Update in Hospital Medicine October 26, 2012 Amy O’Linn, D.O. Clinical Associate, Department of Hospital Medicine [email protected]

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

October 26, 2012October 26, 2012

Amy O’Linn, D.O.Amy O’Linn, D.O.

Clinical Associate, Department of Clinical Associate, Department of Hospital MedicineHospital Medicine

[email protected]@ccf.org

Fairview HospitalFairview HospitalFairview HospitalFairview Hospital450 beds450 beds

DisclosuresDisclosures

• None

MethodsMethodsMethodsMethods

• Reviewed literature (primary studies Reviewed literature (primary studies and guidelines) relevant to hospital and guidelines) relevant to hospital medicine from the past 12 monthsmedicine from the past 12 months

• Summarized most relevant studiesSummarized most relevant studies

Talk OutlineTalk Outline

• Rivaroxaban: What it is and why you need to care about it this year

• The patient’s perspective on anticoagulants

• The ACCP (Chest) Guidelines and VTE

• Hyperglycemia in the hospitalized, non-ICU patient

• Current thinking on DVT prophylaxis

• Hodge Podge

Case PresentationCase PresentationCase PresentationCase Presentation

• ED calls: 72 year old man who was ED calls: 72 year old man who was recently diagnosed with bladder cancer recently diagnosed with bladder cancer presents with acute shortness of presents with acute shortness of breath, CT PE protocol diagnoses a breath, CT PE protocol diagnoses a right sided pulmonary embolus.right sided pulmonary embolus.

Which treatment would you Which treatment would you choose?choose?


1)1) LMWH SQ to VKA (warfarin) POLMWH SQ to VKA (warfarin) PO

2)2) Long-term LMWH (enoxaparin)Long-term LMWH (enoxaparin)

3)3) Dabigatran (Pradaxa) PO aloneDabigatran (Pradaxa) PO alone

4)4) Rivaroxaban (Xarelto) PO aloneRivaroxaban (Xarelto) PO alone

5)5) Apixaban (Eliquis) PO aloneApixaban (Eliquis) PO alone

6)6) Fondaparinux (Arixtra) SQ dailyFondaparinux (Arixtra) SQ daily

7)7) Idrabiotaparinux SQ weeklyIdrabiotaparinux SQ weekly










Rivaroxaban alone to treat PERivaroxaban alone to treat PERivaroxaban alone to treat PERivaroxaban alone to treat PE

• Presented at ACC in MarchPresented at ACC in March• Randomized, open-label, event-driven, Randomized, open-label, event-driven,

noninferiority trialnoninferiority trial• 4832 patients w/ acute symptomatic PE 4832 patients w/ acute symptomatic PE • Rivaroxaban (15 mg BID x 3 weeks, Rivaroxaban (15 mg BID x 3 weeks,

followed by 20 mg qday) v. standard followed by 20 mg qday) v. standard therapy with enoxaparin --> VKA for 3, therapy with enoxaparin --> VKA for 3, 6, or 12 months6, or 12 months

Buller HR et al. NEJM 2012: 366(14), 1292.Buller HR et al. NEJM 2012: 366(14), 1292.

EINSTEIN-PE OutcomesEINSTEIN-PE OutcomesEINSTEIN-PE OutcomesEINSTEIN-PE Outcomes

Rivaroxaban Standard

Recurrent VTE- no. (%) 50 (2.1) 44 (1.8)

Major Bleeding- no. (%) 26 (1.1) 52 (2.2)

Other nonfatal in critical site- no. (%)

7 (0.3) 26 (1.1)

Clinically relevant nonmajor bleeding episode- no. (%)

228 (9.5) 235 (9.8)

Buller HR et al. NEJM 2012: 366(14), 1292.

““What about me?”What about me?”The patient’s voiceThe patient’s voice““What about me?”What about me?”The patient’s voiceThe patient’s voice

• ACCP February 2012: Antithrombotic ACCP February 2012: Antithrombotic Therapy and Prevention of Thrombosis, Therapy and Prevention of Thrombosis, 99thth edition Evidence-Based Clinical edition Evidence-Based Clinical Practice Guidelines.Practice Guidelines.

MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.

48 studies included

16 atrial fibrillation

5 VTE

4 stroke and MI prophylaxis

6 thrombolysis in acute stroke or MI

17 burden of antithrombotic treatment

One selection Summary of One selection Summary of ResultsResults

One selection Summary of One selection Summary of ResultsResults

• Arnsten et al. 1997Arnsten et al. 1997

• 132 (43 noncompliant and 89 compliant) 132 (43 noncompliant and 89 compliant) warfarin patientswarfarin patients

• Case-control studyCase-control study

• Telephone interviewsTelephone interviews

• VTE/AF prophylaxisVTE/AF prophylaxis


One selection Summary of One selection Summary of Results (cont’d)Results (cont’d)

One selection Summary of One selection Summary of Results (cont’d)Results (cont’d)

• ““53% of noncompliant and 31% of 53% of noncompliant and 31% of compliant individuals reported that compliant individuals reported that warfarin affected their lifestyle. 30% and warfarin affected their lifestyle. 30% and 15% respectively, reported that warfarin 15% respectively, reported that warfarin restricted physical activity; 49% and 30% restricted physical activity; 49% and 30% worried about bleeding complications worried about bleeding complications while taking warfarin, and 60% and 34% while taking warfarin, and 60% and 34% reported that regular blood testing was reported that regular blood testing was problematic.”problematic.”


SummarySummarySummarySummary

• Values and preferences vary from person to Values and preferences vary from person to person.person.

• Uncertain “average patient” values.Uncertain “average patient” values.• Higher disutility on stroke than GIB.Higher disutility on stroke than GIB.• Much higher disutility on stroke than treatment Much higher disutility on stroke than treatment

burden.burden.


CHEST Antithrombotic CHEST Antithrombotic Guidelines (Continued)Guidelines (Continued)CHEST Antithrombotic CHEST Antithrombotic Guidelines (Continued)Guidelines (Continued)

• Acute isolated distal DVT? Serial Acute isolated distal DVT? Serial ultrasound (Grade 2C).ultrasound (Grade 2C).

• Anticoagulate empirically if high Anticoagulate empirically if high suspicion for PE (if low suspicion, suspicion for PE (if low suspicion, can wait for test) (Grade 2C).can wait for test) (Grade 2C).

• Early ambulation in acute DVT Early ambulation in acute DVT (Grade 2C).(Grade 2C).

Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.


• Proximal DVT or PE provoked by Proximal DVT or PE provoked by surgery or nonsurgical transient RF: surgery or nonsurgical transient RF: recommend A/C x 3 months (Grade 1B).recommend A/C x 3 months (Grade 1B).

• Unprovoked proximal DVT or PE with Unprovoked proximal DVT or PE with low/mod bleeding risk: suggest low/mod bleeding risk: suggest extended A/C therapy (Grade 1B, 2B). If extended A/C therapy (Grade 1B, 2B). If high bleeding risk, then 3 mos (Grade high bleeding risk, then 3 mos (Grade 2B).2B).



• Early discharge in patients with Early discharge in patients with low-risk PE whose home low-risk PE whose home circumstances are adequate circumstances are adequate (Grade 2B).(Grade 2B).

• In cancer patients with VTE, In cancer patients with VTE, LMWH long-term recommended LMWH long-term recommended over LMWH to coumadin (Grade over LMWH to coumadin (Grade 2B).2B).











You grab a cup of coffee…You grab a cup of coffee…You grab a cup of coffee…You grab a cup of coffee…

• .. And you run into an orthopedic .. And you run into an orthopedic colleague. colleague.

• Is Rivaroxaban FDA-approved for post-Is Rivaroxaban FDA-approved for post-TKR DVT prevention?TKR DVT prevention?

1)1) YesYes

2)2) NoNo

You grab a cup of coffee…You grab a cup of coffee…You grab a cup of coffee…You grab a cup of coffee…

• Is Rivaroxaban FDA-approved for post-Is Rivaroxaban FDA-approved for post-TKR DVT prevention?TKR DVT prevention?

YESYES

Options for VTE prevention Options for VTE prevention post-TKR/THApost-TKR/THA

Options for VTE prevention Options for VTE prevention post-TKR/THApost-TKR/THA

• CoumadinCoumadin

• Low-dose Low-dose unfractionated unfractionated heparin heparin

• FondiparinuxFondiparinux• Pradaxa Pradaxa (Europe)(Europe)

• RivaroxabanRivaroxaban• Apixaban Apixaban (Europe)(Europe)

• Aspirin (reserve)Aspirin (reserve)

• Intermittent Intermittent pneumatic pneumatic compression compression

Case PresentationCase PresentationCase PresentationCase Presentation89 woman s/p R total knee replacement 89 woman s/p R total knee replacement

this morning. this morning.

Pt has h/o HTN, CKD III.Pt has h/o HTN, CKD III.

Blood sugar 250.Blood sugar 250.

Previously taking metformin at home. Previously taking metformin at home.

You are consulted for medical You are consulted for medical management. management.

What do you do?What do you do?

What’s your reaction?What’s your reaction?What’s your reaction?What’s your reaction?

1)1) You do nothing. High sugars You do nothing. High sugars have nothing to do with have nothing to do with mortality. mortality.

2)2) You add sliding scale. You add sliding scale. 3)3) Stop metformin, add long-Stop metformin, add long-

acting insulin and prandial acting insulin and prandial insulin. insulin.

4)4) Continue the metformin.Continue the metformin.

Example of Basal-bolus insulin in the Example of Basal-bolus insulin in the mgmt of non-critically ill DMII ptsmgmt of non-critically ill DMII pts


Basal Insulin

Stop oral and non-insulin injectable hypoglycemics.

Starting insulin: calculate the total daily dose as follows 0.2 to 0.3 U/kg of BW in patients: aged ≥ 70 yr and/or GFR< 60 ml/min. 0.4 U/kg of BW per day for patients not meeting the criteria above who have BG 140–200 mg/dl. 0.5 U/kg of BW per day for patients not meeting the criteria above when BG concentration is 201–400 mg/dl.

Distribute total calculated dose as approximately 50% basal insulin and 50% nutritional insulin.

Give basal insulin once (glargine/detemir) or twice (detemir/NPH) daily, at the same time each day.

Give rapid-acting (prandial) insulin in three equally divided doses before each meal. Hold prandial insulin if patient NPO.

Adjust insulin dose(s) according to the results of bedside BG measurements.

Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38..



Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38.Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38.

Supplemental rapid-acting insulin or analog

If patient is able to eat, give regular or rapid-acting insulin following “usual” column.

If patient not able to eat, give insulin following “sensitive” column every 4-6 h.

BG (mg/dL) Insulin-sensitive

Usual Insulin-resistent

>141-180 2 4 6

181-220 4 6 8

221-260 6 8 10

261-300 8 10 12

301-350 10 12 14

351-400 12 14 16

>400 14 16 18

What’s your reaction?What’s your reaction?What’s your reaction?What’s your reaction?

1)1) You do nothing. High sugars You do nothing. High sugars have nothing to do with have nothing to do with mortality. mortality.

2)2) You add sliding scale. You add sliding scale. 3)3) Stop metformin, add long-Stop metformin, add long-

acting insulin and prandial acting insulin and prandial insulin. insulin.

4)4) Continue the metformin.Continue the metformin.

Case PresentationCase PresentationCase PresentationCase Presentation

Nurse pages you: Mrs. Smith is a Nurse pages you: Mrs. Smith is a medical patient with medical patient with pyelonephritis refusing her SQ pyelonephritis refusing her SQ heparin for DVT prophylaxis.heparin for DVT prophylaxis.

The value of VTE prophylaxisThe value of VTE prophylaxisThe value of VTE prophylaxisThe value of VTE prophylaxis

Medical and Stroke patients

Heparin v. No heparin 10 trials (n=20,717) of medical patients 8 trials (N= 15,405) acute CVA pts

No difference in mortality. Heparin associated with reduced risk of PE in medical pts but increased risk of bleeding in both medical and stroke patients.

LMWH v. UFH 9 trials (n=11,650) medical pts 5 trials (n=2785) acute CVA pts

No difference in mortality or major bleeding.

Mechanical devices v. No mechanical devices

No difference in mortality.

Qaseem A, et al. Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline from the American College of Physicians. Ann InternMed; 2011; 155:625-632.

The OUTs and INsThe OUTs and INsThe OUTs and INsThe OUTs and INs

OUTOUT

• FEVFEV11 (Vestbo J et al. Global (Vestbo J et al. Global

strategy for the diagnosis, strategy for the diagnosis, management and prevention management and prevention of chronic obstructive of chronic obstructive pulmonary disease: GOLD pulmonary disease: GOLD executive summary. Am J executive summary. Am J Respir Crit Care Med 2012 Respir Crit Care Med 2012 Aug 9)Aug 9)

• ““emphysema”emphysema”

• ““chronic bronchitis”chronic bronchitis”

• XigrisXigris

ININ

• FEVFEV11/FVC <0.70/FVC <0.70• Never smoker COPDNever smoker COPD• Good early sepsis careGood early sepsis care (fluids, Abx) (fluids, Abx)

The OUTs and INsThe OUTs and INsThe OUTs and INsThe OUTs and INs

OUTOUT

• Liberal blood Liberal blood transfusions transfusions (Carson JL, et (Carson JL, et al. Red Blood Cell Transfusion al. Red Blood Cell Transfusion Guideliness from AABB, Ann Guideliness from AABB, Ann Intern Med 26 March 2012.)Intern Med 26 March 2012.)

• Confusing ways to Confusing ways to write sodium bicarb write sodium bicarb (Klima T, et al. Sodium chloride (Klima T, et al. Sodium chloride vs. sodium bicarbonate for the vs. sodium bicarbonate for the prevention of contrast medium-prevention of contrast medium-induced nephropathy: a RCT. induced nephropathy: a RCT. Europ Heart J (2012); 33, 2071.)Europ Heart J (2012); 33, 2071.)

ININ

• In stable pt, blood In stable pt, blood transfusion Hg <8transfusion Hg <8

• Normal Saline to Normal Saline to prevent contrast prevent contrast nephropathynephropathy

ReadmissionsReadmissionsReadmissionsReadmissions

• Reacting to 20% readmission rate, Reacting to 20% readmission rate, Medicare is reducing reimbursements Medicare is reducing reimbursements for those hospitals that have high for those hospitals that have high readmission rates. readmission rates.

Teach Me BackTeach Me BackTeach Me BackTeach Me Back

• RivaroxabanRivaroxaban• ACCP guidelines ACCP guidelines

value patient value patient preferences and preferences and suggest weighing suggest weighing risk of bleeding risk of bleeding with VTE in every with VTE in every case. case.

• Sugars are Sugars are importantimportant

• Universal VTE Universal VTE prophylaxis is not prophylaxis is not recommended. recommended.

• Conservative Conservative blood mgmt. blood mgmt.

• NS for kidneysNS for kidneys

Documents

Update in Hospital Medicine October 26, 2012 Amy O’Linn, D.O. Clinical Associate, Department of Hospital Medicine [email protected]