With All the New Drugs, This is How I Treat Acute DVT and Superficial Phlebitis

Size: px
Start display at page:

Download "With All the New Drugs, This is How I Treat Acute DVT and Superficial Phlebitis"

Transcription

1 BRIGHAM AND WOMEN S HOSPITAL With All the New Drugs, This is How I Treat Acute DVT and Superficial Phlebitis Gregory Piazza, MD, MS Division of Cardiovascular Medicine Brigham and Women s Hospital April 20, 2018 HARVARD MEDICAL SCHOOL TEACHING AFFILIATE Disclosures BMS- grant/research support Daichii-Sankyo- grant/research support BTG/EKOS- grant/research support Janssen- grant/research support Bayer- scientific advisory panel Portola- scientific advisory panel 1

2 A 55-year-old woman with acute left leg swelling and pain She recently underwent left knee arthroscopy for a partial medial meniscus tear. She initially noted left knee swelling and pain but subsequently found the symptoms extended to her ankle. She suspected it was typical for knee surgery and self-prescribed bed rest. A 55-year-old woman with acute left leg swelling and pain Her medical history was remarkable for obesity, type 2 diabetes, hypertension, hyperlipidemia, GERD, and obstructive sleep apnea. Her medications included metformin, lisinopril, atorvastatin, omeprazole, and ibuprofen. She was a 1-pack-per-day smoker and worked as a telemarketer. 2

3 A 55-year-old woman with acute left leg swelling and pain On physical examination, she was afebrile with a blood pressure of 128/72 mmhg, heart rate of 77 bpm, and oxygen saturation of 99% on RA. She had 2+ pitting edema from her left ankle to lower thigh and trace edema on the right. Her left leg was slightly erythematous and tender to palpation. A 55-year-old woman with acute left leg swelling and pain Because of the high suspicion for DVT, the patient was referred directly for venous ultrasound. L FV Venous ultrasound demonstrated left femoral and popliteal DVT. 3

4 Risk Stratification for Acute DVT Acute DVT Iliofemoral DVT Non iliofemoral DVT Consider catheterassisted fibrinolysis Pharmacomechanical Therapy Therapeutic anticoagulation and compression stockings Which Anticoagulant to Use in Acute DVT Unfractionated Heparin Preferred in patients undergoing fibrinolysis, surgical or catheter thrombectomy, or IVC filter insertion Injectables or Direct Oral Anticoagulants Preferred in patients who require only anticoagulation Direct Thrombin Inhibitors Used in patients with suspected or confirmed heparin-induced thrombocytopenia (HIT) 4

5 Efficacy of DOACs for VTE Treatment: Meta-Analysis van der Hulle T, et al. J Thromb Haemost. 2014;12:320 Safety of DOACs for VTE Treatment: Meta-Analysis Relative Risk van der Hulle T, et al. J Thromb Haemost. 2014;12:320 5

6 Anticoagulation Strategy in Evolution Overlapping LMWH/Warfarin Bridge UFH/Warfarin Bridge Switching LMWH to Dabigatran (RE-COVER) LMWH to Edoxaban (HOKUSAI-VTE) Oral Monotherapy Rivaroxaban (15 mg 2x/d for 3 wks, then 20 mg/d) (EINSTEIN) Apixaban (10 mg 2x/d for 1 wk, then 5 mg 2x/d) (AMPLIFY) Optimal Anticoagulation for Acute VTE: 2016 CHEST Guideline Update In patients with DVT of the leg or PE and no cancer, as long-term (first 3 months) anticoagulant therapy, we suggest dabigatran, rivaroxaban, apixaban or edoxaban over VKA therapy (all Grade 2B). Kearon C, et al. CHEST 2016 ;149:315 6

7 Contraindication Checklist for Home-Therapy of Acute DVT High Thrombotic Load Massive DVT (iliofemoral) Concomitant PE Increased Risk of Bleeding Active bleeding or bleeding disorder (thrombocytopenia) Advanced renal or liver disease Special Populations Body weight <45 kg or >100 kg Advanced elderly, pediatric patients, or pregnant women Symptom Control Pain Difficulty ambulating Concomitant Medical Disorder Requiring Admission Beware May-Thurner Syndrome Compression of the left common iliac vein by the right common iliac artery Most common in young women May present as a iliofemoral DVT or as chronic venous insufficiency Fazel R, et al. N Engl J Med 2007; 357:53 7

8 Duration of Anticoagulation Acute DVT Provoked Indeterminate Unprovoked (idiopathic) Cancer Treat with 3-6 months of anticoagulation Assess individual risk of VTE recurrence Consider indefinite duration anticoagulation if low bleeding risk Consider prolonged anticoagulation as long as cancer is active Clinical risk factors: Past/family history of VTE Male gender Thrombophilia Chronic medical conditions (COPD, heart failure, inflammatory disorders) Obesity Chronic immobilization Goldhaber SZ and Piazza G. Circulation 2011;123:664 Prevention of Recurrent Unprovoked VTE Study Intervention Recurrent VTE** PREVENT Warfarin, INR vs. placebo ELATE Warfarin, INR 2-3 vs. INR % 63% THRIVE III EINSTEIN- DVT AMPLIFY-EXT RE-SONATE RE-MEDY Ximelagatran vs. placebo Rivaroxaban vs. placebo Apixaban vs. placebo Dabigatran vs. placebo Dabigatran vs. warfarin, INR % 82% 81% 93% Non-inferior **Regardless of thrombophilia status Prandoni P, et al. Haematologica 2007;92:199 Goldhaber SZ and Piazza G. Circulation 2011;123:664 8

9 Extended Secondary Prevention for All VTE: EINSTEIN CHOICE Weitz JI, et al. N Engl J Med 2017;376:1211 Selecting the Optimal Agent for Extended Therapy Increased Risk of Recurrent VTE after Standard Therapy No Cancer Cancer Non-High Bleeding Risk and Willing to Continue Anticoagulation High Bleeding Risk OR Not Willing to Continue Anticoagulation LMWH Monotherapy DOAC OR Low- or Conventional- Intensity Warfarin Low-Dose Aspirin OR Low-Dose Apixaban or Rivaroxaban 9

10 CLOT Trial: Dalteparin Monotherapy vs. Warfarin n = % Lee AYY, et al. N Engl J Med 2003;349:146 DOACs in Cancer Patients with VTE: HOKUSAI VTE CANCER p = 0.09 p = 0.04 Raskob GE, et al. N Engl J Med. 2018; 378:615 10

11 A 55-year-old woman with acute left proximal DVT provoked by surgery The patient was discharged from the office on oral rivaroxaban 15 mg twice daily for 3 weeks and then 20 mg daily for a total of 6 months. She was recommended to use compression stockings, mmhg, thigh-high. In follow-up, her symptoms resolved quickly and she had no further venous thromboembolic events. A 62-year-old man with varicose veins and leg pain The patient had long-standing varicose vein bilaterally but never thought to seek medical attention. He noted a tender firm cord-like mass behind his left knee that felt warm to the touch. His medical history was only significant for hypertension for which he took HCTZ. 11

12 A 62-year-old man with varicose veins and leg pain On physical examination, the patient had a tender, erythematous cord extending superficially through his popliteal fossa. He had numerous severe varicose veins bilaterally. A venous ultrasound confirmed superficial vein thrombosis and no DVT. Algorithm for Superficial Vein Thrombosis Isolated Severe Fondaparinux 2.5 mg QD Superficial Vein Thrombosis Assess Symptom Severity Severe Symptom Treatment With DVT or Cancer If concomitant DVT or cancer, treat with full-dose anticoagulation, otherwise Non-Severe If non-severe, treat conservatively with analgesia, otherwise Enoxaparin 1 mg/kg QD 12

13 CALISTO: Fondaparinux for Superficial Vein Thrombosis Decousus H, et al. N Engl J Med. 2010;363:1222 CALISTO: Fondaparinux for Superficial Vein Thrombosis Decousus H, et al. N Engl J Med. 2010;363:

14 Rivaroxaban vs. Fondaparinux for Superficial Vein Thrombosis: SURPRISE Prospective, randomized, open-label, non-inferiority trial of superficial vein thrombosis to evaluate the efficacy and safety of 10 mg rivaroxaban daily compared to fondaparinux 2.5 mg once daily for 45 days. A combined efficacy endpoint will evaluate thrombus progression, SVT recurrence, DVT, PE and death. Safety end point will focus on major and clinicallyrelevant non-major bleeding. Clinicaltrials.gov: NCT A 62-year-old man with varicose veins and superficial vein thrombosis The patient was prescribed 45 days of low-dose fondaparinux 2.5 mg daily with excellent relief of symptoms and no recurrent events. He was also prescribed compression stockings thighhigh, mmhg but found them difficult to wear. He was eventually referred for consideration of endovenous laser ablation given his episode of superficial vein thrombosis. 14

15 Take-Home Points The DOACs offer enhanced safety and similar efficacy compared with warfarin for acute treatment of DVT as well as long-term secondary prevention. The DOACs have facilitated home treatment of non-high risk acute DVT. The role of the DOACs in treatment of superficial vein thrombosis has yet to be defined. 15

DEEP VEIN THROMBOSIS (DVT): TREATMENT

DEEP VEIN THROMBOSIS (DVT): TREATMENT DEEP VEIN THROMBOSIS (DVT): TREATMENT OBJECTIVE: To provide an evidence-based approach to treatment of patients presenting with deep vein thrombosis (DVT). BACKGROUND: An estimated 45,000 patients in Canada

More information

Risk-Based Evaluation and Management of VTE

Risk-Based Evaluation and Management of VTE 12:50-1:50pm Risk-Based Evaluation and Management of VTE SPEAKER Gregory Piazza, MD, MS BRIGHAM AND WOMEN S HOSPITAL Risk-Based Evaluation and Management of VTE Gregory Piazza, MD, MS Assistant Professor

More information

Warfarin for Long-Term Anticoagulation. Disadvantages of Warfarin. Narrow Therapeutic Window. Warfarin vs. NOACs. Challenges Monitoring Warfarin

Warfarin for Long-Term Anticoagulation. Disadvantages of Warfarin. Narrow Therapeutic Window. Warfarin vs. NOACs. Challenges Monitoring Warfarin 1 2:15 pm The Era of : Selecting the Best Approach to Treatment SPEAKER Gregory Piazza, MD, MS Presenter Disclosure Information The following relationships exist related to this presentation: Gregory Piazza,

More information

Mabel Labrada, MD Miami VA Medical Center

Mabel Labrada, MD Miami VA Medical Center Mabel Labrada, MD Miami VA Medical Center *1-Treatment for acute DVT with underlying malignancy is for 3 months. *2-Treatment of provoked acute proximal DVT can be stopped after 3months of treatment and

More information

Focus: l embolia polmonare Per quanto la terapia anticoagulante orale? Giulia Magnani 27 Gennaio, 2018

Focus: l embolia polmonare Per quanto la terapia anticoagulante orale? Giulia Magnani 27 Gennaio, 2018 Focus: l embolia polmonare Per quanto la terapia anticoagulante orale? Giulia Magnani 27 Gennaio, 2018 NO DISCLOSURE Pulmonary Embolism Venous thromboembolism (VT) is the third most common cause of cardiovascular

More information

Disclosures. Objectives

Disclosures. Objectives BRIGHAM AND WOMEN S HOSPITAL Treatment of Massive and Submassive Pulmonary Embolism Gregory Piazza, MD, MS Assistant Professor of Medicine Harvard Medical School Staff Physician, Cardiovascular Division

More information

Rapid Fire-Top Articles You Need to Know

Rapid Fire-Top Articles You Need to Know Rapid Fire-Top Articles You Need to Know TRACY MINICHIELLO, MD CHIEF, ANTICOAGULATION& THROMBOSIS SERVICE- SAN FRANCISCO VAMC PROFESSOR OF MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Financial Disclosures-NONE

More information

Updates in Diagnosis & Management of VTE

Updates in Diagnosis & Management of VTE Updates in Diagnosis & Management of VTE TRACY MINICHIELLO, MD CHIEF, ANTICOAGULATION& THROMBOSIS SERVICE-SAN FRANCISCO VAMC PROFESSOR OF MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Financial Disclosures-NONE

More information

Venous Thromboembolic Disease Update

Venous Thromboembolic Disease Update Canadian Society of Internal Medicine Annual Meeting Calgary, Alberta, October 2014 Venous Thromboembolic Disease Update Benjamin Bell, MD FRCPC James Douketis, MD FRCPC On Behalf of Thrombosis Canada

More information

UPDATE ON TREATMENT OF ACUTE VENOUS THROMBOSIS

UPDATE ON TREATMENT OF ACUTE VENOUS THROMBOSIS UPDATE ON TREATMENT OF ACUTE VENOUS THROMBOSIS Armando Mansilha MD, PhD, FEBVS 16 th National Congress of the Italian Society of Vascular and Endovascular Surgery Bologna, 2017 Disclosure I have the following

More information

DVT - initial management NSCCG

DVT - initial management NSCCG Background information Information resources for patients and carers Updates to this care map Synonyms Below knee DVT and bleeding risks Patient with confirmed DVT Scan confirms superficial thrombophlebitis

More information

Disclosures. DVT: Diagnosis and Treatment. Questions To Ask. Dr. Susanna Shin - DVT: Diagnosis and Treatment. Acute Venous Thromboembolism (VTE) None

Disclosures. DVT: Diagnosis and Treatment. Questions To Ask. Dr. Susanna Shin - DVT: Diagnosis and Treatment. Acute Venous Thromboembolism (VTE) None Disclosures DVT: Diagnosis and Treatment None Susanna Shin, MD, FACS Assistant Professor University of Washington Acute Venous Thromboembolism (VTE) Deep Venous Thrombosis (DVT) Pulmonary Embolism (PE)

More information

Understanding Best Practices in Anticoagulation Therapy in Patients with Venous Thromboembolism. Rajat Deo, MD, MTR

Understanding Best Practices in Anticoagulation Therapy in Patients with Venous Thromboembolism. Rajat Deo, MD, MTR Understanding Best Practices in Anticoagulation Therapy in Patients with Venous Thromboembolism Rajat Deo, MD, MTR Director of Translational Research in Cardiac Arrhythmias Division of Cardiovascular Medicine

More information

Updates in Diagnosis & Management of VTE

Updates in Diagnosis & Management of VTE Updates in Diagnosis & Management of VTE Financial Disclosures-NONE TRACY MINICHIELLO, MD CHIEF, ANTICOAGULATION& THROMBOSIS SERVICE- SAN FRANCISCO VAMC PROFESSOR OF MEDICINE UNIVERSITY OF CALIFORNIA,

More information

Venous thrombosis is common and often occurs spontaneously, but it also frequently accompanies medical and surgical conditions, both in the community

Venous thrombosis is common and often occurs spontaneously, but it also frequently accompanies medical and surgical conditions, both in the community Venous Thrombosis Venous Thrombosis It occurs mainly in the deep veins of the leg (deep vein thrombosis, DVT), from which parts of the clot frequently embolize to the lungs (pulmonary embolism, PE). Fewer

More information

Medical Patients: A Population at Risk

Medical Patients: A Population at Risk Case Vignette A 68-year-old woman with obesity was admitted to the Medical Service with COPD and pneumonia and was treated with oral corticosteroids, bronchodilators, and antibiotics. She responded well

More information

The latest on the diagnosis and treatment of venous thromboembolism

The latest on the diagnosis and treatment of venous thromboembolism The latest on the diagnosis and treatment of venous thromboembolism Vicky Tagalakis MD FRCP Division of General Internal Medicine Jewish General Hospital McGill University Disclosures Advisory board Pfizer

More information

Spontane und Tumor-assoziierte VTE: womit wie lange antikoagulieren

Spontane und Tumor-assoziierte VTE: womit wie lange antikoagulieren Spontane und Tumor-assoziierte VTE: womit wie lange antikoagulieren Paul Kyrle Allgemeines Krankenhaus Wien Disclosures relevant for this presentation Consultancies, member of advisory boards, speaker

More information

A Review of the Role of Non-Vitamin K Oral Anticoagulants in the Acute and Long-Term Treatment of Venous Thromboembolism

A Review of the Role of Non-Vitamin K Oral Anticoagulants in the Acute and Long-Term Treatment of Venous Thromboembolism Cardiol Ther (2018) 7:1 13 https://doi.org/10.1007/s40119-018-0107-0 REVIEW A Review of the Role of Non-Vitamin K Oral Anticoagulants in the Acute and Long-Term Treatment of Venous Thromboembolism Andrew

More information

Suspected Deep Vein Thrombosis (DVT) Pathway for Non Pregnant patients Updated November 2016, with new D-dimer reference range

Suspected Deep Vein Thrombosis (DVT) Pathway for Non Pregnant patients Updated November 2016, with new D-dimer reference range Suspected Deep Vein Thrombosis (DVT) Pathway for Non Pregnant patients Updated November 2016, with new D-dimer reference range Suspect a DVT? Complete a Two-level DVT Wells score on ICE system (see page

More information

Non commercial use only. The treatment of venous thromboembolism with new oral anticoagulants. Background

Non commercial use only. The treatment of venous thromboembolism with new oral anticoagulants. Background Italian Journal of Medicine 2013; volume 7(s8):29-35 The treatment of venous thromboembolism with new oral anticoagulants Davide Imberti AUSL Piacenza, Italy ABSTRACT Traditional anticoagulants, such as

More information

Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC

Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC 1 st workshop: update to VTE guidelines in 2016 2 nd workshop: VTE controversies + new horizons André Roussin MD, FRCP, CSPQ CHUM

More information

Results from RE-COVER RE-COVER II RE-MEDY RE-SONATE EXECUTIVE SUMMARY

Results from RE-COVER RE-COVER II RE-MEDY RE-SONATE EXECUTIVE SUMMARY Assessment of the safety and efficacy of dabigatran etexilate (Pradaxa ) in the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and the prevention of recurrent DVT and PE Results from

More information

PULMONARY EMBOLISM/VTE CARE PROCESS MODEL

PULMONARY EMBOLISM/VTE CARE PROCESS MODEL PULMONARY EMBOLISM/VTE CARE PROCESS MODEL IMCP FALL CONFERENCE 2017 Scott Stevens, MD Co-Director, Thrombosis Clinic & Thrombosis Research Group Intermountain Medical Center Professor of Clinical Medicine

More information

DOACs in SPECIAL POPULATIONS

DOACs in SPECIAL POPULATIONS DOACs in SPECIAL POPULATIONS Ann K Wittkowsky PharmD, CACP, FASHP, FCCP Clinical Professor University of Washington School of Pharmacy Director, Anticoagulation Services UWMedicine Department of Pharmacy

More information

PULMONARY EMBOLISM (PE): DIAGNOSIS AND TREATMENT

PULMONARY EMBOLISM (PE): DIAGNOSIS AND TREATMENT PULMONARY EMBOLISM (PE): DIAGNOSIS AND TREATMENT OBJECTIVE: To provide a diagnostic algorithm and treatment options for patients with acute pulmonary embolism (PE). BACKGROUND: Venous thromboembolism (VTE)

More information

Obesity, renal failure, HIT: which anticoagulant to use?

Obesity, renal failure, HIT: which anticoagulant to use? Obesity, renal failure, HIT: which anticoagulant to use? Mark Crowther with thanks to Dr David Garcia and others. This Photo by Unknown Author is licensed under CC BY-SA 1 2 Drug choices The DOACs have

More information

Venous Thromboembolism (VTE) in Myeloma. Christine Chen May 2017

Venous Thromboembolism (VTE) in Myeloma. Christine Chen May 2017 Venous Thromboembolism (VTE) in Myeloma Christine Chen May 2017 Objectives 1. Review the magnitude of the problem and why myeloma patients are at risk of VTE 2. Discuss thromboprophylaxis approaches in

More information

New Oral Anticoagulant Drugs in the Prevention of DVT

New Oral Anticoagulant Drugs in the Prevention of DVT New Oral Anticoagulant Drugs in the Prevention of DVT Targets for Anticoagulants ORAL DIRECT VKAs inhibit the hepatic synthesis of several coagulation factors Rivaroxaban Apixaban Edoxaban Betrixaban X

More information

DOACs and CAT. 05 May 2017 NTW St Thomas Hospital

DOACs and CAT. 05 May 2017 NTW St Thomas Hospital DOACs and CAT Alexander (Ander) Cohen Vascular Medicine / Haematology Guy s and St Thomas Hospitals, King s College, London 05 May 2017 NTW St Thomas Hospital Disclosures for Dr. Alexander (Ander) T. Cohen

More information

CURRENT & FUTURE THERAPEUTIC MANAGEMENT OF VENOUS THROMBOEMBOLISM. Gordon Lowe Professor of Vascular Medicine University of Glasgow

CURRENT & FUTURE THERAPEUTIC MANAGEMENT OF VENOUS THROMBOEMBOLISM. Gordon Lowe Professor of Vascular Medicine University of Glasgow CURRENT & FUTURE THERAPEUTIC MANAGEMENT OF VENOUS THROMBOEMBOLISM Gordon Lowe Professor of Vascular Medicine University of Glasgow VENOUS THROMBOEMBOLISM Common cause of death and disability 50% hospital-acquired

More information

Keynote lecture: Oral anticoagulation and DVT

Keynote lecture: Oral anticoagulation and DVT Keynote lecture: Oral anticoagulation and DVT What is the evidence? Is there a need to anticoagulate every lower leg DVT? Disclosure Speaker name:...sebastian Schellong... I have the following potential

More information

The clinical relevance of AMPLIFY programme

The clinical relevance of AMPLIFY programme Venice October 16th 2015 The clinical relevance of AMPLIFY programme Francesco Dentali Department of Clinical Medicine Insubria University Varese Disclosures Bayer Bristol-Myers Squibb/Pfizer Boehringer

More information

Updates in Anticoagulation for Atrial Fibrillation and Venous Thromboembolism

Updates 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 information

DVT PROPHYLAXIS IN HOSPITALIZED MEDICAL PATIENTS SAURABH MAJI SR (PULMONARY,MEDICINE)

DVT PROPHYLAXIS IN HOSPITALIZED MEDICAL PATIENTS SAURABH MAJI SR (PULMONARY,MEDICINE) DVT PROPHYLAXIS IN HOSPITALIZED MEDICAL PATIENTS SAURABH MAJI SR (PULMONARY,MEDICINE) Introduction VTE (DVT/PE) is an important complication in hospitalized patients Hospitalization for acute medical illness

More information

Direct 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 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 information

Updates in Management of Venous Thromboembolic Disease

Updates in Management of Venous Thromboembolic Disease Updates in Management of Venous Thromboembolic Disease November 7 th 2018 UHN Emergency Conference Susan Jenkins RN(EC) NP-Adult Thrombosis and Hemostasis Program University Health Network Disclosures

More information

New areas of development for the direct oral anticoagulants

New areas of development for the direct oral anticoagulants New areas of development for the direct oral anticoagulants Varese March 2016 Disclosures for Harry R Büller Research Support/P.I. Employee Consultant Major Stockholder Speakers Bureau Scientific Advisory

More information

Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2012) NICE guideline CG144

Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2012) NICE guideline CG144 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2012) NICE guideline CG144 Appendix A: Summary of new evidence from Summary of evidence from previous year Diagnosis Diagnostic

More information

Update on the Management of Cancer Associated VTE

Update on the Management of Cancer Associated VTE Update on the Management of Cancer Associated VTE Jean M. Connors, MD 2018 Master Class Course Anticoagulation Management Services BWH/DFCI Hemostatic Antithrombotic Stewardship BWH Associate Professor

More information

Importance of VTE and Superficial Thrombosis for Primary and Emergency Care

Importance of VTE and Superficial Thrombosis for Primary and Emergency Care Importance of VTE and Superficial Thrombosis for Primary and Emergency Care Dr Matthew Fay GP Principal The Willows Medical Practice- Queensbury GPwSI and Co-Founder Westcliffe Cardiology Service GP Partner

More information

Updates in venous thromboembolism. Cecilia Becattini University of Perugia

Updates in venous thromboembolism. Cecilia Becattini University of Perugia Updates in venous thromboembolism Cecilia Becattini University of Perugia News for VTE Diagnosis Treatment the acute phase the agents Pulmonary embolism: diagnosis Vein ultrasonography Meta-analysis 15

More information

La terapia del TEV nel paziente oncologico nell'era dei DOAC

La terapia del TEV nel paziente oncologico nell'era dei DOAC XXVI CONGRESSO NAZIONALE FCSA Bologna, 5-7 Novembre 2015 Tromboembolismo venoso La terapia del TEV nel paziente oncologico nell'era dei DOAC ANNA FALANGA Immunoematologia e Medicina Trasfusionale e Centro

More information

Clinical Cases with Deep Venous Thrombosis - The position of Apixaban Stavros KAKKOS, MD, MSc, PhD, RVT

Clinical Cases with Deep Venous Thrombosis - The position of Apixaban Stavros KAKKOS, MD, MSc, PhD, RVT Clinical Cases with Deep Venous Thrombosis - The position of Apixaban Stavros KAKKOS, MD, MSc, PhD, RVT Department of Vascular Surgery. University Hospital of Patras Chairman: Ioannis Tsolakis DISCLAIMER

More information

Acute Pulmonary Embolism and Deep Vein Thrombosis. Barbara LeVarge MD Beth Israel Deaconess Medical Center Pulmonary Hypertension Center COPYRIGHT

Acute Pulmonary Embolism and Deep Vein Thrombosis. Barbara LeVarge MD Beth Israel Deaconess Medical Center Pulmonary Hypertension Center COPYRIGHT Acute Pulmonary Embolism and Deep Vein Thrombosis Barbara LeVarge MD Beth Israel Deaconess Medical Center Pulmonary Hypertension Center Acute PE and DVT No disclosures. Acute PE and DVT Learning objectives

More information

The 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 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 information

Acute and long-term treatment of PE. Cecilia Becattini University of Perugia

Acute and long-term treatment of PE. Cecilia Becattini University of Perugia Acute and long-term treatment of PE Cecilia Becattini University of Perugia Acute and long-term treatment of VTE What is the optimal acute phase treatment for the patient? Intravenous thrombolysis One

More information

Misunderstandings of Venous thromboembolism prophylaxis

Misunderstandings of Venous thromboembolism prophylaxis Misunderstandings of Venous thromboembolism prophylaxis Veerendra Chadachan Senior Consultant Dept of General Medicine (Vascular Medicine and Hypertension) Tan Tock Seng Hospital, Singapore Case scenario

More information

Implications from the ACCP 2012 Consensus Guidelines for the Management of Thrombosis: a case based approach

Implications from the ACCP 2012 Consensus Guidelines for the Management of Thrombosis: a case based approach Implications from the ACCP 2012 Consensus Guidelines for the Management of Thrombosis: a case based approach Prof. I. Baumgartner Head Clinical and Interventional Angiology About the ACCP guidelines Widely

More information

Dr. Riaz JanMohamed Consultant Haematologist The Hillingdon Hospital Foundation Trust

Dr. Riaz JanMohamed Consultant Haematologist The Hillingdon Hospital Foundation Trust MANAGEMENT OF PATIENTS WITH DEEP VEIN THROMBOSIS (DVT) IN THE COMMUNITY SETTING & ANTICOAGULATION CLINICS THE PAST, PRESENT AND THE FUTURE Dr. Riaz JanMohamed Consultant Haematologist The Hillingdon Hospital

More information

Duration of anticoagulation

Duration of anticoagulation Duration of anticoagulation P. Fontana Service d angiologie et d hémostase Hôpitaux Universitaires de Genève Pomeriggio formativo in coagulazione, Bellinzona, 19.10.2017 Conflict of interest AstraZeneca,

More information

Deep Vein Thrombosis and Pulmonary Embolus: Updates From ACCP, AC Forum & ESC

Deep Vein Thrombosis and Pulmonary Embolus: Updates From ACCP, AC Forum & ESC Deep Vein Thrombosis and Pulmonary Embolus: Updates From ACCP, AC Forum & ESC Steven Deitelzweig, MD, MMM, SFHM, FACC, FACP Professor of Medicine University of Queensland School of Medicine System Chairman

More information

Prevention and management of deep venous thrombosis (DVT) John Fletcher Wound Care Association of New South Wales

Prevention and management of deep venous thrombosis (DVT) John Fletcher Wound Care Association of New South Wales Prevention and management of deep venous thrombosis (DVT) John Fletcher Wound Care Association of New South Wales Merimbula, 6 th November 2010 University of Sydney Department of Surgery Westmead Hospital

More information

Clinical Guideline for Anticoagulation in VTE

Clinical Guideline for Anticoagulation in VTE Clinical Guideline for Anticoagulation in VTE These clinical guidelines are intended to provide evidence-based recommendations regarding the anticoagulation in patients with DVT and PE. Please note that

More information

Venous Thrombo-Embolism. John de Vos Consultant Haematologist RSCH

Venous Thrombo-Embolism. John de Vos Consultant Haematologist RSCH Venous Thrombo-Embolism John de Vos Consultant Haematologist RSCH overview The statistics Pathogenesis Prophylaxis Treatment Agent Duration Incidental VTE Recurrence of VTE IVC filters CVC related thrombosis

More information

4/30/2018 CLOT+ In patients with an acute proximal deep vein thrombosis, pharmacomechanical catheter-directed thrombolysis does not reduce t

4/30/2018 CLOT+ In patients with an acute proximal deep vein thrombosis, pharmacomechanical catheter-directed thrombolysis does not reduce t In patients with an acute proximal deep vein thrombosis, pharmacomechanical catheter-directed thrombolysis does not reduce the rate of post-thrombotic syndrome Question In patients who have symptomatic

More information

Prevention and treatment of venous thromboembolic disease

Prevention and treatment of venous thromboembolic disease REVIEW Prevention and treatment of venous thromboembolic disease SUSAN McNEILL AND CATHERINE BAGOT Awareness of the risk factors for venous thromboembolic (VTE) disease and timely administration of thromboprophylaxis

More information

Clinical issues which drug for which patient

Clinical 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 information

Disclosures. What is a Specialty Vein Clinic? Prevalence of Venous Disease. Management of Venous Disease: an evidence based approach.

Disclosures. What is a Specialty Vein Clinic? Prevalence of Venous Disease. Management of Venous Disease: an evidence based approach. Management of Venous Disease: an evidence based approach Disclosures Ed Boyle, MD Andrew Jones, MD Dr. Ed Boyle and Dr. Andrew Jones disclose Grants/research support: Medtronic, BTG International, Clearflow,

More information

IDEAL MANAGEMENT OF PULMONARY EMBOLISM DISCLOSURES

IDEAL MANAGEMENT OF PULMONARY EMBOLISM DISCLOSURES IDEAL MANAGEMENT OF PULMONARY EMBOLISM Samuel Z. Goldhaber, MD Section Head, Vascular Medicine Director, Thrombosis Research Group Cardiovascular Division Brigham and Women s Hospital Professor of Medicine

More information

Thromboembolism and cancer: New practices. Marc Carrier

Thromboembolism and cancer: New practices. Marc Carrier Thromboembolism and cancer: New practices Marc Carrier Marc Carrier Research Support/P.I. Employee Consultant Major Stockholder Speakers Bureau Honoraria Scientific Advisory Board Leo Pharma, BMS No relevant

More information

10 Key Things the Vascular Community Should Know about the DOACs Heather Gornik, MD, RVT, RPVI

10 Key Things the Vascular Community Should Know about the DOACs Heather Gornik, MD, RVT, RPVI 10 Key Things the Vascular Community Should Know about the DOACs Heather Gornik, MD, RVT, RPVI Cleveland Clinic Heart and Vascular Institute Heather L. Gornik, MD has the following relationships to disclose:

More information

Top 5 (or so) Hematology Consults. Tom DeLoughery, MD FACP FAWM. Oregon Health and Sciences University DISCLOSURE

Top 5 (or so) Hematology Consults. Tom DeLoughery, MD FACP FAWM. Oregon Health and Sciences University DISCLOSURE Top 5 (or so) Hematology Consults Tom FACP FAWM Oregon Health and Sciences University DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant/Research none 1 What I am Talking About

More information

Expanding the treatment options of Superficial vein thrombosis with Rivaroxaban

Expanding the treatment options of Superficial vein thrombosis with Rivaroxaban Expanding the treatment options of Superficial vein thrombosis with Rivaroxaban Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, School of Health

More information

EXTENDING VTE PROPHYLAXIS IN ACUTELY ILL MEDICAL PATIENTS

EXTENDING VTE PROPHYLAXIS IN ACUTELY ILL MEDICAL PATIENTS EXTENDING VTE PROPHYLAXIS IN ACUTELY ILL MEDICAL PATIENTS Samuel Z. Goldhaber, MD Director, VTE Research Group Cardiovascular Division Brigham and Women s Hospital Professor of Medicine Harvard Medical

More information

CANCER ASSOCIATED THROMBOSIS. Pankaj Handa Department of General Medicine Tan Tock Seng Hospital

CANCER ASSOCIATED THROMBOSIS. Pankaj Handa Department of General Medicine Tan Tock Seng Hospital CANCER ASSOCIATED THROMBOSIS Pankaj Handa Department of General Medicine Tan Tock Seng Hospital My Talk Today 1.Introduction 2. Are All Cancer Patients at Risk of VTE? 3. Should All VTE Patients Be Screened

More information

DOACs in CAT. Fellow: Shweta Jain, MD Faculty Discussant: David Garcia, MD

DOACs in CAT. Fellow: Shweta Jain, MD Faculty Discussant: David Garcia, MD DOACs in CAT Fellow: Shweta Jain, MD Faculty Discussant: David Garcia, MD Case 65 year old post menopausal female Left breast lesion Oct 2015 Biopsy Invasive ductal carcinoma Lumpectomy with SNB- pt1cno

More information

Outpatient Treatment of Deep Vein Thrombosis with Low Molecular Weight Heparin (LMWH) Clinical Practice Guideline August 2015

Outpatient Treatment of Deep Vein Thrombosis with Low Molecular Weight Heparin (LMWH) Clinical Practice Guideline August 2015 Outpatient Treatment of Deep Vein Thrombosis with Low Molecular Weight Heparin (LMWH) Clinical Practice Guideline August 2015 General Principles: There is compelling data in the medical literature to support

More information

incidence of cancer-associated thrombosis (CAT) is further increased by additional risk factors such as chemotherapeutic 2

incidence of cancer-associated thrombosis (CAT) is further increased by additional risk factors such as chemotherapeutic 2 CANCER ASSOCIATED THROMBOSIS TREATMENT Patients with cancer are at a greater risk of developing venous thromboembolism than non-cancer patients, partly due to the ability of tumour cells to activate the

More information

Perioperative Management of the Anticoagulated Patient

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 information

The Evidence Base for Treating Acute DVT

The Evidence Base for Treating Acute DVT The Evidence Base for Treating Acute DVT Mr Chung Sim Lim Consultant Vascular Surgeon and Honorary Lecturer Royal Free London NHS Foundation Trust and University College London NIHR UCLH Biomedical Research

More information

Updates in Medical Management of Pulmonary Embolism and Deep Vein Thrombosis. By: Justin Youtsey, Elliott Reiff, William Montgomery, Grant Finlan

Updates in Medical Management of Pulmonary Embolism and Deep Vein Thrombosis. By: Justin Youtsey, Elliott Reiff, William Montgomery, Grant Finlan Updates in Medical Management of Pulmonary Embolism and Deep Vein Thrombosis By: Justin Youtsey, Elliott Reiff, William Montgomery, Grant Finlan Objectives Describe the prevalence of PE and DVT as it relates

More information

Treatment Options and How They Work

Treatment Options and How They Work Treatment Options and How They Work Robin Offord Director of Clinical Pharmacy UCL Hospitals NHS Foundation Trust robin.offord@uclh.nhs.uk Introducing the term anticoagulant... What they do Inhibit the

More information

Anticoagulation Forum: Management of Tiny Clots

Anticoagulation Forum: Management of Tiny Clots Anticoagulation Forum: Management of Tiny Clots Casey O Connell, MD FACP Associate Professor Jane Anne Nohl Division of Hematology Keck School of Medicine USC DISCLOSURES None 4/11/2017 Objectives Define

More information

Patients with cancer are at a greater risk of developing venous thromboembolism than non-cancer patients, partly due to the 1

Patients with cancer are at a greater risk of developing venous thromboembolism than non-cancer patients, partly due to the 1 CANCER ASSOCIATED THROMBOSIS TREATMENT Patients with cancer are at a greater risk of developing venous thromboembolism than non-cancer patients, partly due to the 1 ability of tumour cells to activate

More information

Deep Vein Thrombosis

Deep Vein Thrombosis Deep Vein Thrombosis from NHS (UK) guidelines Introduction Deep vein thrombosis (DVT) is a blood clot in one of the deep veins in the body. Blood clots that develop in a vein are also known as venous thrombosis.

More information

When and How to Use the Newly Approved Oral Anticoagulants to Treat Acute Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Ian del Conde, MD

When and How to Use the Newly Approved Oral Anticoagulants to Treat Acute Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Ian del Conde, MD When and How to Use the Newly Approved Oral Anticoagulants to Treat Acute Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Ian del Conde, MD December 12, 2015 Disclosures CONSULTANT Merck; New Haven

More information

Direct oral anticoagulants to prevent VTE recurrence: full or reduced dosage? MA Sevestre CHU Amiens

Direct oral anticoagulants to prevent VTE recurrence: full or reduced dosage? MA Sevestre CHU Amiens Direct oral anticoagulants to prevent VTE recurrence: full or reduced dosage? MA Sevestre CHU Amiens Faculty disclosure Marie Antoinette Sevestre I disclose the following financial relationships: Paid

More information

Status of anticoagulation therapy in 2016: Is there a need for venous revascularization?

Status of anticoagulation therapy in 2016: Is there a need for venous revascularization? Status of anticoagulation therapy in 2016: Is there a need for venous revascularization? Rupert M. Bauersachs Dept. of Vascular Medicine, Darmstadt Center of Thrombosis Hemostasis, Mainz Status of anticoagulation

More information

10/8/2012. Disclosures. Making Sense of AT9: Review of the 2012 ACCP Antithrombotic Guidelines. Goals and Objectives. Outline

10/8/2012. Disclosures. Making Sense of AT9: Review of the 2012 ACCP Antithrombotic Guidelines. Goals and Objectives. Outline Disclosures Making Sense of AT9: Review of the 2012 ACCP Antithrombotic Guidelines No relevant conflicts of interest related to the topic presented. Cyndy Brocklebank, PharmD, CDE Chronic Disease Management

More information

Objectives. Venous Thromboembolism (VTE) Prophylaxis. Case VTE WHY DO IT? Question: Who Is At Risk?

Objectives. Venous Thromboembolism (VTE) Prophylaxis. Case VTE WHY DO IT? Question: Who Is At Risk? Objectives Venous Thromboembolism (VTE) Prophylaxis Rishi Garg, MD Department of Medicine Identify patients at risk for VTE Options for VTE prophylaxis Current Recommendations (based on The Seventh ACCP

More information

VTE ACHIEVEMENTS AND CHALLENGES: 2012 AND BEYOND Samuel Z. Goldhaber, MD Director, VTE Research Group Cardiovascular Division Brigham and Women s

VTE ACHIEVEMENTS AND CHALLENGES: 2012 AND BEYOND Samuel Z. Goldhaber, MD Director, VTE Research Group Cardiovascular Division Brigham and Women s VTE ACHIEVEMENTS AND CHALLENGES: 2012 AND BEYOND Samuel Z. Goldhaber, MD Director, VTE Research Group Cardiovascular Division Brigham and Women s Hospital Professor of Medicine Harvard Medical School October

More information

Diagnosis and Management of Venous Thromboembolism

Diagnosis and Management of Venous Thromboembolism Diagnosis and Management of Venous Thromboembolism Muhammad Sajid Pervaiz Consultant Haematologist Chairman VTE committee Pennine Acute Hospitals NHS trust TOPICS 1-Introduction (Seriousness of problem)

More information

Cancer Associated Thrombosis: six months and beyond. Farzana Haque Hull York Medical School

Cancer Associated Thrombosis: six months and beyond. Farzana Haque Hull York Medical School Cancer Associated Thrombosis: six months and beyond Farzana Haque Hull York Medical School Disclosure I have no disclosure The Challenge of Anticoagulation in Patients with Venous Thromboembolism and Cancer

More information

Duration of Anticoagulant Therapy. Linda R. Kelly PharmD, PhC, CACP September 17, 2016

Duration of Anticoagulant Therapy. Linda R. Kelly PharmD, PhC, CACP September 17, 2016 Duration of Anticoagulant Therapy Linda R. Kelly PharmD, PhC, CACP September 17, 2016 Conflicts of Interest No conflicts of interest to report Objectives At the end of the program participants will be

More information

SESSION 4 12:45 2:15 PM

SESSION 4 12:45 2:15 PM SESSION 4 12:45 2:15 PM Pulmonary Embolism Update SPEAKER Gregory Piazza, MD, MS Presenter Disclosure Information The following relationships exist related to this presentation: Gregory Piazza, MD, MS:

More information

A VENOUS THROMBOEMBOLISM (VTE) TOWN HALL: Answering Your Top Questions on Treatment and Secondary Prevention

A VENOUS THROMBOEMBOLISM (VTE) TOWN HALL: Answering Your Top Questions on Treatment and Secondary Prevention A VENOUS THROMBOEMBOLISM (VTE) TOWN HALL: Answering Your Top Questions on Treatment and Secondary Prevention This handout is a supplemental resource to an educational video activity released on Medscape

More information

Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis (Review)

Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis (Review) Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis (Review) Robertson L, Kesteven P, McCaslin JE This is a reprint of a Cochrane review, prepared and

More information

Vascular Protection: Preventing Thrombotic Complications of VTE and PAD

Vascular Protection: Preventing Thrombotic Complications of VTE and PAD Vascular Protection: Preventing Thrombotic Complications of VTE and PAD Thursday, October 11, 2018, 2:00pm ET Guest Speakers: Geoff Barnes, MD Scott Damrauer, MD Moderators: Tracy Minichiello, MD; Sara

More information

UC SF. Division of General Internal Medicine UNIVERSITY OF CALIFORNIA SAN FRANCISCO, DIVISION OF HOSPITAL MEDICINE

UC SF. Division of General Internal Medicine UNIVERSITY OF CALIFORNIA SAN FRANCISCO, DIVISION OF HOSPITAL MEDICINE Updates in the Management of Venous Thromboembolism Margaret C. Fang, MD, MPH Associate Professor of Medicine UCSF Division of Hospital Medicine Medical Director, Anticoagulation Clinic Venous Thromboembolism

More information

Changing the Ambulatory Training Paradigm: The Design and Implementation of an Outpatient Pulmonology Fellowship Curriculum

Changing the Ambulatory Training Paradigm: The Design and Implementation of an Outpatient Pulmonology Fellowship Curriculum Online Data Supplement Changing the Ambulatory Training Paradigm: The Design and Implementation of an Outpatient Pulmonology Fellowship Curriculum Stacey M. Kassutto, C. Jessica Dine, Maryl Kreider, Rupal

More information

New Developments in VTE Treatment

New Developments in VTE Treatment Disclosures: Accommodation at this meeting funded by Boehringer Investigator in phase III studies of Rivaroxiban, Dabigatran, Edoxaban New Developments in VTE Treatment GPCME meeting, August, Dunedin Dr

More information

Approach to Thrombosis

Approach to Thrombosis Approach to Thrombosis Theera Ruchutrakool, M.D. Division of Hematology Department of Medicine Siriraj Hospital Faculty of Medicine Mahidol University Approach to Thrombosis Thrombosis: thrombus formation

More information

This chapter will describe the effectiveness of antithrombotic

This chapter will describe the effectiveness of antithrombotic Antithrombotic Therapy for Venous Thromboembolic Disease The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Harry R. Büller, MD, Chair; Giancarlo Agnelli, MD; Russel D. Hull, MBBS,

More information

Disclosures. Practical Considerations for Anticoagulation for Prevention of Venous Thromboembolism and Stroke Due to Atrial Fibrillation

Disclosures. Practical Considerations for Anticoagulation for Prevention of Venous Thromboembolism and Stroke Due to Atrial Fibrillation 12:45 1:45 pm Practical Considerations for Anticoagulation for Prevention of Venous Thromboembolism and Stroke Due to Atrial Fibrillation SPEAKER Christian Ruff, MD, MPH Presenter Disclosure Information

More information

DIRECT ORAL ANTICOAGULANTS: WHEN TO USE, WHICH TO CHOOSE AND MANAGEMENT OF BLEEDING

DIRECT ORAL ANTICOAGULANTS: WHEN TO USE, WHICH TO CHOOSE AND MANAGEMENT OF BLEEDING DIRECT ORAL ANTICOAGULANTS: WHEN TO USE, WHICH TO CHOOSE AND MANAGEMENT OF BLEEDING KATHERINE STIRLING CONSULTANT PHARMACIST ANTICOAGULATION AND THROMBOSIS DR LISHEL HORN CONSULTANT HAEMATOLOGIST HAEMOSTASIS

More information

Deep Vein Thrombosis and Pulmonary Embolism: Patient Information

Deep Vein Thrombosis and Pulmonary Embolism: Patient Information Deep Vein Thrombosis and Pulmonary Embolism: Patient Information A Deep Vein Thrombosis (DVT) and a Pulmonary Embolism (PE) are both disorders of unwanted blood clotting. Unwanted blood clots can occur

More information

Cancer Associated Thrombosis An update.

Cancer Associated Thrombosis An update. Cancer Associated Thrombosis An update. Simon Noble Marie Curie Professor of Supportive and Palliative Medicine Marie Curie Palliative Care Research Centre Cardiff University The coagulation pathway LIQUID

More information

The spectrum of clinical outcome of PE

The spectrum of clinical outcome of PE Practical treatment approach for patients with PE Cecilia Becattini University of Perugia The spectrum of clinical presentation of PE PE-related shock Mild clinical symptoms The spectrum of clinical outcome

More information

Venous Thromboembolism Prophylaxis

Venous Thromboembolism Prophylaxis Approved by: Venous Thromboembolism Prophylaxis Vice President and Chief Medical Officer; and Vice President and Chief Operating Officer Corporate Policy & Procedures Manual Number: Date Approved January

More information