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DVT Prophylaxis of DVT Prophylaxis of the Medical the Medical Patient Patient Nicole Artz, MD Nicole Artz, MD David Lovinger, MD David Lovinger, MD August, 2006 August, 2006

DVT Prophylaxis of the Medical Patient Nicole Artz, MD David Lovinger, MD August, 2006

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Text of DVT Prophylaxis of the Medical Patient Nicole Artz, MD David Lovinger, MD August, 2006

  • DVT Prophylaxis of the Medical PatientNicole Artz, MDDavid Lovinger, MDAugust, 2006

  • CaseMr. Smith- 71 y/o man admitted to general medicine ward service.HPI: gradually increased sob over 3 days assoc. with new productive cough, rhinorrhea, and fatigue.PMH: COPD, CHF (LVEF 35%), CRI (creat 2.5)ROS: No h/o DVT/PE.PE: VSS with SPO2 93% on RABarrel chested, b/l expiratory wheezes, prolonged expiratory phase,CXR: hyperexpanded, no infiltrate, consolidation or edema. DX: COPD Exacerbation

  • Does this man need DVT prophylaxis?Why worry about VTE in inpatients?What is the prevalence of DVT/PE in hospitalized medical patients?Is this man at risk for venous thromboembolism?What are effective methods of prophylaxis?What adjustments need to be made based on his history of renal insufficiency?

  • ImportanceWhat % of all hospital related deaths due to fatal PE?7-10%What % of these pts had NO premorbid symptoms?70-90%200,000 potentially preventable annual deaths due to PE in the USSandler DA JR Soc Med 1989; 82, Lindblad B Br Med J 1991; 302.

  • Prevalence in Medical Pts3 large-scale randomized studies (5500 medically ill patients) DVT identified w/ screening studiesPatients receiving no prophylaxis:VTE 11-15% of patientsProximal DVT- 4-5% of patientsRates similar to moderate-high risk general surgery patients.Samana, MM NEJM, 1999; Leizorovicz, A Circulation 2004; Cohen, AT J Thromb Haemost, 2003.

  • PrevalenceACCP Guidelines, Chest. 2005.

  • PrevalencePendleton, R. Amer J. Hematology 2005.

  • Prevalence3 out of 4 hospital pts dying from PE have NOT had recent surgery2.5% of medical patients immobilized with multiple clinical problems suffer fatal PE.National DVT Free Registry60% of patients dx with acute DVT were in the peri-hospitalization period60% of cases were in non-surgical patients!

    Haas, S. Seminars in Thrombosis and Haemostasis, 2002; Goldhaber, SZ Am J Cardiol 2004.

  • Risk FactorsHeterogeneous population!Need to consider:Acute medical condition (MI, pneumonia, etc.)Underlying risk factors (h/o VTE, estrogen use, etc.)Medical interventions (central venous catheters, chemotherapy, etc.)Relative contribution of various risk factors still being defined.

  • Risk FactorsAcute medical conditions well accepted as high risk:MI (24% VTE risk)Decompensated CHF (40% VTE risk)Acute Stroke (30-75% VTE risk) Spinal Cord Injury (up to 100%)MICU admission (13-33*% VTE risk, * of these were proximal leg vein thromboses)Central venous catheters (25-46% VTE risk)MalignancyHaas, S. Seminars in Thrombosis and Hemostasis, 2002; Pendleton, Amer J Hematology, 2005.

  • Abstracted from Pendleton, R. Amer J Hemat 2005.

  • Current Rates of ProphylaxisIMPROVE studyOngoing multinational observational cohort study in acutely ill medical patientsOnly 34% of potentially at risk patients are receiving any prophylaxis!Only of patients who would have met criteria used for MEDENOX study received any VTE prophylaxis.

    Anderson FA, IMPROVE; Blood 2003.

  • Current Rates of ProphylaxisUniversity of UtahPre and post intervention studyPts stratified into high and low risk groups based on risk factorsPre-intervention group75% of patients admitted to medical service were high riskOnly 43% received prophylaxis of any type.Stinnett, J American Journal of Hematology 2005.

  • How Are We Doing at UCH?Retrospective chart review by Linda Nahlik, Pharm-D, 2005.98 pts admitted to gen med service NOT on therapeutic anticoagulation.20% of pts had a contraindication to prophylaxis (active bleeding)Only 4% had no risk factors for prophylaxis29% of pts had 1 major or 2 minor risk fxs, no contraindications, and yet had NO prophylaxis.

  • What Should We Use for Prophylaxis?Mechanical compression devices? (compression stockings, IPC devices)Unfractionated heparin BID?Unfractionated heparin TID?Low Molecular Weight Heparin? (Enoxaparin, Daltaparin)Fondaparinux?

  • What Do We Know About Prophylaxis?What are the most common regimens in the US? UFH BID, mechanical compression devicesWhich regimens have the least data to support them?UFH BID, mechanical compression devicesWhat are characteristics of the ideal prophylaxis regimen?EffectiveSafeCost-effective

  • Key VTE Prevention TrialsPendleton, R. Amer J. Hemat. 2005**MEDENOX study included 20 mg enoxaparin arm which was no more effective than placebo.

  • *Remember that MEDENOX found enoxaparin 20 mg no more effective than placebo, therefore calling into doubt efficacy of bid heparin dosing.

  • Complications of ProphylaxisBleedingMajor bleeding rates no different from placebo in major trials w/ enoxaparin, dalteparin, and fondaparinux (rates 0.2-1.7%)HITDevelops in 1.4% of medically ill pts exposed to preventive doses of UFH.Potentially catastrophic- thrombosis rates as high as 60%.LMWHs 8-10Xs less likely to cause HIT.Fondaparinux does not cause HIT.Girolami, B. Blood 2003; Warkentin TE, Br J Haematol 2003. Pendleton, R. Am J Hematol 2005.

  • Special PopulationsObesityRenal InsufficiencyElderly

  • ObesityAnti Xa levels with fixed dose LMWH regimens correlate negatively with BMI in critically ill patients. (Priglinger U, 2003)Standard prophylactic regimens twice as likely to fail in orthopedic pts with BMI >32.BMI >32 VTE rate 32% vs 17% for BMI
  • Renal InsufficiencyDelayed renal clearance of LMWHs and Fondaparinux problematic.Lack of outcomes based data.FDA approved enoxaparin 30 mg qd for pts with creat clearance
  • Patients with HITAvoid UFH or LMWHs.? Fondaparinux? Trials ongoing. Mechanical compression devices +/- duplex US surveillance.

  • Elderly PatientsMahe et al. monitored anti-Xa levels in 68 consecutive hospitalized elderly patients (mean age 82) receiving enoxaparin for prophylaxis.By day 2 over half had levels in the therapeutic range.Lack of safety data with use of UFH as well.Lack of outcomes data.Consider empiric dose reduction or use of mechanical devices alone for elderly patients with low body weight and/or marginal creatinine clearance (30-60 ml/min).

    Mahe, I, Pathophysiol Haemost Thromb 2002., Pendleton R, Am J Hemat 2005.

  • Take Home PointsThe majority of hospitalized medical patients are at increased risk for VTE.In the absence of contraindicatons, prophylaxis should be provided for patients based on assessment of risks.Safe and Effective preventive regimens include:Enoxaparin 40 mg SC dailyDaltaparin 5000 IU SC dailyFondaparinux 2.5 mg sc dailyUFH 5000 units SC every 8hrs*Must use clinical judgement for unique patient groups with lack of data.