auto anti-coagulation and vte prophylaxis
DESCRIPTION
Auto Anti-coagulation and VTE Prophylaxis. Hilary Rowe, BScPharm VIHA Pharmacy Resident 2009-10 Internal Medicine Rotation November 5th, 2009. Outline. Objectives Patient Case Background Clinical Question Review of Evidence Recommendation Monitoring. Objectives. - PowerPoint PPT PresentationTRANSCRIPT
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Auto Anti-coagulation and VTE Prophylaxis
Hilary Rowe, BScPharm
VIHA Pharmacy Resident 2009-10
Internal Medicine Rotation
November 5th, 2009
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Outline
• Objectives
• Patient Case
• Background
• Clinical Question
• Review of Evidence
• Recommendation
• Monitoring
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Objectives
• Review pathophysiology for auto anti-coagulation & clinical presentation
• Discuss evidence of auto anti-coagulation• Discuss therapeutic options for VTE
prophylaxis
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Mr. JE
• ID: 33 yo Caucasian male, ht 170cm, wt 55kg
• CC: ER by ambulance Sept 1/09 for weakness & falls-jaundice, ascites
• HPI Oct 19/09: Small esophageal varices, ascites
• PMHx: chronic lower back pain, alcohol abuse x 14 years
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Mr. JE
• Meds PTA: None
• Allergies: None
• SH: Homeless, estranged from family, smoker (30 pack yr hx), drinks 26 oz (780mL) vodka a day x 14 yrs
• Discharge Plan: To family
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Review of Systems
System Findings Medications
CNS •Alert and Oriented x 3•Difficulty sleeping in hospital
Zopiclone 3.75 mg at hs prn
HEENT Unremarkable
Psych Anxiety, headache, seizures CIWA protocol
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Review of Systems
System Findings Medications
Resp Unremarkable
Cardio Unremarkable
GI •No hematemesis, •FOB neg x 3•Endoscopy small esophageal varices
Nadolol 40mg od
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Review of Systems
System Findings Medications
Liver •Alcoholic liver cirrhosis•Ascites•Negative paracentesis cultures
•Furosemide 100mg daily•Spironolactone 100mg bid
GU •SrCr 76 •CrCl 95ml/min
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Review of Systems
System Findings Medications
Heme •↓ Hgb 101, MCV 98, ↑ RDW 21.4, ↓ Plt 92•Iron 8 ↓ , ferritin 50, B12 535, RBC folate 1134•↑ INR 1.9, ↑ Tbili 361, ↓Alb 25, ↑ GGT 78, ALP 129, ↑ AST 81
•Fe fumarate 600mg at hs•Multivitamin daily
Fluids & Lytes
↓ Na 125, K+ 4.3, ↓ Cl 89
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Medical Problems List
• Alcohol addiction
• Alcoholic cirrhosis
• Ascites
• Esophageal varices
• Anemia of chronic disease & iron deficiency anemia
• Chronic lower back pain
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DRP’s
• JE is at increased risk of COPD, CVD and cancer secondary to smoking, requiring tobacco cessation counseling
• JE has a mixed anemia secondary to iron deficiency and anemia of chronic disease, requiring monitoring of his anemia therapy
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DRP’s
• JE is at an increased risk of VTE requiring assessment of his need for DVT prophylaxis despite his elevated INR of 1.9
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Alcoholic Liver Cirrhosis
• Decrease in pro-coagulants– Can’t make II, VII, IX, X
• Decrease in anti-coagulants– Can’t make Protein C, S & antithrombin III
• PT & INR measures activity of pro-coagulants and doesn’t capture changes in anti-coagulants
• PT does not predict bleeding risk
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Risk Factors For VTE
• Recent surgery or major trauma • Immobility or paralysis • Malignancy • Previous VTE • >80 years • Smoking• Varicose veins • Inherited or acquired thrombophilia
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Rounds
• Team discussed that patient had been in hospital for a significant amount of time and might need VTE prophylaxis
• Team wanted to know if his elevated INR of 1.9 would protect him?
CTU Discussion
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Clinical Question
P33 year old male with an elevated INR secondary to alcoholic liver disease
I VTE Prophylaxis
C No VTE Prophylaxis
O
Reduce the risk of DVT and PE
Reduce morbidity and mortality
Decrease hospitalization
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Search Strategy
• PubMed, Embase, Google• Search terms:
– Liver cirrhosis– Risk of Thromboembolism– DVT, Pulmonary embolism– Auto anticoagulation
• Found– 2 retrospective case control studies
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Northup et al. Am J Gastroenterol 2006
DesignRetrospective matched case control study 1993-2001
P•Patients from all admissions (medical, ICU, surgical) with cirrhosis assessed for diagnosis of VTE during hospitalization
I•Patients with an elevated prothrombin time and INR from cirrhosis with a VTE
C•Patients with an elevated prothrombin time and INR from cirrhosis without a VTE
O•VTE in cirrhosis patients: DVT, PE & both•Serum albumin
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Northup et al. Am J Gastroenterol 2006
Inclusion & exclusion:•Patients from all admissions, (medical, ICU, surgical) with cirrhosis assessed for diagnosis of VTE during hospitalization•Matched with a cirrhotic patient with the same gender, age, race, # comorbidities, presence of cancer, occurrence & type of surgery•Excluded if previous VTE or portal vein, splanic vein, mesenteric vein or central line VTE
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Northup et al. Am J Gastroenterol 2006
•Lower albumin in patients with VTE
*38-53g/L normal, 1g/dL=10g/L
•Elevated INR did not protect patients from VTE
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Northup et al. Am J Gastroenterol 2006
Results:•VTE in cirrhosis patients 113/21,000 (0.5%)
-74/113 (65.5%) DVT
-22/113 (19.5%) PE
-17/113 (15%) Both DVT & PE
-Serum albumin independently predicts VTE (p<0.001, OR 0.24 95% CI 0.10-0.55)
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Northup et al. Am J Gastroenterol 2006
Limits:•Retrospective•No “gold standard” for VTE diagnosis so events could have gone undetected•Small sample size = higher type II error•Factors that may have been unmatched•21% had prophylaxis (33% medically, rest SCD’s)•Did not discuss # in each group who got prophylaxis
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Northup et al. Am J Gastroenterol 2006
Conclusions• Deficiencies of antithrombin III, protein C &
protein S are associated with ↑ risk of VTE• Serum albumin may be indicator for level of
proteins made by liver such as Antithrombin III, protein C & S
↑ INR does not decrease risk of VTE
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Sogaard et al. Am J Gastroenterol 2009
Design Retrospective case control study 1980-2005
P•Patients with a discharge diagnosis of DVT or PE
I •Patients that developed a VTE
C •Patients that didn’t develop a VTE
O•Assessed association between liver disease & overall risk of VTE and unprovoked VTE
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• Unprovoked VTE=patient without diagnosis of cancer before or within 90 days of VTE, or diagnosis of fracture, trauma, surgery, pregnancy 90 days before VTE
• Each case matched with 5 population controls without a VTE by age, gender, county
• Patients with several VTE’s had their first event used
Sogaard et al. Am J Gastroenterol 2009
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Sogaard et al. Am J Gastroenterol 2009
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Results• 20% (99,444/496,872) had a VTE• 22% (67,519/308,614) had unprovoked VTE
Sogaard et al. Am J Gastroenterol 2009
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Limits
• Retrospective
• Relied on coding of Danish nationwide registry for diagnosis of VTE
• No data on lifestyle factors
• Declining risk of VTE in past 10 years– Is this due to prophylaxis?
Sogaard et al. Am J Gastroenterol 2009
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Conclusion
• Both cirrhotic and non-cirrhotic liver disease are risk factors for VTE
Sogaard et al. Am J Gastroenterol 2009
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Goals of Therapy
Patients Goals• Abstinent from alcohol
Team Goals• Prevent VTE• Prevent hospitalization• Decrease morbidity & mortality• Minimize adverse drug events• Keep patient abstinent (quality of life)• Find housing (quality of life)
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Therapeutic Options
•No DVT prophylaxis
•Sequential compression devices
•Heparin 5000 units sc bid
•Dalteparin 5000 units sc daily
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Recommendation
• Dalteparin 5000 units subcutaneous daily• Try to mobilize patient as soon as possible• Initiate smoking cessation counseling
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Monitoring
Adverse Events
Monitor Who When How Long
Pain & bruising at inj site
Patient After inj Daily while on therapy
Bleeding-in urine, bowel, nose etc.
Patient & nurse
Daily-after urination, bowel movements etc.
Daily while on therapy
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Monitoring
Efficacy
Monitor Who When How Long
Shortness of breath
Patient & Physician
Daily Duration of therapy
Pain in the legs
Patient & Physician
Daily Duration of therapy
Redness & Swelling in legs
Patient & Physician
During physical exam
Duration of therapy
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summary
Question: Does elevated INR protect patient from a VTE?
Answer:• ↑ INR does not decrease risk of VTE• ↓ albumin independently predicts VTE risk
Future:• Study VTE prophylaxis in this population &
predict benefit & risk of bleed
Summary
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Questions?
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References
• Northup PG, McMahon MM, Ruhl AP et al. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboebolism. Am J Gastroenterol 2006;101:1523-28.
• Sogaard KK, Horvath-Puho E, Gronbaek H et al. Risk of venous thromboembolism in patients with liver disease: a nationwide population-based case-control study. Am J Gastroenterol 2009;104:96-101.