Pulmonary Thromboembolism (1 of 16)
Pulmonary Thromboembolism (1 of 16)
1 Patient presents w/ signs & symptoms suggestive of pulmonary embolism (PE)*
2 No Consider MANAGEMENT EVALUATION Massive/ OF MASSIVE/ Is patient clinically Submassive SUBMASSIVE PE stable? PE See next page
Yes
3 Low ASSESSMENT High probability What is the clinical probability pretest probability of PE? B Pharmacological therapy Parenteral Anticoagulant 3 • Low molecular weight heparin (LMWH) or Is the PE • Unfractionated heparin (UFH) or rule-out criteria Intermediate • probability Fondaparinux or Yes (PERC) met? Oral Anticoagulant • Non-vitamin K oral anticoagulants (NOACs) ALTERNATIVE No 5 DIAGNOSIS 4 CT PULMONARY DDIMER No Negative 4 ANGIOGRAM Is D-dimer positive Is PE visualized? or negative? DDIMER Is D-dimer positive Negative or negative? Positive Positive Yes Assess clinicalMIMS risk ALTERNATIVE DIAGNOSIS
B Pharmacological therapy Parenteral Anticoagulant 6 No • Low molecular weight heparin (LMWH) or • Unfractionated heparin (UFH) or Yes Is PE • Fondaparinux or Assess present in duplex clinical Oral Anticoagulant ultrasound &/or risk • Warfarin other tests? ©• NOACs C Follow-up
*Approach of suspected PE will vary according to the local availability of tests in each specifi c clinical setting Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.
B1 © MIMS 2019 PULMONARY EMBOLISM B No Pharmacological therapy Pharmacological • • rombolysis Streptokinase orUrokinase Streptokinase Reteplase, Alternatives: Alteplase agent: Preferred Absolute contraindications contraindications Absolute to thrombolysis? © EVALUATION 8 Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Yes Pulmonary Thromboembolism(2of16) Pulmonary A SUSPECTED MASSIVE/SUBMASSIVE PE MASSIVE/SUBMASSIVE SUSPECTED Prompt management of clinical instability Prompt management ofclinical B Pharmacological therapy Pharmacological D • Parenteral Anticoagulant Is massive/submassive Is massive/submassive Unfractionated Heparin Unfractionated Invasive procedures Invasive ASSESSMENT MIMSPE confirmed? Yes B2 7 Diagnosis of Diagnosis PE excluded No ALTERNATIVE DIAGNOSIS © MIMS 2019 PULMONARY EMBOLISM • • • Echocardiography • Diff Diagnosis erential • • • • PE &Symptoms ofMassive Signs • ofPE &Symptoms Signs • • • orShock Syncope • Dyspnea Isolated • Pain Chest Pleuritic • • • Typical &Symptoms Signs • Embolism Pulmonary Submassive • Embolism Pulmonary Massive • (PE) Embolism Pulmonary - Normal lung scan or sCT angiogram suggests that found suggests another shouldbe ofshock angiogram cause orsCT lung scan Normal - - adefi stabilized, If patient been has pursued shouldbe nitive diagnosis fi ndings Ifonly patient on compatible is unstable, treatment done based echocardiography thrombolytic be can or surgery changes if acutePEisthe ofhemodynamic cause &RV overload hypertension ofacutepulmonary signs indirect shows which typically initialtest useful Most (MI) infarction myocardial massive pneumonia, dissection, aortic dysfunction, acutevalvular tamponade, cardiac Cardiogenic shock, distress Respiratory hypoxemia Severe Syncope orSBP >110bpm) drop to40mmHg;HR instability (SBP <100mmHg, Hemodynamic present may be Syncope &/orcyanosis - - predominant sign isthe that support hypotension pressor requires arterial & systemic isusually the symptom prime Dyspnea therapy considered shouldbe rombolytic unstableClinically patients may PE have massive - are repercussions Syncope the orshock ofcentral hallmark signs hemodynamic insevere PE&usuallyresult - painthat chest angina-like probably w/substernal isrepresenting RV ischemia associated May be - Usually duetoamore central PE(notaff the pleura) ecting - may dyspnea occur suddenly weeks) orprogressively (overIsolated several the distallynear pleura May located suggest asmallembolism - isoneofthe frequent presentations most dyspnea painw/orwithout chest Pleuritic ofPE PE isindicative ofmassive instabilityClinical arrest orcardiac - frequent sign most whiletachypnea isits isthe frequent symptom, most Dyspnea - ofPE rate ≥20breaths/minute) pain,tachypnea (respiratory chest cases occur inmost pleuritic Dyspnea, the by symptoms clinical Suspicion ofPEisusuallyraised necrosis ormyocardial dysfunction BP)accompanied mmHg systolic either by right ventricular (RV) (≥90 hypotension Acute systemic PEwithout BPfor≥ mmHg systolic Acute PEw/<90 the &pelvis veins inthe legs especially the from veins, clots intheusuallyduetoblood lungs arteries ofoneormoreBlockage pulmonary usually able toconfi diagnosis rm are (TEE) echocardiography transesophageal &bedside spiralcomputed tomography lungscan, (sCT) Both © orsepsis hypovolemia, arrhythmia, new-onset by caused isdefiHypotension minutes ifnot mmHg for>15 mmHg orapressure drop of≥40 BP<90 asystolic as ned cold ofacuteright HF) extremities signs &/orclinical oliguria, hypotension, compromise fl heart ofhemodynamic Signs &reduced usuallypresent are (eg also ow arterial systemic disease or pulmonary Worsening (HF) failure that the may onlysymptom PEinpatients heart dyspnea be indicates w/preexisting &hypotension pain,wheezing, chest nonpleuritic syncope, cough, hemoptysis, Tachycardia that &symptoms present: Other may signs be (bpm)], rate >100beats/minute (HR) [heart Pulmonary Thromboembolism(3of16) Pulmonary 1 SIGNS & SYMPTOMS OF PE OF &SYMPTOMS SIGNS 15 minutes caused by PEwhich inotropic by may therapy ormayminutes caused notneed 15 2 MIMS EVALUATION B3 © MIMS 2019 PULMONARY EMBOLISM • • • • Assessment Risk Prognostic • • • • • Wells Method (Canada) • • • ofPE Probability ofPretest Estimation • • Judgment Clinical Rule versus Prediction • • • • • • (CPTP) Embolism ofPulmonary Probability Pretest Clinical • • • (PERC) Criteria Rule-Out Embolism Pulmonary Modifi from: ed eTask Force of ofthe European Embolism &Management Society forthe Diagnosis ofAcute Pulmonary 6 months) (w/treatment the within last Malignancy Hemoptysis DVT/PE Previous 4days inthe last orsurgery Immobilization >100beats/minute HR likely isless thanAlternative PE diagnosis &symptoms signs Clinical Nov;35(43):3033-3080. 2014 ESC on guidelines the & management diagnosis (ESC). Eur embolism. J. Cardiology 2014 Heart of acute pulmonary cardiac markerscardiac Low risk: Either are present markers of RV cardiac inpatients orsigns dysfunction risk w/ intermediate-low - forabnormalities are positive markers cardiac results both &imaging patients, Inintermediate-high risk - or presence markers ofcardiac &/ tests, imaging III-V PESI upon class orsPESI ofRV ≥1, presence ofsigns dysfunction risk: Intermediate &presence markers ofcardiac tests, imaging upon ofRVpresence ofsigns dysfunction III-V PESI class hypotension), orsPESI persistent ≥1, arterial instability (eg Hemodynamic shock, risk: High tests &imaging markers (eg peptide), I,natriuretic troponin cardiac Index(PESI) &simplifi Severity Embolism using Pulmonary Assessed cardiac PESI criteria, (sPESI), Hestia ed 4weeks intubated the within ortrauma last orhospitalization duetosurgery Previously - If neither then istrue the probability islow then istrue If onlyoneofthe the above probability isintermediate then areIf both true the probability ishigh AbsenceAlong w/2other explanation clinical ofanother orpresence features: factor reasonable ofamajor risk pain,&/orhemoptysis) chest pleuritic thatRequires the patient have clinical features &/or tachypnea w/ or without suggestive of PE (eg breathlessness, ofPE prevalence patients classifi allows tobe evaluation Clinical into toanincreasing corresponding probabilityed categories 30% inmoderate probability, &65%inhighprobability probability, oflow ofpatients the w/PEisaround proportion 10%intheIn any category used, ofthe methods Wells rule prediction clinical isthe frequently most method used - score Wells, Geneva Methods: Wicki, Kline,revised - judgmentClinical isaccurate todiscern whether patient ofPE likelihood isoflow To more accurate tobe appear than judgment clinical rules prediction apatient ofPE, w/ahighlikelihood identify (VTE) forvenous thromboembolism factors forrisk evaluated Patients be shouldalso &documented PEshouldhaveAll patients probability clinical w/possible assessed probability implicitlyClinical rule estimated may judgmentclinical prediction by be or explicitly a validated by ofPE prevalence patients classifi allows tobe evaluation Clinical into toanincreasing corresponding probabilityed categories toavoid ofPE suspicionisrequired clinical missingthe diagnosis A reasonable ofanappropriate &the strategy importance selection inthe diagnostic results interpretation test ofdiagnostic Evaluating patient ofPEinanindividual the according likelihood tothe presentation clinical isofutmost Hemoptysis - <95%at air room oximetry Pulse - rate Pulse >99bpm - old Age >49years - PERC Presence ofany apositive indicates ofthe following Studies that is100%sensitive toD-dimer show testing done prior validation PERC Helps forPE exclude risk low patients at very lung scan have low risk ofPE have risk low lung scan &nondiagnostic Patients (DVT) vein thrombosis that limbdeep nolower have probability clinical low ofPE, No signs of RV dysfunction on imaging tests (eg echocardiography, &negative tests onimaging angiogram) ofRV Nosigns dysfunction CT Variable © MODIFIED WELLSPRE-TEST PROBABILITYSCORINGSYSTEM Pulmonary Thromboembolism(4of16) Pulmonary Original 1.5 1.5 1.5 1 1 3 3 3 ASSESSMENT Points
MIMSSimplified B4 1 1 1 1 1 1 1 - Unilateral leg (calf) swelling Unilateral (calf) leg - ofVTE history Clinical - Patient onexogenous Estrogen therapy - Low Intermediate High groups onrisk Based PE likely likelyPE less onlikelihood Based probability Pretest Original 0-4 0-1 2-6 ≥7 ≥5 Total points Simplified N/A N/A N/A 01 © MIMS 2019 ≥2 PULMONARY EMBOLISM • • • • • • • • • • • • • • • • • • • • • Factors Risk Secondary • • • • • • • • • • • • • • • Factors Risk Primary • • • Factors Risk Evaluate forVTE • • Peptide Natriuretic &Troponin (BNP) B-type • ECG • CXR • ABG • • TestsDiagnostic Hyperviscosity (polycythemia, Waldenstrom) Hyperviscosity chemotherapy w/orwithout Malignancy syndrome Nephrotic Lupus anticoagulant Crohn’s disease Platelet abnormalities Prosthetic surfaces Oral contraceptives (eg Estrogen) Smoking Obesity Chronic venous insufficiency Hypertension Stroke distanceLong travel disease Congenital heart Paresis Pregnancy/puerperium failure Heart Central venous catheters ageAdvanced Surgery Trauma/fractures ofproven VTE Positive history Protein Sdeficiency Excessive activator plasminogen Congenital dysfibrinogenemia Dysplasminogenemia Plasminogen deficiency Factor VLeiden (APC-R) Factor defi XII ciency Prothrombin G20210Adeficiency Anticardiolipin antibody Hyperhomocysteinemia rombomodulin Protein Cdeficiency Antithrombin deficiency factors risk without occur inindividuals also PE can present w/the factors number ofrisk eprobability ofPEincreases ofPE patients the inhypotensive shouldraise possibility forVTE epresence factors ofrisk instability, PE ifconsidering massive especially inthe absence even ofhemodynamic mortality w/RV strain&increased are associated &troponin BNP Elevated Consider inapatient fi orclinical w/substantial clot burden, abnormal echocardiogram, suggestive ofPE ndings Can show right axis deviation, supraventricular S arrhythmia, deviation, right axis show Can vessels w/apaucity ofperipheral associated infi pleural-based May demonstrate atelectasis, ltrates oreff orengorged artery centralusions, pulmonary © (A-a)O &widened hypocapnia, hypoxemia, show Can abnormal fi butsome normal be can results Lab the suspicionforPE increase ndings probability clinical ofPE&general toassess conditionare indicated ofpatient (ABG) First-linegases X-raychest (ECG), electrocardiography blood such as & arterial tests (CXR) diagnostic Pulmonary Thromboembolism(5of16) Pulmonary 3 MIMS ASSESSMENT (CONT’D) B5 2 difference 1 Q 3 T 3 pattern orP-pulmonale © MIMS 2019 PULMONARY EMBOLISM • • • • • • Scan) Ventilation-Perfusion (V/Q Lung Scanning • • • • Venous (US) Ultrasonography Duplex • • • • • • • • • • • • • • • • Further tests should be performed inallother combinations probability &clinical result ofV/Qscan Further performed shouldbe tests PE massive occlusion of≥50%may vasculature signify Presence ofpulmonary suspicion ofPE incontext toestablish diagnosis clinical thepower ofreasonable predictive provide High probability scans incombination probability probabilityLow scans pretest makeprobability w/alow ofPElow are suffi lungscans normal ornear Normal probability ofpretest cient regardless toexclude PE, study imaging Preferred when CTPA iscontraindicated studylung imaging May improve estimation ofthe probability clinical inpatients ofPE&avoid testing more w/anegative invasive - VTE past from abnormalities residual ormay detect studies mayUS positive have false outPE notrule ofthe veins exam does leg US Normal PEpatients in suspected thus veins ofthe the legs from itisrational deep DVT foraresidual tosearch arise emboli pulmonary Most CTPA anegative forpatients despite Recommended &symptoms w/persistent signs &D-dimer test that tests further agree without apatient, treated may inwhomCTPA be experts Most PE, shows maythrombi, investigation 6-Further require (refer therefore, further toSection cases Work-up) these In patients probability, w/ahighpretest CTPA negative able may toexclude notbe signifi cant pulmonary seen likelyless tobe e main disadvantage of CTPA to that of conventional angiography is that clot is subsegmental pulmonary ahighspecifiHas forcentralcity &sensitivity clots disease forpatientsMore &pulmonary w/underlying cardiac useful thatmalities might help toestablish analternative diagnosis parenchymal &may information about emboli provide abnor- ofthe pulmonary visualization Enables direct lung scanning inspecifi &issuperior anadjunct oralternative toother as modalities imaging used Increasingly city toisotope PE fornon-massive the modality initiallungimaging as Recommended studies (eg orCTPA) directly toradiologic duplexUS patients shouldproceed ese - w/recent ortrauma surgery VTE D-dimer isinappropriate forsuspected - w/highCPTP inthose performed D-dimer shouldnotbe CV - toexclude PEadequately evaluation D-dimer further requires A positive reliably (Vidas) excludes PEinpatients w/ intermediate usingELISA D-dimer probabilityA negative test such patients forVTE probability; clinical donotrequire imaging w/ low any Vidas(simpliRed, via D-dimerA negative D-dimer test method or MDA) reliably excludes PE in patients confiRecommended forPERC &positive for patients test CPTP w/low rmatory ofoutpatients inthe forevaluation emergency department used Best - - D-dimer butanonspecifi isahighlysensitive forthe test presence ofPE c screening has a high clinical probability of PE) should serve as a basis for the start oftherapy forthe start abasis as probability ahighclinical has ofPE)shouldserve Only defi but studiesunder certain circumstances clinical nite positive (eg ofVTE patient history without recommended isnot available, echocardiography orifpatient bedside contraindications, isunstable orhas if angiography (CTPA) cases; forthese initialtest pulmonary tomographic as isrecommended Computed age increasing as cancer &many infl disease, vascular peripheral obstetrics, patients, hospitalized well as diseases ammatory However, notconfi ofD-dimer does levels raised are foundin such levels because therm presence ofVTE therapy,is onHeparin ofrecent ortrauma procedure surgical &/orw/history ifthe patient totesting, days prior manifestations is>2-3 ifthe duration ofVTE decreased maySensitivity be 5 © COMPUTED TOMOGRAPHIC PULMONARY ANGIOGRAPHY (CTPA) Pulmonary Thromboembolism(6of16) Pulmonary 6 FURTHER WORK-UP 4 MIMS D-DIMER B6 © MIMS 2019 PULMONARY EMBOLISM • • • • Angiography Conventional Pulmonary • • (MRA) Angiography Resonance Magnetic • • Echocardiography • • • • • • • • • Contraindications Relative • • • • • • to Contraindications Absolute rombolysis • • • • • • diagnosis on patient’s angiography may depend also Use of pulmonary statusclinical toobtainanabsolute & necessity remain inconclusive forpatients tests inwhomnoninvasive orare notavailable reserved Angiography shouldbe disagreement inupto⅓ofcases interobserver there be clot, can W/subsegmental - risks associated &interpretation, &thereLimitations include: inperformance itisinvasive Requirement are ofexpertise considered theHistorically gold standard ofPE forthe diagnosis continue years forseveral access &limited clots islikely to forsubsegmental sensitivity It apoor radiation avoids buthas ionizing promising inhuman tobe Appears &animalmodels therapy orhypotension present shock without ifthey confiIt not been has patients whowouldbenefi identify can ifechocardiography rmed thrombolytic t from defi May also nitively confi - thrombi arterial ofproximal pulmonary visualization ofPEby diagnosis rm - - PE massive forrapidUseful triage inacutely illpatients w/suspected Puncture ofanon-compressible vessel ulcerActive peptic liverAdvanced disease endocarditis Infective Recent traumatic CPR postpartum 1week orwithin Pregnancy DBP>100mmHg) (SBPUncontrolled >180mmHg, hypertension severe On oralanticoagulants Transient ischemic attack 6months the within past risk bleeding Known 30days the within last GI bleeding surgery, 3weeks Major the within past orinjury trauma, tumorPresence ordamage the ofbenign/malignant within CNS Ischemic 6months stroke the within last origin strokeHemorrhagic orstroke ofunknown contraindicationsAbsolute inalife-threatening situation tothrombolysis are rarely fortreatment afactor For toconfi other tests page refer toprevious orexclude ofPE, rm adiagnosis CTPA toconfi used may be perfusion) (≥50%decreased diagnosis rm treatment, defi supportive by stabilized When patient been already has determined shouldbe nite diagnosis compromise &RV overloadhypertension ifacutePEisthe ofhemodynamic cause ofacutepulmonary which signs isable isechocardiography indirect toshow initialtest useful emost - - foundat the usuallybe bedside can RV dysfunction In patients unstable whoare forlungimaging, too of Doppler signs of increased pulmonary arterial pressure arterial pulmonary ofincreased signs of Doppler May suggest/reinforce suspicionofPEw/the clinical fi inthe ofRV presencendings overload &dysfunction dissection) aortic endocarditis, infective tamponade, pericardial AMI, Usually reliable to diff thaterentiate have illnesses diff radically between erent treatment compared to PE (eg waves in leads V1-V4) inleads waves RV or other of RV failure, strain (eg evidence T inverted right bundle branch block, may new ECG show w/ inspiration murmur veinsregurgitations that jugular heave,& systolic of tricuspid distended increases parasternal Left 8 © EVALUATION OF CONTRAINDICATION TO THROMBOLYSIS Pulmonary Thromboembolism(7of16) Pulmonary 7 6 ASSESSMENT OF MASSIVE PE MIMS (CONT’D) WORK-UP FURTHER B7 © MIMS 2019 PULMONARY EMBOLISM • • Epinephrine • • Dopamine • • Dobutamine • Agonists Adrenergic • • Loading Fluid Support Hemodynamic • • VentilationMechanical • • Inhalation Oxide Nitric • O • • Management Outpatient Inpatient versus • • • • Norepinephrine • • 2 Supplementation than beta Vasoconstrictor eff inotropic eff similartoNorepinephrine, ect more duetopotent beta ect effMay be complicates when shock ective acutePE the by development oftachycardiaUse limited may be inPEpatients support forhemodynamic used been also Has right-sided fidecreasing lling pressures Aff contractility myocardial while increases beds, vascular &pulmonary systemic ofboth vasodilatation ects 1st-lineConsidered agent totreat right-sided &cardiogenic HF shock BPorw/impending hypotension index&normal cardiac consideredShould forpatients be w/low contractility causing ventricular by todecreased May RV overstretch, worsen leading function - flAggressive uid challenge isnotrecommended initially&cautiously, administered Fluids may be therapy shouldpromptly butother vasoactive follow - eff adverse hemodynamic taken tolimit its shouldbe Care ects inpatients toxic temporarily &hypoxic whoappear needed May be Based on clinical studies, may exchange improve status the &gas hemodynamic inpatients studies, onclinical w/PE Based &apatent hypertension foramen inpatients ovale indicated w/pulmonary May be evaluation further needs agents Dobutamine Combination such w/other as vasoactive & right ventricular pressure resistance, vascular pulmonary pressure, output, cardiac contractility) blood systemic inimproved resulting supportive therapy couldsupportive have failure amajor role inPEw/circulatory A considerable PE & therefore massive number hours of after deaths appropriate occurthe within 1st few Oxygen saturation (O - instability Hemodynamic - setting inahospital patients managed Intermediate- features tohigh-risk shouldbe w/the following - Monitoring of INR to guide Warfarin toguide ofINR Monitoring therapy - Complications - reserve cardiorespiratory Decreased - of: inthe because Patients treated hospital w/symptomatic PEshouldinitiallybe considered PEpatients forhometreatment shouldbe abovementioned without criteria Low-risk discharge orearly concern unfavorable conditions, treatment eg over living reasons compliance Socioeconomic - hepatic disease stage 4/5orsevere disease W/chronic kidney - confi W/comorbidities hospital requiring nement - pain Severe - Currently anticoagulants assessment during onfull-dose - orat formajor bleeding risk Active bleeding - Stimulates both alpha-adrenergic (inducing vasoconstriction) &beta Stimulates alpha-adrenergic both (inducingvasoconstriction) appropriate PEwhenMay there be inacutemassive isprofound hypotension Consider monitoring ofO Consider monitoring inpatients w/hypoxemia necessary May be Positive intrathoracic ventilation, mechanical induced pressures by may reduce venous RV & return worsen failure 2 © eff resistance accounting vascular ect, pulmonary forimproved A Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 2 sat) <90% Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing MANAGEMENT OF CLINICAL INSTABILITY 2 saturation O supplementary &give Pulmonary Thromboembolism(8of16) Pulmonary MIMSPRINCIPLES OF THERAPY B8 2 ifnecessary 1 -adrenergic receptors (augmenting cardiac 1 stimulation rather © MIMS 2019 PULMONARY EMBOLISM • • PENon-massive • • • PE Massive • rombolytics • • • Parenteral Anticoagulation • • • • • • LMWH • • • • • • • (UFH) Heparin Unfractionated Parenteral Anticoagulants PE inpatients w/low-risk therapy used shouldnotbe rombolytic - iscontroversial ofRV dysfunction) evidence graphic stable therapy patients patients ofthrombolytic innon-high-risk w/echocardio- euse (hemodynamically signifi hemodynamically Massive orprofound hypoxemia hypotension cant systemic PEwithout - Free-floating right ventricular thrombus echocardiography orpatent by documented foramen ovale - oxygenation Compromised - therapy considered may inpatients be rombolytic also w/: hypotension therapy PE rombolytic presenting is recommended in high-risk w/ cardiogenic &/or persistent shock arterial - therapy individualized ofthrombolytic inPEshouldbe euse outcomes relevant noclinically fordeath rate ere ofsymptoms orforthe was resolution - agentspatients thrombolytic whoreceived &anticoagulant agents conventional over anticoagulant agents alone Studies amore have rapid PE improvement shown inacutemassive abnormalities &hemodynamic inradiographic isappropriate orUFH Either forthe initialtreatment LMWH ofPE - course treatments short UFH confi are for objectively recommended or IV SC LMWH Both PE non-massive rmed Treatment longer the site from could delayed surgical ifthere even be isany ofbleeding evidence - consultationafter w/surgeon If PE occurs postoperatively, until 12-24 therapy started & Heparin major should not be surgery hours after probability &inlow patients oncestudies are PEisconfi performed rmed inpatients administered w/intermediate shouldbe probability orhighclinical imaging Heparin ofPEbefore LMWH is not recommended for high-risk PE w/ hemodynamic instability PEw/hemodynamic for high-risk isnotrecommended LMWH treatmentLMWH iscontinued treatment before ofplateletMonitoring count initiation &onthe isnecessary 5th day, 2-3 days if then every issafe,eff ofLMWH euse may stay hospital shorten ective, &improve the quality oflifeforpatients effi equal has A number that ofstudies have shown LMWH inpatients PE toUFH w/non-massive cacy inpatients PE UFH over preferred isnow w/acutenon-massive LMWH Enoxaparin, Tinzaparin Nadroparin, Eg Dalteparin, complication isarare butserious thrombocytopenia Heparin-induced - adjustment &dose w/frequent monitoring hospitalization requires typically UFH IV - disease totreat VTE used been rate mortality when has Studies UFH areduced have shown - proven eff been has UFH IV inthe therapyective ofPE renal inpatients failure w/severe LMWH over Preferred PE massive PEorclinically high-risk to as initialanticoagulation as given Should referred be forpatients also w/PEpresentingorhypotension, w/shock ofbleeding w/ highrisk & when of effrapid bolus reversal a 1st considereddose as should be UFH in patients as mayrequired, ect be treatment UFH IV inPEiswell-established treatment traditionalanticoagulant over therapy patients inthese improvement relevant aclinically toshow Further inthe benefi are studies needed t-risk ratio ofthrombolytic are the appropriate most unstable candidates PEwhoareofbleeding Patients at risk low w/hemodynamically © attained been daily when the has target therapeutic dose adjustment, oronce dose each hours after then injection, 3 bolus hours after 4-6 measured shouldbe aPTT 24hours within are reached &when adequate levels value at arate the >1.5times control that isunusual the prolongs when isinfused aPTT UFH Recurrence ofVTE Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Pulmonary Thromboembolism(9of16) Pulmonary PRINCIPLES OF THERAPY (CONT’D) THERAPY OF PRINCIPLES B MIMS PHARMACOLOGICAL THERAPY B9 © MIMS 2019 PULMONARY EMBOLISM • Drugs Investigational • • • • Antithrombotics rombolysis • • • Warfarin • • • Rivaroxaban • • Edoxaban • • etexilate Dabigatran • • Apixaban • • Non-Vitamin (NOACs) Anticoagulants KOral • of Duration erapy • • • • • Fondaparinux (Cont’d)Parenteral Anticoagulants being studied for PEinthe studied contextbeing half life&fi that better ithas specifibrin city compared toAlteplase Tenecteplase that activator isatissueplasminogen &iscurrently infarction foracutemyocardial isapproved - Reteplase effi thrombolytic equivalent has 12hoursofUrokinase - to24hoursofStreptokinase cacy - orUrokinase Streptokinase administration shorter time ofits agent thrombolytic Preferred because - - (r-tPA)Alteplase (r-tPA), Urokinase Eg Alteplase Streptokinase, Reteplase, optimalattempts despite adjustment Highrate at ofmajor dose INR bleeding by - erapy w/Warfarin remains unsatisfactory - isnoteff dose Bolus eff full therefore its 5daysective, toachieve at itrequires least ect - reliably been confi has onlywhen VTE started Should be rmed Studies that have shown iscomparable Rivaroxaban toWarfarin forthe prevention ofPE probability An alternative treatment forparenteral anticoagulants inthe initialtreatment ofpatients pretest w/highclinical Xainhibitorthat factor effA direct thrombin prevents generationectively fortreatment used PEinpatientsMay w/parenteral be treated anticoagulant for5-10days Xainhibitorthat factor effA direct thrombin prevents generationectively treated ofrecurrent &toreduce PEinpatients risk previously whohavedays, been Approved forthe management w/parenteral ofPEinpatients treated whohave been anticoagulant for5-10 thrombinA direct inhibitorthat eff thrombin prevents generationectively W/ signifi compared risk toWarfarincantly bleeding lower & other vitamin K antagonists Xainhibitorthat factor effA direct thrombin prevents generationectively &complicationsevents anticoagulantLong-term treatment recurrent &nonfatal ofPEisforpreventionfatal venous thromboembolic Eg Apixaban, Edoxaban, Dabigatran Rivaroxaban, etexilate initiation ofWarfarin &until isstable days therapeutic &≥2(range: INR 2.0-3.0)for2consecutive treatment or Fondaparinux LMWH, the continued w/UFH, days after Acute-phase should be 5-7 forat least thrombocytopenia ofheparin-induced history forpatientsRecommended w/known renal impairment instability w/severe &those PEw/hemodynamic forhigh-risk Not recommended Obtain aplatelet forany tocheck count bleeding oftherapy tothe prior start &periodically tomonitoreff used been (anti-factor assay Xa) has Heparin ofFondaparinuxects initialtreatment apreferred Also forPE plasmin, resulting tofi resulting plasmin, &clot dissolution brinolysis agent converting that for catheter-basedby thrombolysis A thrombolytic functions to plasminogen used ©24 hours&3xthatasseenw/Heparinalone ese2 agents have similar thrombolytic eff ects in PE&have been shown to resolve PE comparativelyat duration (2hours) forashorter administered be comparable butcan &Urokinase Has capacity to Streptokinase thrombolytic stable days &≥2x 2 consecutive that it is recommended Warfarin us, therapy 5 at overlapdays least until w/ Heparin is therapeutic INR Warfarin-induced skinnecrosisorothertransienthypercoagulablecomplications S defi oftreatment start before wherein adequate anticoagulationciency) isneeded w/Heparin to prevent on Start day therapy, 1 of Heparin except hypercoagulable in patients state (Protein w/ suspected C or Protein Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not B Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) Pulmonary Thromboembolism(10of16) Pulmonary
B10 MIMS © MIMS 2019 PULMONARY EMBOLISM • • • Anticoagulation During Monitoring • • • • • • • • Anticoagulation During Factors Bleeding forMajor Risk • Anticoagulant Oral • LMWH • • • • • • Embolectomy Pulmonary • • VenaInferior Filter Placement (IVC) Cava • • Extraction Catheter • • Target patients is2.5formost &3.0forpatients INR w/recurrent VTE butnot>4weeks 4weeks, then every 2weeks If stable, monitorevery ofWarfarin weeks the therapy during 1stseveral weekly at least checked shouldbe INR Comorbid illness oftherapy monitoring Suboptimal Poor anticoagulant control Concomitant antiplatelet therapy Chronic hepatic &renal disease stroke noncardioembolic Previous GIbleeding Previous Age >75years - - - - ofanticoagulationDuration &the ofevent coexistence factors: isdependent risk onthe ofprolonged type - forpatients drug Preferred w/PE&cancer contraindicated orimpractical patients inwhomoralanticoagulants forselected indicated are may be orLMWH ofUFH doses Adjusted Treatment w/oralanticoagulantisthepreferredmethodoflong-termmanagementmostPEpatients &therefore anticoagulant require long-term VTE treatment (20-50%)ofsymptomaticextension ofthrombusPatients &/orrecurrent w/acutePEhave ahighfrequency lung/RV necrosis orcardiac failure, worsening unstable, considered severe May inpatients acutePEwhoare be hemodynamically w/submassive therapy ofthrombolytic orcontraindication orfailure &resuscitation, use Heparin toits instability despite forpatients PE(preferably hemodynamic documented), w/massive angiographically Reserved have inemergency failed Performed situations measures when more conservative incidence onanticoagulant ofPEinpatients w/proximal therapy DVT Studies decreased show hypertension w/recurrent &those acutePEw/underlying pulmonary complications, active bleeding &/orintolerant forpatientsRecommended unresponsive toanticoagulant/thrombolytic therapy, patients w/ isnotavailable bypass access tocardiopulmonary toimprove therapy an adjunct ifimmediate circulation, alternative when tosurgery thrombolytic as failed oras forhighlycompromised patients therapy receive whocannot thrombolytic due tocontraindications, Reserved Catheter extractioninvolves suctionextractionofPEunder fl monitoring w/ECG uoroscopy forpatientsPreferred w/contraindications thrombolysis tosystemic arteries thrombi istoremove the the from obstructing mainpulmonary purpose Main © treatment isrecommended Long-term Unprovoked PE(2ndepisode): oralanticoagulationConsider long-term & in whom stable anticoagulation achieved: of bleeding be can w/ low-risk Unprovoked PE (1st episode), Unprovoked PE:Oralanticoagulation 3months forat isrecommended least Oralanticoagulation 3months factor: PE duetotransient forat isrecommended risk least orreversible indefinitely oruntil resolved cancer has forthe 1st3-6 used Should anticoagulant be months oflong-term therapy, then continued oraltherapy as Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Pulmonary Thromboembolism(11of16) Pulmonary D INVASIVE PROCEDURES C FOLLOW-UP
B11 MIMS © MIMS 2019 PULMONARY EMBOLISM Apixaban Factor XaInhibitors Direct Edoxaban (Fondaparin) Fondaparinux Drug ANTICOAGULANTS, ANTIPLATELETS &FIBRINOLYTICS (THROMBOLYTICS) Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products anticoagulant hrly orw/ another treatment 12 w/5mgPO completion of6-mth To following initiated be 12hrly 2.5 mgPO Prevention: 10mgPO dose: Max 12hrly PO 5mg dose: Maintenance 20mgPO dose: Max 12 hrly x 7 days 10mgPO dose: Initial Treatment: established until oralcoagulation is Continue for5-9days or SC 24hrly body>100 kg wt SC 24hrly body50-100 kg wt 30 mg PO 24hrly30 mg PO Ketoconazole) are given Erythromycin, Dronedarone, inhibitors (Ciclosporin, concomitant ofP-gp use kg body or weight, 15-50mL/min),(CrCl ≤60 renalsevere impairment Patients w/moderate or days anticoagulant 5 forat least ofparenteralinitial use 24hrly following 60 mgPO 24 hrly 5mgSC wt: <50 kgbody placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Pulmonary Thromboembolism(12of16) Pulmonary : 10mg : 7.5mg Dosage Guidelines • • • • Instructions Special • Reactions Adverse • • • • Instructions Special • • Reactions Adverse • • • • Instructions Special • Reactions Adverse impairment, hepatic impairment renal severe intolerance, malabsorption, glucose-galactose Use w/caution inhipfracture surgery, galactose impairment ofneurological Monitor forsigns Discontinue hemorrhage insevere use risk bleeding relevant w/coagulopathy hepatic disease &clinically bleeding, in patientsContraindicated signifi w/clinically cant active eff (nausea) ect Hematologic eff hemorrhage, contusion); (anemia, ects GI the end oftreatment &at at isrecommended ofplatelets baseline Monitoring anticoagulated forthromboprophylaxis inpatientsis employed anticoagulated ortobe versus benefiConsider risk intervention neuraxial t before ofHIT,impairment, w/history elderly >75yr patients hepatic w/moderate renal impairment, severe <50 kg, w/caution inpatients use brain, spinalorophthalmic surgery; acute GIulcer, recent intracranial hemorrhage, after orshortly ofhemorrhage; risk Use w/ caution inpatients w/anincreased renal impairment w/confi orinthose HIT rmed Avoid inpatients signifi w/clinically severe cant bleeding, allergic Rare reactions pruritus); (rash, eff constipation, Dermatologic diarrhea); dyspepsia, ects eff CV headache); GIeff (hypotension); ect (N/V,ects commonLess eff eff CNS ects: (vertigo, dizziness, ects eff eff Misc (fever); ect (edema) ect Hepatic eff purpura); anemia, CNS (abnormal LFT); ect Hematologic eff (hemorrhage, thrombocytopenia, ects therapy &thereafter totreatment prior &CrClatPerform of the LFT start impairment, concomitant aff ofmedicines use hemostasis ecting renal impairment, mildormoderate hepatic moderate orsevere ofbleeding, risk Use w/caution inpatients w/anincreased centralan open catheter venous orarterial tomaintain necessary therapy at orwhenisgiven doses UFH anticoagulants except oralanticoagulant when switching HTN,uncontrolled concomitant severe treatment w/any other w/coagulopathy risk, bleeding disease relevant &clinically hepatic orconditions at formajor bleeding, risk bleeding in patientsContraindicated signifi w/clinically cant active monotherapyEdoxaban as 15mgisnotindicated pruritus) rash, &gammaglutamyltransferase, bilirubin eff Misc (nausea); (abnormal LFT, blood ects increased Hematologic eff hemorrhage); GIeff (anemia, ects ect
B12 MIMS Remarks © MIMS 2019 PULMONARY EMBOLISM ANTICOAGULANTS, ANTIPLATELETS &FIBRINOLYTICS (THROMBOLYTICS) (CONT’D) Reteplase (rt-PA) Alteplase Enzymes etexilate Dabigatran Direct Inhibitor rombin Rivaroxaban Factor (Cont’d) XaInhibitors Direct Drug the start of1st injthe start once, 30minafter dose May repeat symptoms of the onset after 1-2min over IV slow via 10 units 1.5 mg/kg dose: total max Patient <65kg 2hr over infusion 90 mgIV Followed by: 1-2 min over bolus anIV 10 mgas dose: Loading 12 hrly 150 mgPO 20 mg/day dose: Max 24hrly PO onwards: 22 Days 30 mg/day dose: Max 12hrly PO 1-21:15mg Days Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © Dosage Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 20 mg Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Pulmonary Thromboembolism(13of16) Pulmonary • • Instructions Special • Reactions Adverse • Instructions Special • • • • Reactions Adverse • • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse Dosage Guidelines arrhythmias, cholesterol embolism arrhythmias, hepatic/renal impairment, severe hypertension, GU bleed, Use w/caution inpatients w/recent major surgery, recent CVD, GI/ contraindications management page 7ofthis forspecifi chart disease See c thrombosis) bradycardia, pericarditis, hypertension, (hypotension, Hematologic eff eff CV (hemorrhage, intracranialects bleeding); ects S prophylaxis forHeparin need hence elsewhere emboli the cause mayBreak-up ofclots occasionally ofreperfusion may & arrhythmias bradycardia occur because reperfusion), of aresult &as direct (both w/hypotension associated may be Infusion symptoms) anaphylactic sickness-like &serum fl Allergic (rashes, reactions Rarely: &rarely urticaria ushing, eff (N/V,ects eff pain);CNS abdominal (fever) ect GI intracranial hemorrhage occurred); has internal bleeding, severe Hematologic eff puncture from sites, (hemorrhage especially ects Discontinue inpatients acuterenal use failure whodevelop lumbarpuncture anesthesia, spinal/epidural risk, hemorrhagic Use w/caution inhepatic impairment, renal insuffi ciency, increased replacement) valve prosthetic heart Ketoconazole, 6mth,the last patients onconcomitant therapy w/systemic significlinically (including stroke hemorrhagic within cant bleeding hemostatic impairment, atpharmacological organ of lesions risk patients or w/spontaneous diathesis, bleeding manifestations, renal in patientsContraindicated impairment, hemorrhagic w/severe discharge) postprocedural eff Misc abnormal hepatic function); (woundsecretion, ects N/V, gastroesophagitis, GIhemorrhage, pain,diarrhea, abdominal Renal effthrombocytopenia); (hematuria);ect GIeff (dyspepsia, ects Hematologic eff hematoma, (hemorrhage, anemia, ects intolerance, renal impairment w/moderate tosevere &those orgalactose lactose Use w/caution inpatients risk, w/hemorrhagic ofbleeding risk torelevant lead can w/coagulopathy associated that lactating &hepatic disease pregnant, in patientsContraindicated signifi w/clinically cant activebleeding, hemorrhage) postprocedural edema, peripheral eff Dermatologic (nausea); eff Misc rashes); (pruritus, ects (fever,ects eff CV syncope), headache, GIeff hypotension) (tachycardia, ects ect Hepatic eff ALT eff (increased ect CNS &AST); (dizziness, ects Hematologic eff hemoglobin); decreased (hemorrhage, anemia, ects ee page 7 of this disease management page 7ofthis forspecifiee chart disease c contraindications
B13 MIMS Remarks © MIMS 2019 PULMONARY EMBOLISM ANTICOAGULANTS, ANTIPLATELETS &FIBRINOLYTICS (THROMBOLYTICS) (CONT’D) nxprn1.5mg/kg(150anti-Xa iu/ Enoxaparin sodium Dalteparin Group Heparin Urokinase Streptokinase (Cont’d)Enzymes Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © SC 12hrly 1 mg/kg(100anti-Xa iu/kg) kg) SC24hrly 18,000iu/day dose: Max continuous infusion IV 12hras 100 iu/kgover or bleeding of risk patients w/increased 100 iu/kgSC12hrly for 200 iu/kgSC24hrly or dose aloading donotgive used, control is IfHeparin value. to<2xthe normal decreased has once aPTT started Anticoagulation shouldbe x12-24hr infusion IV 4400iu/kg/hr Followed by: 10min over in 15mLsoln dose: Loading is<100sec when aPTT or infusion Streptokinase 3-4hrafter Heparin Begin x24-72hr infusion IV Followed 100,000iu/hr by 30min over 250,000 iuIV dose: Loading thrombolysis: Long-term Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Pulmonary Thromboembolism(14of16) Pulmonary or 4400 iu/kg IV iu/kg IV 4400 Dosage Guidelines • • • • Instructions Special • Reactions Adverse • • Instructions Special • • • • Reactions Adverse
B14 MIMS periodically during treatment during periodically & at isrecommended ofplatelets baseline Monitoring anticoagulatedto be forthromboprophylaxis intervention inpatients isemployed anticoagulated or versus benefiConsider risk neuraxial t before toHeparin hypersensitivity tobrain,spinalorophthalmicsurgery surgery, post-major trauma or recent liver disease, severe recent cerebral hypertension, hemorrhage, severe ulcer, peptic thrombocytopenia), Heparin-induced of disordershemorrhagic (including history Use w/ caution inpatients w/hemophilia orother heparin forantiplatelet test in vitro Ab tothepositive specific patientsAvoid w/ inpatients w/activemajor bleeding, alopecia) that (osteoporosis, use may occur w/long-term Eff (anaphylaxis); reactions hypersensitivity Rare ects Hematologic eff (hemorrhage, thrombocytopenia); ects - may resistance cause or antibodies ese - use Streptokinase 5 days after about after are formed antibodies Anti-streptokinase specific contraindications management page 7ofthis for chart disease See thanUrokinase w/Streptokinase likely allergic less may tooccur reactions w/ Serious be elsewhere emboli cause may upofclots occasionally Break ofreperfusion mayarrhythmias occur because & bradycardia ofreperfusion), aresult & as direct (both w/ hypotension mayassociated be Infusion occurred has syndrome Guillain-Barré back pain);GIeff &abdominal (N/V); ects eff Misc symptoms); sickness-like (fever,ects chills w/ fl &rarely anaphylactic urticaria &serum ushing, Allergic (rashes, reactions hemorrhage occurred); has intracranial internal bleeding, severe puncture sites, Hematologic eff from (hemorrhage especially ects thrombolytic not including Anistreplase may be used) may be notincluding Anistreplase thrombolytic mth5 days-12 1stadministration (alternative after Recommend nottoadminister Streptokinase ofStreptokinase doses tosubsequent hypersensitivity Remarks © MIMS 2019 PULMONARY EMBOLISM ANTICOAGULANTS, ANTIPLATELETS &FIBRINOLYTICS (THROMBOLYTICS) (CONT’D) Tinzaparin sodium • • • Heparin) (Unfractionated Heparin (Cont’d) Group Heparin Sulodexide 250-500 LSU PO 12hrly or PO 250-500LSU Sulodexide 6400anti-Xa iuSC12hrly x7-10days sodium Reviparin Parnaparin calcium Nadroparin • • • • • Dose adjusted based onaPTT: based adjusted Dose therapeutic range once itisoutside dailyunless monitoraPTT ereafter - quent dosage according toaPTT therapeutic within range (1.5-2.3xcontrol) aPTT &adjust subse- hr tokeep 6hrly forthe 1st24 Monitor aPTT 80u/kgIV, dose: 18u/kg/hr Loading infusion byIV followed aPTT >90 sec (>3 x mean normal) (>3xmean >90sec aPTT normal) (2.3-3xmean 71-90sec aPTT rate 2u/kg/hr by infusion then increase bolus, IV 40u/kg Give normal) (1.5-2.3xmean 46-70sec aPTT normal) (1.2-1.5xmean 35-45sec aPTT normal) (<1.2xmean <35sec aPTT Drug UFH INFUSIONRATE ADJUSTEDACCORDINGTOBODY WEIGHT&APTT Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All SC 8 hrly (adjust dose based onaPTT) based SC 8hrly (adjust dose 15,000uSC12hrly UFH: or 10,000u SC or onaPTT) based 24hr(adjustover dose given 20,000-40,000uIV Followed by: 5000uIV dose: Loading or onaPTT) based (adjust dose infusion 15-25u/kg/hrIV Followed by: PE: 10,000uIV forsevere dose Loading 5000uIV dose: Loading infusion: IV UFH or nomogram on Weight-adjusted based dosing 171 anti-Xa iu/kg SC 24 hrly 171 anti-Xa iu/kgSC or 85 anti-Xa iu/kgSC12hrly forupto10days © 175 anti-Xa iu/kgSC24hrly 24hrly IM/IV 600 LSU x 5-7days w/anoralanticoagulant given tobe Doses >60 kg:6300anti-Xa iuSC12hrly 46-60 kg: 35-45 kg: Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Pulmonary Thromboembolism(15of16) Pulmonary 4200 anti-Xa iuSC12hrly 3500 anti-Xa iuSC12hrly Dosage Dosage Guidelines Stop infusion for 1 hr then decrease infusion rate 3u/kg/hr by infusion for1hrthenStop decrease infusion rate 2u/kg/hr by infusion Decrease No change rate 4u/kg/hr by infusion then increase bolus, IV 80u/kg Give
B15 MIMS • • • • Instructions Special • • Reactions Adverse baseline & periodically during treatment during &periodically baseline at isrecommended ofplatelets Monitoring anticoagulated forthromboprophylaxis patients anticoagulated ortobe intervention in isemployed neuraxial versus benefiConsider risk t before toHeparin hypersensitivity brain, spinalorophthalmic surgery, post-major trauma orrecent to surgery liver disease, severe hypertension, severe ulcer,peptic recent cerebral hemorrhage, thrombocytopenia), Heparin-induced of disorders (including history hemophilia orother hemorrhagic Use w/caution inpatients w/ heparin forantiplatelettest Ab tothe specific in patients vitro w/positive bleeding, Avoid inpatients w/activemajor Inj: sensation & Pain,burning - N/V, Cap: epigastralgias diarrhea, - Sulodexide alopecia) (osteoporosis, Eff that use mayects occur w/long-term (anaphylaxis); reactions hypersensitivity Rare thrombocytopenia); Hematologic eff (hemorrhage, ects hematoma at inj site Remarks © MIMS 2019 PULMONARY EMBOLISM ANTICOAGULANTS, ANTIPLATELETS &FIBRINOLYTICS (THROMBOLYTICS) (CONT’D) Warfarin 5-10 mg PO 24hrly 5-10mgPO Warfarin Vitamin KAntagonist Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed (range 2-3) Target INR=2.5 to adjusted should be that dose subsequent Followed by & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © Dosage Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Pulmonary Thromboembolism(16of16) Pulmonary Please see the end of this section for reference list. reference for section this of end the see Please Dosage Guidelines • • • • • Instructions Special • • Reactions Adverse onthe depending often wklyorless ismonitored en INR - 2-3x/wkfor2wk ismonitored en INR - achieved been range (2.0-3.0)has dailyuntil the therapeutic isusuallyperformed monitoring INR or hepatic impairment Use w/extreme caution ornotat renal allinpatients w/severe endocarditis bacterial cerebrovascular disorders & wounds, severe ulcer disease, Avoid in patients w/activeorat ofhemorrhage, risk peptic interactions &food drug oftherapyPatients counseled onthe alongw/ risks shouldbe ofINR monitoring onregular based adjusted mustDosage be pancreatitis) effMisc hepatic dysfunction, skinreactions, (alopecia, ects discoloration GIeffpurple ofthe toes); (N/V,ects diarrhea); commonLess eff & (skinnecrosis Cholesterol embolization ects: levels therapeutic within INR Hemorrhage occur even can stability ofINR
B16 MIMS Remarks © MIMS 2019