determined above that that patient is having a high bleed risk. a. Here, the guide recommends giving the last dose of Xarelto (rivaroxaban) 3 days before the
6 b. Based on your updated med reconciliation, you also noted that the patient is taking aspirin. Using table 4 you note that based on your patient s past medical history they have not had a cardiac event such as MI or stent placement and thus consider the patient low risk (always room for clinical judgment) for a cardiovascular event at present. c. The rationale for aspirin use likely requires further investigation, nevertheless, here you note it is recommended that the patient stop aspirin 7 to 10 days prior to the. 7. When to resume the held meds? Use table 2 for Xarelto (rivaroxaban) and for aspirin generally using clinical judgment to be resumed when hemodynamically stable. a. Here, guide recommends resuming Xarelto (rivaroxaban) 2 to 3 days after the because it was a high bleed risk. b. Using clinical judgment the aspirin could be resumed when hemodynamically stable or 2 to 3 days after as well. 8. Monitor post up to at least 7 10 days.
WARFARIN: PERI OPERATIVE MANAGEMENT
WARFARIN: PERI OPERATIVE MANAGEMENT OBJECTIVE: To provide an approach to the perioperative management of warfarin treated patients who require an elective or urgent surgery/procedure. To provide an approach
More informationWARFARIN: PERI-OPERATIVE MANAGEMENT
WARFARIN: PERI-OPERATIVE MANAGEMENT OBJECTIVE: To provide an approach to the perioperative management of warfarin-treated patients who require an elective or urgent surgery/procedure. To provide an approach
More informationNOACS/DOACS*: PERI-OPERATIVE MANAGEMENT
NOACS/DOACS*: PERI-OPERATIVE MANAGEMENT OBJECTIVE: To provide guidance for the peri-operative management of patients who are receiving a newer direct oral anticoagulant (DOAC) and require an elective surgery/procedure.
More informationGestione peri-operatoria del paziente in terapia con antagonisti della vitamina K. B. Cosmi
Gestione peri-operatoria del paziente in terapia con antagonisti della vitamina K B. Cosmi Department of Angiology and Blood Coagulation S. Orsola-Malpighi University Hospital Bologna, Italy Overview Background
More informationProstate Biopsy Alerts
Prostate Biopsy Alerts Saskatchewan Prostate Assessment Pathway Guidelines for the Primary Care Provider for Patient Preparation and the Management of Medications and Complications September 2016 Table
More informationAnticoagulation Management Around Endoscopy: GI Perspective. Nathan Landesman, DO FACOI Flint Gastroenterology Associates October 11, 2017
Anticoagulation Management Around Endoscopy: GI Perspective Nathan Landesman, DO FACOI Flint Gastroenterology Associates October 11, 2017 EDUCATIONAL OBJECTIVES Understand risks of holding anticoagulation
More informationt. Recommendations for periprocedural anticoagulation are available lhrough the American College of Chest Physicians Clinical Practice Guidelines.
Name or Policy: Policy Number: 3364-133-116 Department: Approving Officer: Responsible Agent: cope: x Management of Anticoagulation with Invasive Procedures Pharmacy Chief Operating Officer Director of
More informationEAU GUIDELINES ON THROMBOPROPHYLAXIS IN UROLOGICAL SURGERY
EAU GUIDELINES ON THROMBOPROPHYLAXIS IN UROLOGICAL SURGERY K.A.O. Tikkinen (Chair), R. Cartwright, M.K. Gould, R. Naspro, G. Novara, P.M. Sandset, P.D. Violette, G.H. Guyatt Introduction Utilising recent
More informationPeri-Procedural Management of Antithrombotic Agents
u Peri-Procedural Management of Antithrombotic Agents An Integrated Care Pathway of the Collaborative Care Network Subject Matter Experts: Will Maxted, MD Veronica Kerner, PharmD Pathway Custodian: Pat
More information2017 Bryan Health Primary Care Conference. Dale Hansen MD Bryan Heart 5/20/17
2017 Bryan Health Primary Care Conference Dale Hansen MD Bryan Heart 5/20/17 I have no financial disclosures or conflicts of interest Bridging Anticoagulation Primum Non Nocere 67 y.o. male with mechanical
More information**If pre-procedure instructions are not followed, it is likely we will have to cancel or reschedule this injection**
Procedure Date: Procedure Check-in Time: Procedure Start Time: Check In at Diagnostic Imaging on the 2 nd Floor of the Madison Center PRE-PROCEDURE INSTRUCTIONS Please make sure to read over these instructions
More informationDisclosures. Overview. Have you ever. The Perioperative Management of Anticoagulants. No financial conflicts of interest to disclose
Disclosures No financial conflicts of interest to disclose The Perioperative Management of Anticoagulants Margaret C. Fang, MD, MPH Associate Professor of Medicine UCSF Division of Hospital Medicine Medical
More informationPerioperative Management of Anticoagulation
Perioperative Management of Anticoagulation Presented By: Nibal R. Chamoun, PharmD, BCPS Clinical Assistant Professor, Clinical Coordinator Lebanese American University, School of Pharmacy Presented at:
More informationThe Management of Patients on Chronic Oral Anticoagulant Therapy (VKA and DOAC) who Need Elective Surgery. Alex C. Spyropoulos MD, FACP, FCCP, FRCPC
The Management of Patients on Chronic Oral Anticoagulant Therapy (VKA and DOAC) who Need Elective Surgery Alex C. Spyropoulos MD, FACP, FCCP, FRCPC Professor of Medicine Hofstra Northwell School of Medicine
More informationOral anti-thrombotic therapy-management in patients requiring endoscopy
Oral anti-thrombotic therapy-management in patients requiring endoscopy Management of anti-thrombotic therapy in patients requiring endoscopy This guideline suggests appropriate management of patients
More informationNSAIDs. NSAIDs are important but they can have side effects.
NSAIDs Pain Treatment Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended for initial treatment of pain and can be added to more powerful drugs to treat worse pain. Acetaminophen, such
More informationI. Mechanisms of action the role of prostaglandins a. Mediators of inflammation b. and much more
NSAID steroid update Leo Semes, OD, FAAO I. Mechanisms of action the role of prostaglandins a. Mediators of inflammation b. and much more II. Topical NSAIDS ophthalmic application III. Oral NSAIDs a. Precautions
More informationCASE IN... Anticoagulation: When to Start,When to Stop. The management of patients who require an. Meet Tracey. Anticoagulation
Anticoagulation: When to Start,When to Stop Ebtisam Bakhsh, MD; and James D. Douketis, MD, FRCPC Presented at McMaster University s Thrombosis and Hematology Update, October 2006. CASE IN... Anticoagulation
More informationClinical Practice Guideline for Anticoagulation Management
Clinical Practice Guideline for Anticoagulation Management This guideline is to inform practitioners of the Standard of Care for providing safe and effective anticoagulation management for ambulatory patients.
More informationPeriprocedural Anticoagulation Adult Inpatient and Ambulatory Clinical Practice Guideline
Periprocedural Anticoagulation Adult Inpatient and Ambulatory Clinical Practice Guideline A. Scope (disease/condition, treatment, clinical specialty) 1. Adult patients undergoing a procedure or surgery
More informationSlide 1: Perioperative Management of Anticoagulation
Perioperative Management of Anticoagulation by Steven L. Cohn, MD, FACP Director, Medical Consultation Service, Kings County Hospital Center, Clinical Professor of Medicine, SUNY Downstate, Brooklyn, NY
More informationPerioperative Anticoagulation Management
Perioperative Anticoagulation Management ACP Delaware Chapter Scientific Meeting Feb 9, 2019 Andrew Dunn, MD, MPH, MACP Chief, Division of Hospital Medicine Mount Sinai Health System, NY DISCLOSURES Desai
More informationAsif Serajian DO FACC FSCAI
Anticoagulation and Antiplatelet update: A case based approach Asif Serajian DO FACC FSCAI No disclosures relevant to this talk Objectives 1. Discuss the indication for antiplatelet therapy for cardiac
More informationFDA strengthens warning that non-aspirin nonsteroidal antiinflammatory drugs (NSAIDs) can cause heart attacks or strokes
FDA strengthens warning that non-aspirin nonsteroidal antiinflammatory drugs (NSAIDs) can cause heart attacks or strokes Safety Announcement [7-9-2015] The U.S. Food and Drug Administration (FDA) is strengthening
More informationANTITHROMBOTIC THERAPY 2010 Antitrombotik tedavi alan hastalarda operasyon hazırlığı
ANTITHROMBOTIC THERAPY 2010 Antitrombotik tedavi alan hastalarda operasyon hazırlığı Dr. Sabri DEMİRCAN Ondokuz Mayıs Üniversitesi Tıp Fakültesi Kardiyoloji ABD, Samsun Copyright 2001 Harcourt Canada Ltd.
More informationUpdate in Perioperative Anticoagulation and Antiplatelet management
Update in Perioperative Anticoagulation and Antiplatelet management Grand Rounds October 31, 2014 Brooke Hall, MD Steve Kornfeld, MD Bruce McLellan, MD Nothing to disclose Objectives Describe the updates
More informationAlberta Colorectal Cancer Screening Program (ACRCSP) Antithrombotic Management
Alberta Colorectal Cancer Screening Program (ACRCSP) Antithrombotic Management Assessment Tools and Suggested Management for the Patient on Antithrombotics Undergoing a Screening-Related Colonoscopy Version
More informationBridging anticoagulation definition
Bridging anticoagulation definition Giving a short-acting anticoagulant, consisting of sc LMWH or ev UFH for 10 to 12 day period during interruption of VKA therapy when the INR is not within therapeutic
More informationAnticoagulation Transitions: Perioperative Care
Anticoagulation Transitions: Perioperative Care Alan Brush, MD, FACP Clinical Co-Director, Anticoagulation Management Service Harvard Vanguard Medical Associates Four Questions for each Consultation 1.
More informationANTICOAGULATION: THE DO'S AND DON'TS OF BRIDGE THERAPY
ANTICOAGULATION: THE DO'S AND DON'TS OF BRIDGE THERAPY SATURDAY/11:30AM-12:30PM ACPE UAN: 0107-9999-17-236-L01-P 0.1 CEU/1.0 hr Activity Type: Application-Based Learning Objectives for Pharmacists: Upon
More informationTo Bridge or Not to Bridge? Preop Evaluation of the Patient on Coumadin
To Bridge or Not to Bridge? Preop Evaluation of the Patient on Coumadin Omprakash Pansara, MD Brian Kline, MD St. Joseph s Health Family Medicine Residency Program, Syracuse, NY Case 75yr old male, who
More informationLow-Molecular-Weight Heparin
Low-Molecular-Weight Heparin Policy Number: Original Effective Date: MM.04.019 10/15/2007 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 05/01/2016 Section: Prescription Drugs
More informationLow-Molecular-Weight Heparin
Low-Molecular-Weight Heparin Policy Number: Original Effective Date: MM.04.019 10/15/2007 Line(s) of Business: Current Effective Date: HMO; PPO 10/28/2011 Section: Prescription Drugs Place(s) of Service:
More information4.7 Algorithm for the Peri-operative Management of Anticoagulants and Antiplatelet agents in Adult patients
4.7 Algorithm for the Peri-operative Management of Anticoagulants and Antiplatelet agents in Adult patients Assess Thrombosis risk: baseline risk in an individual patient plus additional thrombotic risk
More informationChallenging Anticoagulation Case Studies. Earl J. Hope, M.D. Tower Health Cardiology
Challenging Anticoagulation Case Studies Earl J. Hope, M.D. Tower Health Cardiology Financial Disclosures Nothing to disclose Objectives: 1. Understand indications for heparin bridging. 2. Recognize the
More informationTreatment with Apixaban Eliquis
Treatment with Apixaban Eliquis Anticoagulation Clinic 416-530-6000 ext 3477 This handout explains the medicine rivaroxaban, a drug that helps prevent blood clots. What is apixaban? Apixaban (brand name
More informationon Anti-coagulants -- Is It Safe? And When to Stop?
Endoscopy for Your Patient on Anti-coagulants -- Is It Safe? And When to Stop? John R. Saltzman MD, FACG Director of Endoscopy Brigham and Women s Hospital Associate Professor of Medicine Harvard Medical
More informationPerioperative management of Anticoagulant and Antiplatelet medication GL067
Perioperative management of Anticoagulant and Antiplatelet medication GL067 Approval Approval Group Job Title, Chair of Committee Date Anaesthetics Clinical Governance Chair, Anaesthetics Clinical November
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Celebrex) Reference Number: CP.CPA.239 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important Reminder at the end of this policy
More informationClinical Practice Committee Anticoagulation Bridging Document
Original: 10/23/06 Last Updated: 10/30/07 Clinical Practice Committee Do patients on long term oral anticoagulant therapy who require short term interruption of warfarin for an elective invasive procedure
More informationPreoperative Management of Patients Receiving Antithrombotics
Preoperative Management of Patients Receiving Antithrombotics Bleeding complications remain an important concern for most surgical procedures. Attempts to minimize the risk of these complications by removing
More informationHEART OF THE MATTER: cardiac issues in safe endoscopy & sedation
HEART OF THE MATTER: cardiac issues in safe endoscopy & sedation YUVAL KONSTANTINO M.D. CARDIOLOGY DEPARTMENT, ELECTROPHYSIOLOGY UNIT, SOROKA MEDICAL CENTER, BEN-GURION UNIVERSITY OUTLINE 1 2 3 Anticoagulation
More informationPerioperative Management of Warfarin Interruption
Perioperative Management of Warfarin Interruption Victoria Lambert, PharmD, CACP Medication Management Pharmacist William W. Backus Hospital Faculty Disclosures There are no actual or potential conflicts
More informationHoly Crap! Why is a Cardiologist Speaking at a GI Meeting? Jonathan A. Rapp, MD, FACC, FSCAI Cardiologist, Mercy Heart Institute Cincinnati, OH
Holy Crap! Why is a Cardiologist Speaking at a GI Meeting? Jonathan A. Rapp, MD, FACC, FSCAI Cardiologist, Mercy Heart Institute Cincinnati, OH Goals and Objectives Discuss cardiac considerations for patients
More informationJoost van Veen Consultant Haematologist
Joost van Veen Consultant Haematologist Bridging anticoagulation - conclusion Aim Questions What is the evidence? Does oral anticoagulation need to be stopped and if so when? When and at what dose is alternative
More informationAntiplatelets and Anticoagulants. Helen Leung, PharmD PGY1 Pharmacy Resident Memorial Hermann-Texas Medical Center
Antiplatelets and Anticoagulants Helen Leung, PharmD PGY1 Pharmacy Resident Memorial Hermann-Texas Medical Center Mechanism 2 http://www.medicinehack.com/2011/07/virchows-triad.html Mechanism 3 http://drtedwilliams.net/kb/index.php?pagename=coagulation%20cascade
More informationOUTPATIENT ANTITHROMBOTIC MANAGEMENT POST NON-ST ELEVATION ACUTE CORONARY SYNDROME. TARGET AUDIENCE: All Canadian health care professionals.
OUTPATIENT ANTITHROMBOTIC MANAGEMENT POST NON-ST ELEVATION ACUTE CORONARY SYNDROME TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To review the use of antiplatelet agents and oral
More informationPost-procedure dose ok after hours. 12 hours (q 24h dosing only) assuming surgical hemostasis; second dose 24 hours after first dose.
Medication Time to wait after last dose Post-procedure dose ok after hours Can pull catheter hours after last dose Can give next dose hours after pulling catheter Enoxaparin (Lovenox) Prophylactic dose
More informationTreatment with Rivaroxaban Xarelto
Treatment with Rivaroxaban Xarelto Anticoagulation Clinic This handout explains the medicine rivaroxaban, a drug that helps prevent blood clots. What is rivaroxaban? Rivaroxaban (brand name Xarelto) is
More informationPatients on anticoagulant or antiplatelet therapy undergoing elective endoscopic procedures
This is an official Northern Trust policy and should not be edited in any way Patients on anticoagulant or antiplatelet therapy undergoing elective endoscopic procedures Reference Number: NHSCT/11/454
More informationBleeding Management Strategies. Aiming for the best Outcomes August 27, Amit Gupta, MD FACC FSCAI Interventional Cardiologist CANM
Bleeding Management Strategies Aiming for the best Outcomes August 27, 2016 Amit Gupta, MD FACC FSCAI Interventional Cardiologist CANM Learning Objectives Review the use of anti-coagulants in patients
More informationAnticoagulation Overview Jed Delmore, MD, FACS, FACOG Professor Obstetrics and Gynecology University of Kansas School of Medicine, Wichita
Anticoagulation Overview 2018 Jed Delmore, MD, FACS, FACOG Professor Obstetrics and Gynecology University of Kansas School of Medicine, Wichita The ideal lecture is like a miniskirt. Short enough to get
More informationOral Anticoagulation Drug Class Prior Authorization Protocol
Oral Anticoagulation Drug Class Prior Authorization Protocol Line of Business: Medicaid P & T Approval Date: February 21, 2018 Effective Date: April 1, 2018 This policy has been developed through review
More informationManaging Perioperative Anticoagulation. Edie Shen MD
Managing Perioperative Anticoagulation Edie Shen MD Anticoagulation VKA Warfarin (Coumadin) DOACs Direct Thrombin Inhibitor Dabigatran (Pradaxa) Factor Xa Inhibitor Rivaroxaban(Xarelto) Apixaban(Eliquis)
More informationGuidelines for testing and perioperative management of dabigatran and rivaroxaban
Guidelines for testing and perioperative management of dabigatran and rivaroxaban: for possible use in local management protocols These guidelines have been produced by PHARMAC in conjunction with bpac
More informationStolling en anesthesie. Erik Vandermeulen MD, PhD Dept. of Anesthesia
Stolling en anesthesie Erik Vandermeulen MD, PhD Dept. of Anesthesia Preoperative use of anticoagulation Vitamin K-antagonists (VKA) Fenprocoumon (Marcoumar ) Warfarin (Marevan ) Acenocoumarol (Sintrom
More informationPerioperative Management of the Anticoagulated Patient
Perioperative Management of the Anticoagulated Patient Citywide Resident Perioperative Medical Consultation Conference 5/5/17 Matthew Eisen, MD Director, Anticoagulation Services MetroHealth Medical Center
More information3/23/2017. Angelika Cyganska, PharmD Austin T. Wilson, MS, PharmD Candidate Europace Oct;14(10): Epub 2012 Aug 24.
Angelika Cyganska, PharmD Austin T. Wilson, MS, PharmD Candidate 2017 Explain the efficacy and safety of triple therapy, in regards to thromboembolic and bleeding risk Summarize the guideline recommendations
More informationDISCLOSURE. What I am Talking About. Rational Use of Antiplatelet Agents. Aspirin. Tom DeLoughery, MD MACP FAWM
Rational Use of Antiplatelet Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau None Tom DeLoughery, MD MACP FAWM Oregon Health and Sciences University What I am Talking About 1. Current
More informationin people who have heart disease
Medication Guide DUEXIS (due ex is) (ibuprofen and famotidine) tablets Read this Medication Guide before you start taking DUEXIS and each time you get a refill. There may be new information. This information
More informationAngelika Cyganska, PharmD Austin T. Wilson, MS, PharmD Candidate 2017
Angelika Cyganska, PharmD Austin T. Wilson, MS, PharmD Candidate 2017 Explain the efficacy and safety of triple therapy, in regards to thromboembolic and bleeding risk Summarize the guideline recommendations
More informationNEW/NOVEL ORAL ANTICOAGULANTS (NOACS): COMPARISON AND FREQUENTLY ASKED QUESTIONS
NEW/NOVEL ORAL ANTICOAGULANTS (NOACS): COMPARISON AND FREQUENTLY ASKED QUESTIONS OBJECTIVES: To provide a comparison of the new/novel oral anticoagulants (NOACs) currently available in Canada. To address
More information2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Process
Measure #204 (NQF 0068): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet National Quality Strategy Domain: Effective Clinical Care 2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: potassium (Zipsor), (Zorvolex) Reference Number: CP.CPA.280 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end
More informationEndoscopy in the Era of Anti- Platelet and Anti-Coagulation
Endoscopy in the Era of Anti- Platelet and Anti-Coagulation Larissa Fujii-Lau, MD Assistant Professor of Medicine University of Hawaii Clinical Updates in Gastroenterology, Hepatology, and Nutrition 1/20/2017
More informationNanik Hatsakorzian Pharm.D/MPH
Pharm.D/MPH 2014 1 Therapeutics FDA indication & Dosing Clinical Pearls Anticoagulants Heparin Antiphospholipid antibody syndrome Cerebral thromboembolism Prosthetic heart valve Acute coronary syndrome
More informationTitle of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author)
Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Guideline for Patients on antiplatelet agents undergoing Elective, Non-cardiac
More informationCERVICAL EPIDURAL INJECTION
Overview and Indications for Procedure: Cervical epidural injection helps with a radiating pain from the neck to the arm often associated with herniated disc in the cervical spine. Cervical Epidural Steroid
More informationMUSCULOSKELETAL PHARMACOLOGY. A story of the inflamed
MUSCULOSKELETAL PHARMACOLOGY A story of the inflamed 1 INFLAMMATION Pathophysiology Inflammation Reaction to tissue injury Caused by release of chemical mediators Leads to a vascular response Fluid and
More informationWMC PHARMACY ANTICOAGULATION PROTOCOL Current Revision: July 2017 GENERAL ORDER PROCESSING AND MANAGEMENT
WMC PHARMACY ANTICOAGULATION PROTOCOL Current Revision: July 2017 GENERAL ORDER PROCESSING AND MANAGEMENT - Entering orders for anticoagulation in Cerner Providers will enter individual orders (oneoffs)
More informationChange from lovenox to pradaxa
P ford residence southampton, ny Change from lovenox to pradaxa 14-11-2017 We wanted to put out a friendly reminder that the Ask 3 Teach 3 (A3T3) initiative is indeed full swing. This is an multidisciplinary
More informationGENICULAR NERVE ABLATION
Overview and Indications for Procedure: Osteoarthritis (OA) of the knee is the leading cause of knee pain in adults. Knee OA results in the thinning of the covering cartilage and remodeling of the knee
More informationTiming of Surgery After Percutaneous Coronary Intervention
Timing of Surgery After Percutaneous Coronary Intervention Deepak Talreja, MD, FACC Bayview/EVMS/Sentara Outline/Highlights Timing of elective surgery What to do with medications Stopping anti-platelet
More informationManagement of Anticoagulation during Device Implants; Coumadin to Novel Agents
Management of Anticoagulation during Device Implants; Coumadin to Novel Agents DR D Birnie Invited Faculty Core Curriculum Heart Rhythm Society May 8 th 2014 Disclosures Boehringer Ingleheim Research Support
More informationLUMBAR FACET INJECTION
Overview and Indications for Lumbar Facet Injections: A zygapophyseal joint (facet joint) connects two adjacent vertebrae. They exist on the right as well as left side of the spine. The joints may become
More informationAnti-thrombotics and Colonoscopy. Anna Rahmani, MD. Ph.D. FRCPC
Anti-thrombotics and Colonoscopy Anna Rahmani, MD. Ph.D. FRCPC DICLOSURES: consultations fees: Servier and Sanofi Pharmaceuticals Thrombosis Clinic Educational Fund: Servier CONFLICT OF INTEREST: NONE
More informationNew oral anticoagulants and perioperative management of anticoagulant/antiplatelet agents.
New oral anticoagulants and perioperative management of anticoagulant/antiplatelet agents. Author Rahman, Atifur, Latona, Jilani Published 2014 Journal Title Australian Family Physician Copyright Statement
More informationChallenges in Anticoagulation and Thromboembolism
Challenges in Anticoagulation and Thromboembolism Ethan Cumbler M.D. Assistant Professor of Medicine Hospitalist Medicine Section University of Colorado Denver May 2010 No Conflicts of Interest Objectives
More informationIntrinsic + Common = aptt. Extrinsic + Common = PT. Common Pathway
Anticoagulant Cases 12 11 Intrinsic + Common = aptt 9 8 10 7 4 Extrinsic + Common = PT 5 2 Common Pathway 1 Xa Inhibitors rivaroxaban (Xarelto) apixaban (Eliquis) edoxaban (Savaysa) What is true regarding
More informationAntiplatelet and Anticoagulant Therapy Management Surrounding Regional Anesthesia
1 Antiplatelet and Anticoagulant Therapy Management Surrounding Regional Anesthesia Key Points: Neuraxial complications are extremely rare. Epidural hematomas are one possible complication of neuraxial
More informationXarelto (rivaroxaban)
Xarelto (rivaroxaban) Policy Number: 5.01.575 Last Review: 7/2018 Origination: 6/2014 Next Review: 7/2019 LoB: ACA Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for Xarelto
More informationNucleoplasty What is Nucleoplasty? Why do I need a Nucleoplasty? What is the typical procedure? not Is this procedure effective?
Nucleoplasty What is Nucleoplasty? Nucleoplasty is a minimally invasive procedure for percutaneous disc decompression that uses radiofrequency based technology to ablate and coagulate soft tissue to decompress
More informationPerioperative Management of Antithrombotic Therapy
CHEST Supplement ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Perioperative Management of Antithrombotic Therapy Antithrombotic Therapy and Prevention of Thrombosis, 9th
More informationChallenges in Anticoagulation Bridging and Emerging Therapies. Disclosures and Relationships. Objectives. Dr. Cumbler has no conflicts of interest
Challenges in Anticoagulation Bridging and Emerging Therapies Ethan Cumbler MD FACP Associate Professor of Medicine Hospitalist Medicine Section University of Colorado Denver 2011 Disclosures and Relationships
More informationXarelto (rivaroxaban) Prescriber Guide
Xarelto (rivaroxaban) Prescriber Guide October 2018 PP-XAR-IE-0031 Contents Patient Alert Card 4 Dosing Recommendations 4 Stroke prevention in adult patients with non-valvular atrial fibrillation 4 Patients
More informationNew Study Presented at American Heart Association (AHA) Scientific Sessions 2016:
Investor News Not intended for U.S. and UK Media Bayer AG Investor Relations 51368 Leverkusen Germany www.investor.bayer.com New Study Presented at American Heart Association (AHA) Scientific Sessions
More informationInterventional Physiatry
Overview and Indications for Procedure: Thoracic Facet Steroid Injections are performed to reduce mid-back pain. Facet injection can help localize the pain generator, improve flexibility, enhance function,
More informationNew Oral Anticoagulants in Everyday Practice: Addressing Common Clinical Scenarios and Questions not covered by the big trials
New Oral Anticoagulants in Everyday Practice: Addressing Common Clinical Scenarios and Questions not covered by the big trials James Douketis, MD, FRCPC Specialty: Internal Medicine Professor, Department
More informationSTELLATE GANGLION BLOCK
OVERVIEW AND INDICATIONS: This is a procedure performed for diagnostic or therapeutic purposes. It is indicated for diagnosis of complex regional pain syndrome involving the upper extremity. Stellate ganglion
More informationComplicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital
Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital Complicated issues in GI bleeding; Survey results from internists Optimal resuscitation
More informationTim Brown, PharmD, BCACP, FASHP Director of Clinical Pharmacotherapy, Akron General Medical Center for Family Medicine Professor, Northeast Ohio
Tim Brown, PharmD, BCACP, FASHP Director of Clinical Pharmacotherapy, Akron General Medical Center for Family Medicine Professor, Northeast Ohio Medical University Objectives 1. 2. 3. 4. Review and discuss
More informationThrombosis Canada Clinical Tools. Perioperative Management of Anticoagulants Antithrombotic Use in Atrial Fibrillation
Thrombosis Canada Clinical Tools Perioperative Management of Anticoagulants Antithrombotic Use in Atrial Fibrillation Dr. Benjamin Bell, MD FRCPC Staff General Internist North York General Hospital Lecturer,
More informationShared Care Protocol for the Prescription and Supply of Low Molecular Weight Heparins
Tameside Hospital NHS Foundation Trust and NHS Tameside and Glossop Shared Care Protocol for the Prescription and Supply of Low Molecular Weight Heparins Version 5.2 Version: 5.2 Authorised by: Joint Medicines
More informationManagement of antithrombotic agents before endoscopy 삼성서울병원소화기내과임상강사이세옥
Management of antithrombotic agents before endoscopy 삼성서울병원소화기내과임상강사이세옥 Risk vs Benefit Hemorrhage Thrombosis Hemorrhage rarely fatal, controlled by endoscoic therapeutic measures, TAE, operation Thrombotic
More information4/27/2015. Cardiac Events #1 cause of postoperative complications/ mortality- CHF, complete heart block, MI,
Not intended for medical clearance Identify, document, and evaluate health conditions Medication Management Stratify Risks Optimize conditions within context of surgical illness Recommend measures that
More informationSACROILIAC JOINT INJECTION
OVERVIEW AND INDICATIONS FOR SACROILIAC INJECTION: The left and right Sacroiliac Joints (SI joints) are located in the lower portion of spine and they have a cartilage layer covering the two adjacent sacrum
More informationAfib, Stroke, and DOAC. Albert Luo, MD. Cardiology Lindsey Frischmann, DO. Neurology Xiao Cai, MD. HBS
Afib, Stroke, and DOAC Albert Luo, MD. Cardiology Lindsey Frischmann, DO. Neurology Xiao Cai, MD. HBS Disclosure of Relevant Financial Relationships I have no relevant financial relationships with commercial
More informationDrug Class Monograph
Drug Class Monograph Class: Oral Anticoagulants Drug: Coumadin (warfarin), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), arelto (rivaroxaban) Formulary Medications: Eliquis (apixaban),
More informationNoval Oral Anticoagulants: Life Is Not As Simple as Anticipated
Noval Oral Anticoagulants: Life Is Not As Simple as Anticipated PRESENTED BY VICKI L GROO, PHARMD CLINICAL ASSOCIATE PROFESSOR DEPARTMENTS OF PHARMACY PRACTICE AND CARDIOLOGY UNIVERSITY OF ILLINOIS AT
More informationANTIPLATELET THERAPY ANTIPLATELET THERAPY ANTIPLATELET THERAPY
ANTIPLATELET THERAPY 2018 UPDATE ANTIPLATELET THERAPY ANTIPLATELET THERAPY About this Pocket Guide This pocket guide is a quick-reference tool that features diagnostic and management recommendations based
More information