ANTICOAGULATION RELATED BLEEDING - GUIDELINE SUMMARY Click Here for the Full Thrombosis Prevention Investigation and Management of Anticoagulation Guideline
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Enoxaparin Sodium Solution for Injection, Manufacturer's Standard
PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION PrLOVENOX® Enoxaparin sodium solution for injection 30 mg in 0.3 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 40 mg in 0.4 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 60 mg in 0.6 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 80 mg in 0.8 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 100 mg in 1 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 300 mg in 3 mL solution (100 mg/mL), multidose vials for subcutaneous or intravenous injection PrLOVENOX® HP Enoxaparin sodium (High Potency) solution for injection 120 mg in 0.8 mL solution (150 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 150 mg in 1 mL solution (150 mg/mL), pre-filled syringes for subcutaneous or intravenous injection Manufacturer’s standard Anticoagulant/Antithrombotic Agent ATC Code: B01AB05 Product Monograph – LOVENOX (enoxaparin) Page 1 of 113 sanofi-aventis Canada Inc. Date of Initial Approval: 2905 Place Louis-R.-Renaud February 9, 1993 Laval, Quebec H7V 0A3 Date of Revision September 7, 2021 Submission Control Number: 252514 s-a version 15.0 dated September 7, 2021 Product Monograph – LOVENOX (enoxaparin) Page 2 of 113 TABLE OF CONTENTS Sections or subsections that are not applicable at the time of authorization are not listed. TABLE OF CONTENTS .............................................................................................................. -
Treatment of 51 Pregnancies with Danaparoid Because of Heparin
©2005 Schattauer GmbH,Stuttgart Blood Coagulation, Fibrinolysis and CellularHaemostasis Treatment of 51 pregnancies withdanaparoidbecause of heparin intolerance EdelgardLindhoff-Last1 ,Hans-Joachim Kreutzenbeck2 ,Harry N. Magnani3 1 Division ofVascular Medicine,Department of Internal Medicine,University Hospital Frankfurt, Germany 2 MedicalDepartment, Celltech, Essen, Germany 3 Clinical Consultant Marketing, OrganonBV, Oss,The Netherlands Summary Pregnant patients withacute venous thrombosis or ahistoryof required (3/14) or an adverse eventled to atreatment discon- thrombosis mayneed alternative anticoagulation, when heparin tinuation (11/14).Four maternal bleeding events were recorded intolerance occurs. Onlylimited dataonthe useofthe hepari- during pregnancy, deliveryorpostpartum, twoofthemwere noiddanaparoid areavailable in literature.We reviewedthe use fatal duetoplacental problems.Three fetal deathswererec- of danaparoid in 51 pregnancies of 49 patients identified in litera- orded,all associated with maternal complications antedating da- turebetween 1981 and 2004.All patients had developed hepa- naparoiduse.Danaparoid cross-reactivity was suspectedin4 rin intolerance (32 duetoheparin-induced thrombocytopenia, HITpatientsand 5non-HITpatientswith skin reactions and was 19 mainlydue to heparin-induced skin rashes)and had acurrent confirmedserologicallyinone of the twoHIT patients tested.In and/or pasthistoryofthromboembolic complications.The initial none of fivefetal cordblood- andthree maternal breast milk- danaparoid doseregimens ranged -
The Evolving Role of Direct Thrombin Inhibitors in Acute Coronary
View metadata, citation and similar papers at core.ac.uk brought to you by CORE Journal of the American College of Cardiology providedVol. by 41, Elsevier No. 4 - SupplPublisher S Connector © 2003 by the American College of Cardiology Foundation ISSN 0735-1097/03/$30.00 Published by Elsevier Science Inc. PII S0735-1097(02)02687-6 The Evolving Role of Direct Thrombin Inhibitors in Acute Coronary Syndromes John Eikelboom, MBBS, MSC, FRACP, FRCPA,* Harvey White, MB, CHB, DSC, FRACP, FACC,† Salim Yusuf, MBBS, DPHIL, FRCP (UK), FRCPC, FACC‡ Perth, Australia; Auckland, New Zealand; and Hamilton, Ontario, Canada The central role of thrombin in the initiation and propagation of intravascular thrombus provides a strong rationale for direct thrombin inhibitors in acute coronary syndromes (ACS). Direct thrombin inhibitors are theoretically likely to be more effective than indirect thrombin inhibitors, such as unfractionated heparin or low-molecular-weight heparin, because the heparins block only circulating thrombin, whereas direct thrombin inhibitors block both circulating and clot-bound thrombin. Several initial phase 3 trials did not demonstrate a convincing benefit of direct thrombin inhibitors over unfractionated heparin. However, the Direct Thrombin Inhibitor Trialists’ Collaboration meta-analysis confirms the superiority of direct thrombin inhibitors, particularly hirudin and bivalirudin, over unfractionated heparin for the prevention of death or myocardial infarction (MI) during treatment in patients with ACS, primarily due to a reduction in MI (odds ratio, 0.80; 95% confidence interval, 0.70 to 0.91) with little impact on death. The absolute risk reduction in the composite of death or MI at the end of treatment (0.8%) was similar at 30 days (0.7%), indicating no loss of benefit after cessation of therapy. -
Streptokinase) and Streptococcal Desoxyribonuclease on Fibrinous, Purulent, and Sanguinous Pleural Exudations
THE EFFECT IN PATIENTS OF STREPTOCOCCAL FIBRINOLYSIN (STREPTOKINASE) AND STREPTOCOCCAL DESOXYRIBONUCLEASE ON FIBRINOUS, PURULENT, AND SANGUINOUS PLEURAL EXUDATIONS William S. Tillett, Sol Sherry J Clin Invest. 1949;28(1):173-190. https://doi.org/10.1172/JCI102046. Research Article Find the latest version: https://jci.me/102046/pdf THE EFFECT IN PATIENTS OF STREPTOCOCCAL FIBRINOLYSIN (STREPTOKINASE) AND STREPTOCOCCAL DESOXYRIBO- NUCLEASE ON FIBRINOUS, PURULENT, AND SAN- GUINOUS PLEURAL EXUDATIONS' By WILLIAM S. TILLETT AND SOL SHERRY (From the Department of Medicine, New York University College of Medicine, and the Third Medical Division of Bellevue Hospital, New York City) (Received for publication August 6, 1948) The results described in this article were ob- coccal groups C and G (3). The product is tained by the injection of concentrated and par- abundantly excreted into the culture medium in tially purified preparations derived from broth which the organisms are grown and is readily ob- cultures of hemolytic streptococci into the pleural tainable free from the bacterial cells in sterile cavity of selected patients who were suffering filtrates. from different types of diseases that gave rise to The fibrinolytic action, in tests conducted un- pleural exudations. The possibility has been ex- der optimal laboratory conditions, is unusually plored of utilizing two of the defined properties rapid in action on the fibrin coagulum of normal elaborated by hemolytic streptococci that have the human blood, requiring only a few minutes when unique capacity of causing rapid lysis of the solid whole plasma is employed as a source of fibrin, elements (fibrin and nucleoprotein) that are sig- and an even shorter time when preparations of nificant parts of exudates. -
Thrombocytopenia
© Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 | Fax 503-947-2596 Drug Class Review: Thrombocytopenia Date of Review: January 2019 End Date of Literature Search: 11/05/2018 Purpose for Class Review: Treatments for thrombocytopenia are being reviewed for the first time, prompted by the recent approval of three new drugs; avatrombopag (Doptelet®), fostamatinib (Tavalisse™) and lusutrombopag (Mulpleta®). Research Questions: 1. What is the evidence for efficacy and harms of thrombocytopenia treatments (avatrombopag, eltrombopag, lusutrombopag, fostamatinib, and romiplostim)? 2. Is there any comparative evidence for therapies for thrombocytopenia pertaining to important outcomes such as mortality, bleeding rates, and platelet transfusions? 3. Is there any comparative evidence based on the harms outcomes of thrombocytopenia treatments? 4. Are there subpopulations of patients for which specific thrombocytopenia therapies may be more effective or associated with less harm? Conclusions: Three guidelines, six randomized clinical trials and five high-quality systematic reviews and meta-analyses met inclusion criteria for this review. There was insufficient direct comparative evidence between different therapies to treat thrombocytopenia. A majority of trials were small and of short duration. Guidelines recommend corticosteroids and intravenous immunoglobulin (IVIg) as first-line therapy for most adults with idiopathic thrombocytopenia (ITP). Thrombopoietin receptor agonists (TPOs) and the tyrosine kinase inhibitor, fostamatinib, are recommended as second-line treatments after failure of at least one other treatment.1–3 Avatrombopag and lusutrombopag are only approved for short-term use before procedures in patients with chronic liver failure. -
Streptokinase Available Forms Indications & Dosages Interactions
streptomycin sulfate 145 streptokinase streptomycin sulfate Kabikinase, Streptase Aminoglycoside; antibiotic Plasminogen activator; thrombolytic PRC: D enzyme PRC: C Available forms Injection: 400 mg/ml; Lyophilized cake/ Available forms powder for injection: 200 mg/ml Injection: 250,000, 750,000, 1,500,000 IU in vials for reconstitution Indications & dosages ➤ TB—Adult: 1 g or 15 mg/kg IM daily, Indications & dosages or 25-30 mg/kg (max 1.5 g) 2-3 times/wk ➤ Arteriovenous cannula occlusion— ϫ ≥ 1 yr. Elderly: Reduce daily dosage Adult: 250,000 IU in 2 ml IV solution in based on age, renal function, and 8th cra- each cannula limb over 25-35 min. Clamp nial nerve function. Suggested dosage cannula 2 hr. Aspirate, flush, and re- 10 mg/kg (max 750 mg) IM daily. Child: connect. 20-40 mg/kg (max 1 g) IM daily, or 25- ➤ Venous thrombosis, PE, arterial throm- 30 mg/kg (max 1.5 g) 2-3 times/wk ≥ bosis and embolism—Adult: 250,000 IU 1yr.† IV over 30 min. Then 100,000 IU/hr IV ϫ ➤ Enterococcal endocarditis—Adult: 1 g 72 hr for DVT and 100,000 IU/hr ϫ 24- IM q 12 hr ϫ 2 wk; then 500 mg IM q 72 hr for PE and arterial thrombosis or 12 hr ϫ 4 wk with a PCN.† embolism. ➤ Tularemia—Adult: 1-2 g IM daily in di- ➤ Lysis of coronary artery thrombi asso- vided doses ϫ 7-14 d or until patient ciated with MI—Adult: 20,000 IU IV bolus afebrile for 5-7 d.† via coronary catheter; then 2,000 IU/min ➤ Plague—Adult: 2 g (30 mg/kg) IM daily infusion over 60 min. -
• All Doacs Are Cleared to Some Extent by the Kidneys
• All DOACs are cleared to some extent by the kidneys – Dabigatran 80% – Rivaroxaban 33% – Apixaban 25% – Potential for drug accumulation in patients with severe renal impairment especially below eGFRs <30 Warfarin is unaffected by renal impairment (only • Rivaroxaban & Apixaban are both oral direct inhibitor of factor Xa. • Rivaroxaban doses recommended for clinical use are 15mg od and 20 mg od (15 mg bd for first 3 weeks of treatment of DVT). • Apixaban 5mg bd or 2.5mg bd • Rivaroxaban peak plasma levels are reached 2 to 3 h after ingestion • Apixaban peak plasma levels are reached ~3hrs after ingestion • Rivaroxaban is taken with food – Apixaban without food • Rivaroxaban is 33% renaly excreted and has a half-life of 9 h in patients with normal renal function. – There is an analogy with Therapeutic LMWH – We very rarely ask for an anti-Xa assay • And what is the clinical significance of a Xa assay ? (Cut off values are largely arbitrary) – Fixed doses – Importance of When the last dose was taken ? – Importance of What is the renal function ? – If bleeding • What is the nature of the bleeding ? • In extremis we can give protamine sulphate (? Efficacy) • How to manage bleeding on a DOAC? –How severe is the bleeding ? –When was the last dose of medication ? –What is the renal function ? – Recheck –If minor bleeding; epistaxis, gingival, bruising, menorrhagia • Withhold the NOAC (when was the last dose taken?) • Recheck renal function • Check FBC • Local measures • Unlikely to require further intervention – Re-challenge – ? Switch NOAC -
Heparin-Induced Thrombocytopenia (Hit)
HEPARIN‐INDUCED THROMBOCYTOPENIA (HIT) OBJECTIVE: To assist clinicians with the diagnosis and initial management of heparin‐induced thrombocytopenia (HIT) and suspected HIT. BACKGROUND: HIT is a transient, immune‐mediated adverse drug reaction in patients recently exposed to heparin that generally produces thrombocytopenia and often results in venous and/or arterial thrombosis. HIT occurs in up to 5% of patients receiving unfractionated heparin (UFH) and in <1% who receive low molecular weight heparin (LMWH). HIT is characterised by immunoglobulin G (IgG) antibodies that recognize an antigen complex of platelet factor 4 (PF4) bound to heparin. These antibodies trigger a highly prothrombotic state by causing intravascular platelet aggregation, intense platelet, monocyte and endothelial cell activation and excessive thrombin generation. CLINICAL FEATURES: HIT typically presents with a fall in platelet count with or without venous and/or arterial thrombosis. Thrombocytopenia: A platelet count fall >30% beginning 5‐10 days after heparin exposure, in the absence of other causes of thrombocytopenia, should be considered to be HIT, unless proven otherwise. A more rapid onset of platelet count fall (often within 24 hours of heparin exposure) can occur when there is a history of heparin exposure within the preceding 3 months. Bleeding is very infrequent. Thrombosis: HIT is associated with a high risk (30‐50%) of new venous or arterial thromboembolism. Thrombosis may be the presenting clinical manifestation of HIT or can occur during or shortly after the thrombocytopenia. Other clinical manifestations of HIT: Less frequent manifestations include heparin‐induced skin lesions, adrenal hemorrhagic infarction, transient global amnesia, and acute systemic reactions (e.g. chills, dyspnea, cardiac or respiratory arrest following IV heparin bolus). -
Low Molecular Weight Heparins and Heparinoids
NEW DRUGS, OLD DRUGS NEW DRUGS, OLD DRUGS Low molecular weight heparins and heparinoids John W Eikelboom and Graeme J Hankey UNFRACTIONATED HEPARIN has been used in clinical ABSTRACT practice for more than 50 years and is established as an effective parenteral anticoagulant for the prevention and ■ Several low molecular weight (LMW) heparin treatment of various thrombotic disorders. However, low preparations, including dalteparin, enoxaparin and molecularThe Medical weight Journal (LMW) of heparinsAustralia haveISSN: recently 0025-729X emerged 7 October as nadroparin, as well as the heparinoid danaparoid sodium, more2002 convenient, 177 6 379-383 safe and effective alternatives to unfrac- are approved for use in Australia. 1 tionated©The heparin Medical (BoxJournal 1). of AustraliaIn Australia, 2002 wwwLMW.mja.com.au heparins are ■ LMW heparins are replacing unfractionated heparin for replacingNew Drugs,unfractionated Old Drugs heparin for preventing and treating the prevention and treatment of venous thromboembolism venous thromboembolism and for the initial treatment of and the treatment of non-ST-segment-elevation acute unstable acute coronary syndromes. The LMW heparinoid coronary syndromes. danaparoid sodium is widely used to treat immune heparin- ■ induced thrombocytopenia. The advantages of LMW heparins over unfractionated heparin include a longer half-life (allowing once-daily or twice-daily subcutaneous dosing), high bioavailability and Limitations of unfractionated heparin predictable anticoagulant response (avoiding the need -
Review Article
SHOCK, Vol. 41, Supplement 1, pp. 44Y46, 2014 Review Article TRANEXAMIC ACID, FIBRINOGEN CONCENTRATE, AND PROTHROMBIN COMPLEX CONCENTRATE: DATA TO SUPPORT PREHOSPITAL USE? Herbert Scho¨chl,*† Christoph J. Schlimp,† and Marc Maegele‡ *AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg; and †Ludwig Boltzmann Institute for Experimental and Clinical and Traumatology, AUVA Research Centre, Vienna, Austria; and ‡Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center, Cologne, Germany Received 15 Sep 2013; first review completed 1 Oct 2013; accepted in final form 8 Nov 2013 ABSTRACT—Trauma-induced coagulopathy (TIC) occurs early after severe injury. TIC is associated with a substantial increase in bleeding rate, transfusion requirements, and a 4-fold higher mortality. Rapid surgical control of blood loss and early aggressive hemostatic therapy are essential steps in improving survival. Since the publication of the CRASH-2 study, early administration of tranexamic acid is considered as an integral step in trauma resuscitation protocols of severely injured patients in many trauma centers. However, the advantage of en route administration of tranexamic acid is not proven in prospective studies. Fibrinogen depletes early after severe trauma; therefore, it seems to be reasonable to maintain plasma fibrinogen as early as possible. The effect of prehospital fibrinogen concentrate administration on outcome in major trauma patients is the subject of an ongoing prospective investigation. The use of prothrombin complex concentrate is potentially helpful in patients anticoagulated with vitamin K antagonists who experience substantial trauma or traumatic brain injury. Beyond emergency reversal of vitamin K antagonists, safety data on prothrombin complex concentrate use in trauma are lacking. -
Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI—Two Medical Specialties Facing a Rare Dilemma
Published online: 2019-12-05 THIEME Case Report 191 Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI—Two Medical Specialties Facing a Rare Dilemma Anastasios Tsarouchas1 Dimitrios Mouselimis1 Constantinos Bakogiannis1 Grigorios Gkasdaris2 George Dimitriadis3 Dimitrios Zioutas4 Christodoulos E. Papadopoulos1 13rd Cardiology Department, Hippokrateio University Hospital, Address for correspondence Grigorios Gkasdaris, MD, Department Aristotle University of Thessaloniki, Thessaloniki, Greece of Neurosurgery, KAT General Hospital of Attica, Athens 145 61, 2Department of Neurosurgery, KAT General Hospital of Attica, Greece (e-mail: [email protected]). Athens, Greece 3General Hospital of Katerini, Katerini, Greece 4St. Luke’s Hospital, Thessaloniki, Greece J Neurosci Rural Pract 2020;11:191–195 Abstract Spontaneous spinal epidural hematoma (SSEH) is a rare, albeit well-documented complication following thrombolysis treatment in ST elevation myocardial infarction (STEMI). A SSEH usually manifests with cervical pain and neurologic deficits and may require surgical intervention. In this case report, we present the first reported SSEH to occur following thrombolysis with reteplase. In this case, the SSEH manifested with cervical pain shortly after the patient emerged from his rescue percutaneous coronary intervention (PCI). Although magnetic resonance imaging reported spinal cord com- Keywords pression, the lack of neurologic symptoms prompted the treating clinicians to delay ► spinal epidural surgery. A dangerous dilemma emerged, as the usual antithrombotic regimen that hematoma was necessary to avoid stent thrombosis post-PCI, was also likely to exacerbate the ► spontaneous spinal bleeding. As a compromise, the patient only received aspirin as a single antiplatelet epidural hematoma therapy. Ultimately, the patient responded well to conservative treatment, with the ► cervical spine hematoma stabilizing a week later, without residual neurologic deficits. -
December 4 Saturday
ASH Meeting – Dec 5-8, 2020 CanVECTOR Oral & Poster Presentations Day / Time / Session Title Presenter Wednesday – December 2 December 2- 7:05 AM-8:30 AM The Immunohemostatic Response to Ed Pryzdial, PhD Infection Overview Program: Scientific Workshops @ ASH Session: The Immunohemostatic Response to Infection Friday – December 4 December 4 - 7:05 AM-8:05 AM Approach to Pregnancy and Delivery in Michelle Sholzberg, MDCM, FRCPC, MSc Women with Bleeding Disorders Program: Scientific Workshops @ ASH Session: Thrombosis and Bleeding in Pregnancy Prevention and Treatment of Venous Leslie Skeith, MD Thromboembolism in Pregnancy Saturday – December 5 December 5 - 7:00 AM-3:30 PM A Retrospective Cohort Study Evaluating the Kanza Naveed, Grace H Tang, MSc, McKenzie Safety and Efficacy of Peri-Partum Quevillon, RN, BScN, MN, Filomena Meffe, MD, MSc, Program: Oral and Poster Abstracts Tranexamic Acid for Women with Inherited Rachel Martin, MD, Jillian M Baker, MD, MSc, and Bleeding Disorders Michelle Sholzberg, MDCM, FRCPC, MSc Session: 322. Disorders of Coagulation or Fibrinolysis: Poster I Number: 863 Page 1 of 7 Day / Time / Session Title Presenter December 5 - 7:00 AM-3:30 PM A Retrospective Cohort Study Evaluating the Kanza Naveed, Grace H Tang, MSc, McKenzie Safety and Efficacy of Peri-Partum Quevillon, RN, BScN, MN, Filomena Meffe, MD, MSc, Program: Oral and Poster Abstracts Tranexamic Acid for Women with Inherited Rachel Martin, MD, Jillian M Baker, MD, MSc, and Bleeding Disorders Michelle Sholzberg, MDCM, FRCPC, MSc Session: 322. Disorders of Coagulation or Fibrinolysis: Poster I Number: 863 Frequency of Venous Thromboembolism in Mark Crowther, MD, David A.