Professional Practice Minutes December 7, 2016

Transcription

1 Professional Practice Minutes December 7, 2016 **New Opportunity for Patient Education** We can now request the educational videos we want our patients to watch after our visit. Video topics include colon health, flu vaccination, bladder control, exercise, and more Videos are all less than 4 minutes, 3 rd grade and below literacy level, Spanish/English Green forms are in the patient rooms o Fill out which educational videos you would like the patients to watch On the Facesheet Write Theo and whichever video you selected for them Please stop by the waiting room if you d like to watch a video to see what is in it ***Who Should be on Aspirin?*** Age 50-59, greater or equal to 10% cardiac risk with a life expectancy of 10 years using the ASCVD risk calculator, a low dose aspirin is suggested same determinants but discussion is suggested before starting 1. Anticoagulation Agents a. Atrial fibrillation is the most common cardiac arrhythmia. It increases a patient risk of stroke by 5 times. Anticoagulation reduces the risk of stroke by two thirds. Today we will review the new oral anticoagulants and discuss the best evidence based approach to treating CVIM patient with atrial fibrillation. b. CVIM Anticoagulant Formulary i. Warfarin (Coumadin) vitamin K antagonist ii. Apixaban (Eliquis) iii. Rivaroxaban (Xarelto) iv. Dabigatran (Pradaxa) direct thrombin inhibitor 2. Anticoagulation Pathway

2 Coagulation Cascade Tip: To draw the coagulation cascade remember: It's like the Olympics with the goal of reaching X. Start counting down from the left 12, 11, (10 is already there) 9, 8. Put 7 on the right side. Below X factor to get 5 * 2 * 1 is ten. The left side has more factors so you can remember it has more letters and that's where HEP works and it's measure by PTT. The right side has fewer factors so put PT there. To remember the vitamin K favors remember that 2+7=9 +1=10. So HEP 8 7 PT PTT X Warfarin (Coumadin) a. Class: Vitamin K antagonist b. Dosing: 2-10 mg daily i. Duration varies based on indication, in VTE # of episodes c. Dosing adjustments: none d. Drug interactions: many e. Warnings: bleeding risk f. Monitoring: i. INR at baseline, then after 2-3 doses, then 2x/week until target INR, then weekly, then every other week, then monthly (target range depends on indication; 2-3.5) g. Reversal: i. Vitamin K, if life threatening use PCC (Kcentra), FFP, rfviia

3 4. Factor Xa Inhibitors a. Apixiban(Eliquis) i. Dosing: 1. Nonvalvular a-fib 5mg BID 2. DVT/PE 10 mg BID x7 days, then 5mg BID 3. Post-op (hip/knee) 2.5mh BID 12-24hrs post-op x 35 days for hip, 12 days for knee ii. Dosing Adjustments 1. If 2 or more: a. Older than 80 b. heavier than 60kg c. SCr>1.5 use 2.5 mg BID iii. Drug Interactions: 1. CYP3A4 inducers and inhibitors iv. Warnings: 1. Risk of thrombotic events if premature discontinuation 2. Risk of spinal/epidural hematoma with neuraxial anaesthesia or spinal puncture 3. Risk of bleeding. Medications for reversal still in trials. v. Monitoring: 1. Renal function (baseline and annual), hepatic function, signs of bleeding 2. No routine coagulation monitoring tests b. Rivaroxaban (Xarelto) i. Dosing: 1. Nonvalvular a-fib 20 mg once daily with evening meal 2. DVT/PE 15mg BID with food x 21 days, then 20mg once daily 3. Post-op(knee/hip) 10mg once daily x35 for hip, 12 days for knee ii. Dose adjustments: 1. Renal: CrCl ml/min 15 mg qd

4 2. Hepatic: avoid use in Child-Pugh class B or C 3. Geriatric: none iii. Drug Interactions: 1. CYP3A4 inducers and inhibitors iv. Warnings: 1. Not recommended for patients with a BMI >40 2. Risk of thrombotic events if premature discontinuation 3. Risk of spinal/epidural hematoma with neuraxial anaesthesia or spinal puncture 4. Risk of bleeding. Medications for reversal still in trials. v. Monitoring: 1. CBC with differential, renal function (baseline and annual), hepatic function 2. No routine coagulation monitoring tests 5. Reversal of Factor Xa inhibitors a. Prothrombin complex concentrate (PCC) i. Showed reversal of rivaroxaban in humans b. Activated prothrombin complex concentrate (apcc) i. In vitro study showed apcc = rfviia > PCC c. Recombinant factor VIIa (rfviia) i. Decreased bleeding time in animal models ii. Does not reverse anticoagulant effect of rivaroxaban d. 4-factor PCC recommended for life-threatening bleeding 6. Direct Thrombin Inhibitors a. Pradaxa (Dabigitran) i. Dosing: 1. Nonvalvular a-fib 150mg BID 2. DVT/PE 150mg BID

5 3. Post-op(hip/knee) 110mg 1-4 hours post-op, then maintain 220mg once daily x days (hip replacement only) ii. Dosing adjustments: 1. Renal: CrCl < 30 ml/min 2. Hepatic: none 3. Geriatric: no adjustments, but use with extreme caution in patients > 75 y/o iii. Drug interactions: PGP substrates iv. Warnings: 1. Risk of thrombotic events if premature discontinuation 2. Risk of spinal/epidural hematoma with neuraxial anesthesia or spinal puncture v. Monitoring: no routine monitoring required vi. Reversal: 1. Praxbind (Idarucizumab), activated charcoal if recent intake, HD 7. Evidence Based Research on DOACs a. Overview i. There are high quality, industry funded, trials with patient centered outcomes suggesting that DOACs do a better job of preventing stroke and MI while also causing less bleeding than warfarin in patients with non valvular atrial fibrillation. b. Major named trials i. Trails performed by manufacturers which make up a majority of the evidence base for DOACs, including meta0analyses 1. RE-LY Dabigatran 2009, N = 19, ROCKET-AF Rivaroxaban 2011, N = 14, ARISTOTLE Apixaban 2011, N = 18, ENGAGE AF-TIMI48 Edoxaban 2013, N = 21,105

6 c. Efficacy and Safety of the Novel Oral Anticoagulants in Atrial Fibrillation. Dentali et al. Circulation. 2012;126; i. Meta analysis which tells us that the number of patients needed to treat to save one life is patients from warfarin over to a DOAC, to prevent one episode eof major bleeding we need to switch patients. d. Coparision of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta analysis of randomized trials. Ruff et al. The Lancet, 2013; Vol.383 No.9921: i. Found similar benefits and harms with the only major difference being that DOACs are associated with increased risk for GI bleeding as compared to warfarin. 8. Practical Pointers a. History of GI Bleeding Apixaban has a reduced tendency to cause GI Bleeding b. None of these drugs are indicated for Creatinine Clearance less than 30 c. When switching from warfarin to NOAC, wait 48 hours and check INR, once <2 can start d. When switching from NOAC to warfarin, discontinue NOAC once INR >2 9. Expense a. The cash cost of a 30 day supply data from one pharmacy per GoodRx.com as reported on MedPage Today i. $16 for generic warfarin 2 or 5 mg once daily ii. $383 for rivaroxaban 20 mg once daily iii. $400 for apixaban 5 mg twice daily iv. $373 for dabigatran 150 mg twice daily 10. Renal Dosing a. Dabigatran CrCl mg BID b. Rivaroxaban CrCl ml/min 15 mg qd c. Edoxaban CrCl mg daily, >50 60 mg day, >95 can cause stroke 11. Advantages of DOACs Over Warfarin a. Fixed dosing b. Fewer drug reactions c. No blood monitoring d. Bleeding risk the same 12. When to stay on Warfarin a. Already on it and controlled>65% of time b. No complaint with dosing c. cost d. chronic kidney disease e. on phenytoin and HIV protease

7 13. CVIM Treatment of Patients with A-fib a. A great phone App for the following scoring is free - MDCalc b. First determine the patients CHAS2S2-VACs score i. If 2 or greater, the patient is a candidate for anticoagulation c. Then determine the patients risk of bleeding by using the HAS-BLED score. i. If the risk is <3, then the risk of bleeding is low enough to start anticoagulants. ii. If the risk is>3, evaluate if any risk of bleeding can be changed. d. Baseline Labs i. CBC, platelet count, PT, PTT, renal and liver function

8 e. In deciding which oral anticoagulant is best for the patient from your discussion with them, consider: i. Activity level ii. Diet iii. Alcohol intake iv. Medications f. Need to evaluate patients yearly 14. Finally, we reviewed all cases of CVIM patients on anticoagulants a. 3 patients on Coumadin b. 1 patient on Pradaxa, Eliquis, and Xarelto c. After discussion, it was decided that one patient on Coumadin could be switched to a DOAC. d. One patient on Xarelto was found to be on the incorrect dose and needs to be switched to Coumadin since she is not a candidate for Xarelto through the PAP program. Happy Holidays!