ANTICOAGULATION: THE DO'S AND DON'TS OF BRIDGE THERAPY
|
|
- Bernadette Alexandra Palmer
- 5 years ago
- Views:
Transcription
1 ANTICOAGULATION: THE DO'S AND DON'TS OF BRIDGE THERAPY SATURDAY/11:30AM-12:30PM ACPE UAN: L01-P 0.1 CEU/1.0 hr Activity Type: Application-Based Learning Objectives for Pharmacists: Upon completion of this CPE activity participants should be able to: 1. Apply recent literature data to guide bridging anticoagulation decision making. 2. Review the pharmacology and kinetic properties of various anticoagulant agents. 3. Describe timing of anticoagulation interruption and resumption around procedural therapies. 4. Summarize current guidelines regarding bridging anticoagulation. 5. Identify appropriate patient populations to receive bridge therapy. Speaker: Tadd Hellwig, PharmD, BCPS Dr. Tadd Hellwig graduated from the Texas Tech University Health Sciences Center School of Pharmacy in 2006 and completed a Pharmacy Practice Residency at Christiana Care Health System in Newark, DE in He is currently an Associate Professor of Pharmacy Practice at the South Dakota State University College of Pharmacy and Allied Health Professions. Dr. Hellwig holds a clinical practice site in Internal Medicine at the Sanford USD Medical Center in Sioux Falls, SD. Dr. Hellwig is also very active in the South Dakota Society of Health-System Pharmacists (SDSHP) where he has served as a both President and Board Member. Speaker Disclosure: Tadd Hellwig reports no actual or potential conflicts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation.
2 Anticoagulation: The Do s and Don'ts of Bridge Therapy Tadd Hellwig, PharmD, BCPS Associate Professor South Dakota State University College of Pharmacy and Allied Health Professions Disclosure I report no actual or potential conflicts of interest associated with this presentation 1
3 Learning Objectives Upon successful completion of this activity, participants should be able to: - Apply recent literature to guide anticoagulation bridging decision making - Review the pharmacology and kinetic properties of various anticoagulant agents - Describe timing of anticoagulation interruption and resumption around procedures - Summarize current guidelines regarding anticoagulation bridging - Identify appropriate patient populations to receive bridging therapy Peri-operative bridging Patients that are chronically anticoagulated with warfarin who require an invasive procedure may need to have their warfarin interrupted to prevent bleeding Use of heparin or LMWH in the pre/post operative period until an INR becomes therapeutic Bridging therapy relates only to warfarin patients - What to do with patients on DOACs 2
4 Background Approx 400,000 patients on anticoagulation will require interruption of warfarin for a procedure annually - Up to 20% of patients receiving warfarin Decision to bridge depends on balancing the risk of acute thromboembolic events and bleeding - Grades of bridging recommendations (Level 2C) CHEST 2012; 141(2)(Suppl):e326S e350s What does BRIDGEing look like 3
5 Perioperative checklist Stopping of an agent before an invasive procedure - Half-life of the agent Renal function, hepatic function, drug interactions What is the thromboembolic risk of the patient What is the bleeding risk of the patient/procedure - DOAC laboratory monitoring When should heparin/lmwh be used When to resume an agent after a procedure How to control a bleeding event Target fixation 4
6 Comparison of common agents Dabigatran Rivaroxaban Apixaban Edoxaban Warfarin Target Factor IIa Factor Xa Factor Xa Factor Xa Vitamin K epoxidase reductase Tmax (h) Anticoag effect (72-96 h) Half-life (h) healthy elderly Elimination 80% renal 33% unchanged by the kidney % renal 50% renal Hepatic CYP substrate No 3A4 3A4 3A4 2C9, 2C19, 1A2, 3A4 P-gp substrate Yes Yes Yes Yes CHEST Guidelines 2012 Risk Group Atrial Fibrillation VTE Mechanical Heart Valve High CHADS2 score of 5 or 6 CVA/TIA <3 months prior Rheumatic valvular disease VTE <3 months prior Severe thrombophilia Mitral valve prosthesis Cage-ball Tilting disc aortic valve CVA/TIA <6 months prior Moderate CHADS2 score of 3 or 4 VTE 3-12 months prior Recurrent VTE Active cancer Bileaflet aortic valve with risk factors* Low CHADS2 score of 2 or less without prior CVA/TIA VTE >12 months prior with no other risk factors Bileaflet aortic valve without risk factors* *Risk factors: Protein C & S or antithrombin deficiency CHEST 2012; 141(2)(Suppl):e326S e350s 5
7 Thromboembolic risk in Afib Bleeding risk assessments Pisters et al. Chest 2010;138:
8 Risk of bleeding Minimal Low to Moderate High Tooth extraction Peridontology Simple endoscopy, NO biopsy Abscess incision Minor dermatologic procedures Cataract procedure Endoscopy with simple biopsy Prostate/bladder biopsy Coronary angiography Abdominal hernia repair Pace-maker/ICD implant Laparoscopic hysterectomy Neuraxial anesthesia Intracranial surgery Thoracic surgery Cardiac surgery Major orthopedic surgery Liver/Kidney biopsy TURP Robotic surgery Dubois et al. Thrombosis Journal 2017;15:14 Case 1 D.G. is a 75 y.o. M with Afib. He has a planned surgical procedure next week. PMH: Afib, DM, stroke, CAD, HTN. Meds: warfarin 2.5 mg daily, metformin 1000mg BID, atorvastatin 40mg daily, lisinopril 5mg daily. Should D.G. receive bridging therapy prior to his surgical procedure? 7
9 What is the evidence of bridging Siegal, et al. Circulation. 2012;126: ORBIT AF Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry is a prospective, observational registry study of US outpatients with atrial fibrillation Analyzed temporary interruptions for invasive procedures 7372 patients treated with oral anticoagulation interruptions in 2200 patients Circulation. 2015;131:
10 ORBIT AF- Baseline Characteristics NO bridging (n= 1608) Bridging (n= 592) Age CHADS 2 score Prior stroke (%) Significant valve dx (%) Prior mechanical valve replacement (%) TTR (%) Circulation. 2015;131: Outcomes Circulation. 2015;131:
11 RE-LY Analysis RE-LY is the trial that led to FDA approval of dabigatran etexilate for NVAF stroke risk reduction - Open label trial Analyzed all the patients in the study who had an interruption of dabigatran or warfarin for an elective surgery/procedure Perioperative management was completely up to the treating physician Outcomes at 30 days Douketis JD, et. al. Thromb Haemost 2015; 113: RE-LY Analysis Results Douketis JD, et. al. Thromb Haemost 2015; 113:
12 Huh.. To BRIDGE or NOT to BRIDGE.?. The BRIDGE Trial Randomized, double blind, placebo controlled trial - Funded by NIH Analyzed atrial fibrillation patients who needed interruptions to warfarin therapy of an elective invasive procedure Patients were randomized to: - LMWH bridging - No bridging with placebo injections Douketis JD, et al. New Engl J Med. 2015; 373:
13 Bridge Trial Inclusion/Exclusion Inclusion - 18 yo with chronic a. fib. (permanent or paroxysmal) or flutter, confirmed by EEG or pacemaker interrogation; valvular a. fib patient were eligible - Warfarin therapy for 3 months with goal INR 2-3 needing a procedure necessitating interruption - CHADS 2 score of at least 1 Exclusion - Mechanical heart valve - Stroke, systemic embolism, TIA in last 12 weeks - Major bleeding in the last 6 weeks - Estimate creatinine clearance of < 30 mls/min - Platelet count < 100K - Planned cardiac, intracranial, or intraspinal surgery Douketis JD, et al. New Engl J Med. 2015; 373:
14 Design Designed as a non-inferiority trial Primary efficacy outcome was arterial thromboembolism at 30 days - Assumed baseline rate for no bridging would be 1% and that absolute non inferiority margin would be an absolute difference of 1% Primary safety outcome was major bleeding - Assumed baseline rate for no bridging would be 1% and 3% in bridging arm Power calculations were done during interim analysis and recruitment was adjusted as needed Douketis JD, et al. New Engl J Med. 2015; 373: Baseline Characteristics NO Bridging (N= 918) Bridging (N= 895) Age (yr) Male (%) Weight (kg) MI history (%) Previous Stroke CrCl (ml/min) Minor surgical procedure Major surgical procedure Douketis JD, et al. New Engl J Med. 2015; 373:
15 Baseline Characteristics CHADS2 Scores NO Bridging Bridging
16 The FINAL Bridge Bridge Trial exceptions Few patients with CHADS 2 score of 5 or 6 Few surgical procedures associated with high arterial risk or bleeding - (carotid endarterectomy, major cancer surgery, cardiac surgery, neurosurgery) No mechanical heart valves were in the study Douketis JD, et al. New Engl J Med. 2015; 373:
17 Case 1 D.G. is a 75 y.o. M with Afib. He has a planned surgical procedure next week. PMH: Afib, DM, stroke, CAD, HTN. Meds: warfarin 2.5 mg daily, metformin 1000mg BID, atorvastatin 40mg daily, lisinopril 5mg daily. Should D.G. receive bridging therapy prior to his surgical procedure?? Literature to support Bridging Prior to the BRIDGE trial in 2015 there wasn t a single prospective, randomized trial to support bridging vs. no bridging Accumulating evidence that bridging may not be beneficial prior to the BRIDGE trial - Retrospective or non-randomized Ongoing PERIOP 2 trial - Evaluating LMWH bridging post-operatively in patients with mechanical heart valves or atrial fib/flutter - Study ended Dec
18 2017 ACC Expert Consensus for Periprocedural Management in Atrial Fibrillation Patients at LOW risk (CHA 2 DS 2 -VASc 4) - Parenteral bridging is not needed Patients at MODERATE risk (CHA 2 DS 2 -VASc of 5-6 or history of TIA/stroke) - Patients with history of TIA/stroke: likely bridge - Patients without history of TIA/stroke: likely do not bridge Patients at HIGH risk (CHA 2 DS 2 -VASc of 7-9) - Parenteral bridging should be considered ACC 2017 Guidelines. J Am Coll Cardiol 2017 Re-initiation of anticoagulation 17
19 Unanswered Questions What to do with.. - Patients with VTE - Patients receiving DOACs - Neuraxial anesthesia - Pacemaker implantation Case 2 D.G. is a 75 y.o. M with hx of PE. He has a planned surgical procedure next week. PMH: PE (2016), DM, stroke, CAD, HTN. Meds: warfarin 2.5 mg daily, metformin 1000mg BID, atorvastatin 40mg daily, lisinopril 5mg daily. Should D.G. receive bridging therapy prior to his surgical procedure? 18
20 Clark, et al. Retrospective cohort study at Kaiser Permanente Colorado on patients receiving warfarin for secondary VTE prophylaxis Included patients where warfarin therapy was interrupted for invasive diagnostic or surgical procedures - January 1, 2006-March 31, procedures in 1178 patients met inclusion criteria JAMA Intern Med. doi: /jamainternmed Baseline 19
21 Outcomes Case 2 D.G. is a 75 y.o. M with hx of PE. He has a planned surgical procedure next week. PMH: PE (2016), DM, stroke, CAD, HTN. Meds: warfarin 2.5 mg daily, metformin 1000mg BID, atorvastatin 40mg daily, lisinopril 5mg daily. Should D.G. receive bridging therapy prior to his surgical procedure?? What if the PE was 2 months ago? 20
22 What to do with DOACs Pharmacokinetic profile of DOACs differ dramatically compared to warfarin Is bridging necessary with these agents? How to determine when surgery is good to go? What if a patient starts to bleed? When to hold DOACs Low Bleed Risk Mod/High Bleed Risk ACC 2017 Guidelines. J Am Coll Cardiol
23 Clinical Practice Byron, et al. Am J Health-Syst Pharm 2017:74:e DOACs restart after surgery Should parenteral bridging be used following a surgical procedure prior to reinitiated a DOAC? Low bleed risk procedure - Could consider restarting as soon as 8 hours after Likely better to wait 24 hours before restarting High bleed risk procedure - Likely hold off for hours after the procedure - May consider prophylactic dose until full dose resumes 22
24 Neuraxial anesthesia Neuraxial anesthesia Narouze S. Reg Anesth Pain Med 2015;40:
25 Pacemaker implantation Birnie DH. N Engl J Med 2013;368: Take Home Points No good prospective trials to support bridging The majority of bridging is likely unnecessary - Might consider in patients with Atrial fibrillation at high risk of thromboembolic events Recent VTE Mechanical heart valves Be aware of renal function with DOACs 24
26 Questions? 25
Perioperative 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 informationWhat s new with DOACs? Defining place in therapy for edoxaban &
What s new with DOACs? Defining place in therapy for edoxaban & Use of DOACs in cardioversion Caitlin M. Gibson, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy University of North Texas
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 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 informationAtrial Fibrillation. 2 nd Annual National Hospitalist Conference San Antonio, TX September 7, 2018
2 nd Annual National Hospitalist Conference San Antonio, TX September 7, 2018, MSc, FACP, SFHM Division of Hospital Medicine Henry Ford Hospital Detroit, USA Clinical Associate Professor of Medicine Wayne
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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 informationDo s and Don t of DOACs DISCLOSURE
Do s and Don t of DOACs Tom DeLoughery, MD MACP FAWM Oregon Health and Sciences University DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant/Research none Content Expert: Elsevier
More informationPractical Considerations for Using Oral Anticoagulants in Patients with Chronic Kidney Disease
Practical Considerations for Using Oral Anticoagulants in Patients with Chronic Kidney Disease Cyrille K. Cornelio, Pharm.D. PGY2 Cardiology Pharmacy Resident The University of Oklahoma College of Pharmacy
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 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 informationACCP Cardiology PRN Journal Club
ACCP Cardiology PRN Journal Club 1 Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation and Valvular Heart Disease Cody A. Carson, PharmD, BCPS PGY2 Cardiology Pharmacy Resident
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 informationIndividual Therapeutic Selection Of Anti-coagulants And Periprocedural. Miguel Valderrábano, MD
Individual Therapeutic Selection Of Anti-coagulants And Periprocedural Management Miguel Valderrábano, MD Outline Does the patient need anticoagulation? Review of clinical evidence for each anticoagulant
More informationDual Antiplatelet Therapy Made Practical
Dual Antiplatelet Therapy Made Practical David Parra, Pharm.D., FCCP, BCPS Clinical Pharmacy Program Manager in Cardiology/Anticoagulation VISN 8 Pharmacy Benefits Management Clinical Associate Professor
More information6 th ACC-SHA Joint Meeting Jeddah, Saudi Arabia
6 th ACC-SHA Joint Meeting Jeddah, Saudi Arabia October 31 st - November 1 st, 2015 NOACS vs. Coumadin in Atrial Fibrillation: Is It Worth to Switch? Raed Sweidan, MD, FACC Consultant and Head of Cardiac
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 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 informationAnticoagulation: Novel Agents
Anticoagulation: Novel Agents Scott C. Woller, MD Medical Director, Anticoagulation Management, Intermountain Healthcare Central Region, co-director Venous Thromboembolism Program, Intermountain Medical
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 informationEdoxaban. Direct Xa inhibitor Direct thrombin inhibitor Direct Xa inhibitor Direct Xa inhibitor
This table provides a summary of the pharmacotherapeutic properties, side effects, drug interactions and other important information on the four anticoagulant medications currently in use or under review
More informationUpdate on Oral Anticoagulation for Mechanical Heart Valves
Update on Oral Anticoagulation for Mechanical Heart Valves Douglas C. Anderson, Pharm.D., D.Ph. Professor and Chair Dept. of Pharmacy Practice Cedarville University School of Pharmacy OHIO SOCIETY OF HEALTH-SYSTEM
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 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 informationCOAGULATION TESTING AND NEW ORAL ANTICOAGULANTS
COAGULATION TESTING AND NEW ORAL ANTICOAGULANTS SOPHIE TESTA Haemostasis and Thrombosis Center ASST-Cremona, Italy ANTICOAGULANT DRUGS Eikelboom JW, Weitz JI. Circulation 2010;6:1523-32 DRUGS UH LAB aptt
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 informationNibal R. Chamoun, Pharm.D., BCPS Clinical Assistant Professor of Pharmacy Practice at the Lebanese American University Clinical Pharmacy Coordinator
Nibal R. Chamoun, Pharm.D., BCPS Clinical Assistant Professor of Pharmacy Practice at the Lebanese American University Clinical Pharmacy Coordinator at LAUMCRH Review the mechanism of action, indications
More informationAnticoagulation Therapy in LTC
Anticoagulation Therapy in LTC By: Cynthia Leung, RPh, BScPhm, PharmD. Clinical Consultant Pharmacist MediSystem Pharmacy Jun 11, 2013 Agenda Stroke and Bleeding Risk Assessment Review of Oral Anticoagulation
More informationDIRECT ORAL ANTICOAGULANTS
2017 Cardiovascular Symposium DIRECT ORAL ANTICOAGULANTS ERNESTO UMAÑA, MD, FACC ORAL ANTICOAGULANTS Vitamin K Antagonists (VKAs): Warfarin Non Vitamin K Antagonists Direct oral anticoagulants Novel Oral
More informationThe Pendulum of Bridging Periprocedural Anticoagulant Therapy. Alan K. Jacobson, MD Cardiology Section Loma Linda VA Medical Center Loma Linda, CA
The Pendulum of Bridging Periprocedural Anticoagulant Therapy Alan K. Jacobson, MD Cardiology Section Loma Linda VA Medical Center Loma Linda, CA Disclosures Department of Veterans Affairs Industry Relationships:
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 informationAnticoagulation with Direct oral anticoagulants (DOACs) and advances in peri-procedural interruption of anticoagulation-- Bridging
Anticoagulation with Direct oral anticoagulants (DOACs) and advances in peri-procedural interruption of anticoagulation-- Bridging Scott C. Woller, MD Co-Director, Thrombosis Program Intermountain Medical
More informationANTI-THROMBOTIC THERAPY in NON-VALVULAR ATRIAL FIBRILLATION
ANTI-THROMBOTIC THERAPY in NON-VALVULAR ATRIAL FIBRILLATION Colin Edwards Auckland Heart Group Waitemata Health June 2015 PFIZER Lecture series Disclosures EPIDEMIOLOGY Atrial fibrillation is the most
More informationA Cascade of Updates: Hot Topics in Anticoagulation
A Cascade of Updates: Hot Topics in Anticoagulation Heather A. Powell, PharmD, BCPS Assistant Professor of Clinical Sciences Roosevelt University College of Pharmacy Golden L. Peters, PharmD, BCPS Associate
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 informationUpdates in Anticoagulation for Atrial Fibrillation and Venous Thromboembolism
Disclosures Updates in Anticoagulation for Atrial Fibrillation and Venous Thromboembolism No financial conflicts of interest Member of the ABIM Focused- Practice in Hospital Medicine Self Examination Process
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 informationUpdate on Oral Anticoagulants. Dr. Miten R. Patel Cancer Specialists of North Florida Cell
Update on Oral Anticoagulants Dr. Miten R. Patel Cancer Specialists of North Florida Cell 904-451-9820 Email miten.patel@csnf.us Overview Highlights of the 4 new approved oral anticoagulants Results from
More informationDirect Oral Anticoagulants
Direct Oral Anticoagulants Holly Jahn, PharmD, CACP Objectives Identify the FDA approved indications for use, appropriate dosing, and monitoring parameters for each direct oral anticoagulant. Distinguish
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 informationNOACs in AF. Dr Colin Edwards Auckland Heart Group and Waitemata DHB. Dr Fiona Stewart Auckland Heart Group and Auckland DHB
NOACs in AF Dr Colin Edwards Auckland Heart Group and Waitemata DHB Dr Fiona Stewart Auckland Heart Group and Auckland DHB Conflict of Interest Dr Fiona Stewart received funding from Pfizer to attend the
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 informationApixaban for Atrial Fibrillation in Patients with End-Stage Renal Disease on Dialysis
Apixaban for Atrial Fibrillation in Patients with End-Stage Renal Disease on Dialysis Caitlin Reedholm, PharmD PGY1 Pharmacy Resident St. David s South Austin Medical Center November 2, 2018 Abbreviations
More informationDavid Stewart, PharmD, BCPS Assistant Professor of Pharmacy Practice East Tennessee State University Bill Gatton College of Pharmacy
David Stewart, PharmD, BCPS Assistant Professor of Pharmacy Practice East Tennessee State University Bill Gatton College of Pharmacy stewardw@etsu.edu At the conclusion of this program, the audience should
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 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 informationThe Treatment of Venous Thromboembolism (VTE): Has Warfarin Met Its Match? Michael P. Gulseth, Pharm. D., BCPS, FASHP Program Director for
The Treatment of Venous Thromboembolism (VTE): Has Warfarin Met Its Match? Michael P. Gulseth, Pharm. D., BCPS, FASHP Program Director for Anticoagulation Services Sanford USD Medical Center Sioux Falls,
More informationA Patient Unsuitable for VKA Treatment
Will Apixaban change practice in atrial fibrillation? A Patient Unsuitable for VKA Treatment Professor Yoseph Rozenman The E. Wolfson Medical Center Jerusalem June 2013 Disclosures I have the following
More informationCanadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC
Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC DEBATE: DOAC vs Good Old Warfarin André Roussin MD, FRCP, CSPQ CHUM and ICM/MHI Associate professor University of Montreal A. Roussin
More informationNew Antithrombotic Agents DISCLOSURE
New Antithrombotic Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau None Research Alexion (PNH) delought@ohsu.edu Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University What
More informationSurvey patients for Sx, signs of AF. Establish AF Dx. Evaluate & Tx underlying heart disease/other causes. Assess adequacy of rate or rhythm control
Suggested General Approach to Managing Atrial Fibrillation Survey patients for Sx, signs of AF Establish AF Dx ECG Holter Event monitor Implanted device (pacer) Determine & Tx stroke risk (CHA 2 DS 2 VASc)
More informationDisclosure and Conflict of Interest
A Cascade of Updates: Hot Topics in Anticoagulation Heather A. Powell, PharmD, BCPS Assistant Professor of Clinical Sciences Roosevelt University College of Pharmacy Golden L. Peters, PharmD, BCPS Associate
More informationNOACs in AF. Dr Fiona Stewart. Auckland Heart Group and Auckland DHB
NOACs in AF Dr Fiona Stewart Auckland Heart Group and Auckland DHB NOACS for AF True/False All patients should have a CHA 2 DS 2 VASc risk assessment on diagnosis of AF NOACS are more effective than warfarin
More informationOral Anticoagulants Update. Elizabeth Renner, PharmD, BCPS, BCACP, CACP Outpatient Cardiology and Anticoagulation
Oral Anticoagulants Update Elizabeth Renner, PharmD, BCPS, BCACP, CACP Outpatient Cardiology and Anticoagulation Objectives List the direct oral anticoagulant (DOAC) drugs currently available Describe
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 informationClinical issues which drug for which patient
Anticoagulants - a matter of heart! Towards a bright future? Clinical issues which drug for which patient Sabine Eichinger Dept. of Medicine I Medical University of Vienna/Austria Conflicts of interest
More informationShow Me the Outcomes!
Show Me the Outcomes! Real-World Safety Data on Oral Anticoagulants in Nonvalvular Atrial Fibrillation Gabby Anderson, PharmD PGY1 Pharmacy Resident anderson.gabrielle@mayo.edu Pharmacy Grand Rounds October
More informationAtrial fibrillation and anticoagulation JIR-PING BOEY, DEPARTMENT OF HAEMATOLOGY, FLINDERS MEDICAL CENTRE FEBRUARY 2016
1 Atrial fibrillation and anticoagulation JIR-PING BOEY, DEPARTMENT OF HAEMATOLOGY, FLINDERS MEDICAL CENTRE FEBRUARY 2016 Disclosures 2 No conflicts of interest Some questions 3 Should my patient with
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 informationNewer Anti-Anginal Agents and Anticoagulants
Newer Anti-Anginal Agents and Anticoagulants Satish Gadi, MD FACC FSCAI Interventional Cardiologist, Cardiovascular Institute of the South (CIS) Baton Rouge Clinical Assistant Professor, Tulane University
More informationIndications of Anticoagulants; Which Agent to Use for Your Patient? Marc Carrier MD MSc FRCPC Thrombosis Program Ottawa Hospital Research Institute
Indications of Anticoagulants; Which Agent to Use for Your Patient? Marc Carrier MD MSc FRCPC Thrombosis Program Ottawa Hospital Research Institute Disclosures Research Support/P.I. Employee Leo Pharma
More information3/19/2012. What is the indication for anticoagulation? Has the patient previously been on warfarin? If so, what % of the time was the INR therapeutic?
Abigail E. Miller, PharmD, BCPS Clinical Specialist, Cardiology University of North Carolina Hospitals I have no personal financial relationships with the manufacturers of the products to disclose. Boehringer
More informationUpdates in Stroke Management. Jessica A Starr, PharmD, FCCP, BCPS Associate Clinical Professor Auburn University Harrison School of Pharmacy
Updates in Stroke Management Jessica A Starr, PharmD, FCCP, BCPS Associate Clinical Professor Auburn University Harrison School of Pharmacy Disclosure I have no actual or potential conflict of interest
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 Oral Anticoagulants in treatment of VTE, PE DR.AMR HANAFY (LECTURER OF CARDIOLOGY ) ASWAN UNIVERSITY
New Oral Anticoagulants in treatment of VTE, PE DR.AMR HANAFY (LECTURER OF CARDIOLOGY ) ASWAN UNIVERSITY Fact VTE is deadly! It nibbles after it bites! The 30-day mortality rates for first-time DVT or
More informationACCP Cardiology PRN Journal Club
ACCP Cardiology PRN Journal Club Dr. Lianjie Xiong Dr. Xiong is a PGY2 cardiology pharmacy resident at Vanderbilt University Medical Center in Nashville, TN. She went to Nova Southeastern University and
More informationCost and Prevalence of A fib. Atrial Fibrillation: Guideline Directed Treatment. Prevalence of A Fib. Risk Factors for A Fib. Risk Factors for A Fib
Atrial Fibrillation: Guideline Directed Treatment Melissa Wendell, FNP-C, MSN Heart Failure - Lead Nurse Practitioner, Aspirus Wausau Hospital and Aspirus Cardiology Cost and Prevalence of A fib 33.5 million
More informationAtrial Fibrillation: Risk Stratification and Treatment New Cardiovascular Horizons St. Louis September 19, 2015
Atrial Fibrillation: Risk Stratification and Treatment New Cardiovascular Horizons St. Louis September 19, 2015 Christopher E. Bauer, MD, FACC, FHRS SSM Health Heart & Vascular Care Clinical Cardiac Electrophysiology
More informationJoshua D. Lenchus, DO, RPh, FACP, SFHM Associate Professor of Medicine and Anesthesiology University of Miami Miller School of Medicine
Joshua D. Lenchus, DO, RPh, FACP, SFHM Associate Professor of Medicine and Anesthesiology University of Miami Miller School of Medicine Antithrombotics Antiplatelets Aspirin Ticlopidine Prasugrel Dipyridamole
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 informationPCI in Patients with AF Optimizing Oral Anticoagulation Regimen
PCI in Patients with AF Optimizing Oral Anticoagulation Regimen Walid I. Saliba, MD Director, Atrial Fibrillation Center Heart and Vascular Institute Cleveland Clinic 1 Epidemiology and AF and PCI AF and
More informationDirect Oral Anticoagulants (DOACs). Dr GM Benson Director NI Haemophilia Comprehensive Care Centre and Thrombosis Unit BHSCT
Direct Oral Anticoagulants (DOACs). Dr GM Benson Director NI Haemophilia Comprehensive Care Centre and Thrombosis Unit BHSCT OAC WARFARIN Gold standard DABIGATRAN RIVAROXABAN APIXABAN EDOXABAN BETRIXABAN
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 informationAtrial Fibrillation. Alan Bell, MD, CCFP. Staff Physician, Humber River Regional Hospital. University of Toronto
Pearls in Thrombosis 1 Atrial Fibrillation Alan Bell, MD, CCFP Staff Physician, Humber River Regional Hospital Assistant tprofessor, Department tof Family and Community Mdii Medicine University of Toronto
More informationDebate: New Generation Anti-Coagulation Agents are a Better Choice than Warfarin in the Management of AF
Debate: New Generation Anti-Coagulation Agents are a Better Choice than Warfarin in the Management of AF Bradley P. Knight, MD Director of Cardiac Electrophysiology Bluhm Cardiovascular Institute Northwestern
More informationADC Slides for Presentation 02/10/2017
ADC 2017 Slides for Presentation ANTI THROMBOTIC THERAPY FOR NON VALVULAR ATRIAL FIBRILLATION IN PATIENTS WITH CHRONIC KIDNEY DISEASE: CURRENT VIEWS Martin A. Alpert, MD Brent M. Parker Professor of Medicine
More informationMODULE 1: Stroke Prevention in Atrial Fibrillation Benjamin Bell, MD, FRCPC
MODULE 1: Stroke Prevention in Atrial Fibrillation Benjamin Bell, MD, FRCPC Specialty: General Internal Medicine Lecturer, Department of Medicine University of Toronto Staff Physician, General Internal
More informationThe INR: No Need Anymore? Daniel Blanchard, MD Professor of Medicine Director, Cardiology Fellowship Program UCSD Sulpizio Cardiovascular Center
The INR: No Need Anymore? Daniel Blanchard, MD Professor of Medicine Director, Cardiology Fellowship Program UCSD Sulpizio Cardiovascular Center What is the INR? Tissue Factor (Factor III) is added to
More informationIschemic and hemorrhagic strokes in the context of the direct acting oral anticoagulants
Ischemic and hemorrhagic strokes in the context of the direct acting oral anticoagulants Van Hellerslia, PharmD, BCPS, CACP Clinical Assistant Professor Temple University School of Pharmacy Over 4 million
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 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 informationADVANCES IN ANTICOAGULATION
ADVANCES IN ANTICOAGULATION The Clinicians Perspective Claudine M. Lewis Cardiologist OUTLINE Indications for anticoagulants Review - Physiology of Hemostasis Types of anticoagulants New anticoagulants
More informationNAVIGATING THROMBOSIS AND BLEEDING AT THE INTERSECTION OF ATRIAL FIBRILLATION AND CORONARY STENTING
NAVIGATING THROMBOSIS AND BLEEDING AT THE INTERSECTION OF ATRIAL FIBRILLATION AND CORONARY STENTING Snehal H. Bhatt, Pharm.D., BCPS-AQ Cardiology, FASHP, AACC Associate Professor of Pharmacy Practice MCPHS
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 informationANTICOAGULANTS AND HIP FRACTURE SURGERY. Jon Antrobus Anaesthetist Borders General Hospital
ANTICOAGULANTS AND HIP FRACTURE SURGERY Jon Antrobus Anaesthetist Borders General Hospital Anticoagulation is common amongst the hip fracture patient population (6-10%) Anticoagulation signifies co-morbidity
More informationPradaxa (dabigatran)
Pradaxa (dabigatran) Policy Number: 5.01.574 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 Pradaxa
More information