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Transcript of Unique Anticoagulation Issues at University Hospitals Case Medical Center Teresa L. Carman, MD...
![Page 1: Unique Anticoagulation Issues at University Hospitals Case Medical Center Teresa L. Carman, MD Director, Vascular Medicine Case Medical Center Pager 33515.](https://reader030.fdocuments.in/reader030/viewer/2022032517/56649c9b5503460f949590d6/html5/thumbnails/1.jpg)
Unique Anticoagulation Issues at University Hospitals Case
Medical Center
Teresa L. Carman, MDDirector, Vascular Medicine
Case Medical CenterPager 33515
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Discussion
• Use of the heparin protocol
• Anti-Xa assay vs. aPTT
• Safe discharge of patients
• Anticoagulation monitoring service referrals
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Heparin Order Set
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IV Heparin Protocol• Diagnosis / Weight Based Dosing
Low intensity dosing• ACS, Stroke
High intensity dosing• VTE, CVT, Afib
• Nurse Driven Titration Titration table based on 4 hr anti-xa lab value
obtained after initial dosing or titration changes With the change in monitoring the titration table
will change to reflect a 6 hr interval for required titrations
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IV Heparin Protocol
• Full Protocol Includes:
Initial Loading Bolus
Titrated Drip
Additional (Repeat) Bolus
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IV Heparin Protocol Ordering
Choose the “Loading Dose” to order the initial bolus
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IV Heparin Protocol Ordering
Choose “Continuous Infusion” to order the drip
• Includes standard nurse driven titration protocol
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IV Heparin Protocol Ordering
Choose the “Repeat Bolus” for nursing to give a bolus based on Q 4 hr aPTT (anti-Xa) lab value
X
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IV Heparin Protocol
Why order the full protocol?
Clinical Results:
• Full protocol NOT ordered 39 hr average time to therapeutic
• Full protocol ordered 11 hr average time to therapeutic
• All patients were either therapeutic or supratherapeutic within 6 hrs
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IV Heparin Protocol
Why the 4 hour dosing change to the protocol?
• With a 6 hour protocol it usually takes 8 hours between dose adjustments
• The 4 hour protocol should decrease this interval to approximately 6 hours
• This should allow patients to a reach consistent therapeutic range sooner thus impact the risk for recurrent events
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aPTT VS. Heparin Assay Monitoring
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Overview of aPTT• The aPTT is used in most clinical laboratories to monitor
coagulation and specifically monitor anticoagulants ie. intravenous unfractionated heparin and direct thrombin inhibitors
• Clinicians have familiarity with assay
• Readily automated
• Current targets were established based on data from a post-hoc analysis of a 1972 study which suggested 1.5-2.5 times aPTT control reduced risk the of recurrent thromboembolism
Eikelboom JW. Thromb Haemost 2006;96:547-52.
Francis JL. Pharmacotherapy 2004;24:108S-19S.
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Disadvantages of Using aPTT to Monitor Heparin
• aPTT has variable a response to heparin determined by the different coagulometers and the reagents There is no aPTT “standard” When the tissue thromboplastin lot changes, a new
therapeutic range needs to be established for the new lot of reagent
• Test may be affected by numerous factors other than heparin concentration Baseline elevated aPTT makes titration difficult and
inaccurate
Eikelboom JW. Thromb Haemost 2006;96:547-52.
Francis JL. Pharmacotherapy 2004;24:108S-19S.
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Conditions that May Prolong the Baseline aPTT
• Lupus anticoagulants• Other antiphospholipid antibodies• Prekallikrein, High Molecular Weight
Kininogen Level• Low levels (<40%) of:
Fibrinogen Prothrombin Factors V, VIII, IX, X, XI, and XII
Eikelboom JW. Thromb Haemost 2006;96:547-52.
Francis JL. Pharmacotherapy 2004;24:108S-19S.
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Current Recommendations from CHEST Guidelines
• Each coagulation laboratory determines the therapeutic range for their aPTT reagent that correlates with a heparin assay level of 0.3 to 0.7 international units (IU)/mL (by anti-Factor Xa assay)
• Each laboratory must determine its own therapeutic range for heparin for the aPTT whenever the aPTT reagent changes or with a change in instrumentation Therefore, the range changes almost annually
Hirsh J. Chest 2008;133:141-59
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Monitoring
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Update on Monitoring
• As of summer 2011 the use of the “aPTT, heparin” is not available for monitoring IV unfractionated heparin therapy at University Hospitals Case Medical Center. (no correlations have been done)
• The “aPTT, heparin” has been replaced by anti-Xa monitoring using the “heparin assay, UFH”
• The use of the “heparin assay, UFH” will standardize IV unfractionated heparin monitoring and make the use of the aPTT inaccurate
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Heparin Assay
• Specifically determines anticoagulant activity of IV unfractionated heparin by measuring ability of heparin-bound antithrombin to inhibit a single enzyme
• More specific than aPTT since it measures inhibition of a single enzyme
• Major advantage is lack of biologic factors that affect its result
Eikelboom JW. Thromb Haemost 2006;96:547-52.
Francis JL. Pharmacotherapy 2004;24:108S-19S.
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Limitations of Heparin Assay
• Clinical data examining outcomes is limited
Eikelboom JW. Thromb Haemost 2006;96:547-52.
Francis JL. Pharmacotherapy 2004;24:108S-19S.
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Comparison of Monitoring with aPTT vs. Anti-Factor Xa Assay
• Prospective, single-center study
• 268 patients on IV heparin for variety of indications
• Utilizing anti-Factor Xa assay led to fewer tests and dose adjustments
• Cost increase of $1.09/day more using anti-Factor Xa assay
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
MonitoringTests/24 hours
DosageChanges/24
N=
Anti-Factor XaAssay
APTT
P<0.0001
P<0.0001
Rosborough TK. Pharmacotherapy 1999;19:760-66.
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“High-Intensity Therapeutic Heparin” Anticoagulation Orders for Adult Patients
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Current “High-Intensity Therapeutic Heparin” Anticoagulation Orders Using Heparin Assay for
Adult Patients (VTE etc)
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Current “Low-Intensity Therapeutic Heparin” Anticoagulation Orders Using Heparin Assay
for Adult Patients (ACS, stroke)
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No Changes for the Monitoring of Other Anticoagulants
• Prothrombin time/INR is still be used to monitor warfarin
• Therapeutic monitoring of direct thrombin inhibitors (bivaliruding and argatroban) still use the aPTT
• Special monitoring for enoxaparin (Lovenox®) is done by Heparin assay, Lovenox
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Summary Order Set Changes
Heparin assay, UFH will be done after initiation and dose changes as well as each morning. Timing will be changed to a 4 hour response time for all dose adjustments.
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Summary
• UH uses the heparin assay, UFH for monitoring all intravenous unfractionated heparin therapy.
• The order set will change to reflect the therapeutic ranges for “High-dose” and “Low-dose” indications “high-dose” anti-Xa = 0.3-0.7 IU/ml “low-dose” anti-Xa = 0.3-0.6 IU/ml
• The time between adjustments and monitoring will decrease to 4 hours in an effort to shorten the time to therapeutic
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Summary
• No changes will occur related to warfarin monitoring Prothrombin time/INR is the
standard
• No changes will occur related to direct thrombin inhibitor monitoring, aPTT
• Enoxaparin (Lovenox®) is monitored by the Heparin assay, Lovenox.
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Overview of the Trends In VTE Management
• Prevention** - to decrease the incidence of VTE ALL PATIENTS REQUIRE PROPHYLAXIS**
• Improved sensitivity/specificity and ease of diagnosis
• Improve treatment – increased efficacy and reliability of pharmaceuticals
• Improve outcomes - decrease risk of recurrence• Decrease longterm morbidity from VTE
Post-thrombotic syndrome (PTS) Chronic thromboembolic disease (CTED)
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Anticoagulation Committee
• Meaningful Use VTE quality measure– VTE prophylaxis within 24 hours of arrival– ICU VTE– Anticoagulation overlap therapy– Platelet monitoring for unfractionated heparin– Comprehensive discharge instructions– Incidence of potentially preventable VTE
• Approach– Fit compliance into current clinician workflow
• No additional resources• No retrospective chart abstraction
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Essentials
1. All patients require DVT prophylaxis screen on admission
2. The proper prophylaxis is ordered or an appropriate reason of ommission is documentedHospital acquired VTE is considered a “never event”
3. VTE treatment transition must meet current guidelines and this is documented and supported by the discharge orders
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VTE Quality Measure
• To meet certain care standards to prevent and treat DVT/PE
• Must complete the DVT Risk Assessment Screening on admission
– Includes orders based on risk score for both pharmacologic and mechanical
– Be sure to enter omission reason if choosing not to order prophylaxis
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Deep Vein Thrombosis Risk Screening
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Deep Vein Thrombosis Risk Screening
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Deep Vein Thrombosis Risk Screening
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Deep Vein Thrombosis Risk Screening
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Deep Vein Thrombosis Risk Screening
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Deep Vein Thrombosis Risk Screening
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Safe Discharge on Anticoagulation
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Anticoagulation Medication Reconciliation
• New drop down box specific to anticoagulant drugsShow screen shot of the drop down
• May enter up to 2 anticoagulants that the patient is being discharged on
• Will include a question about whether the patient had a DVT or PE confirmed during this hospital admission. If yes, then you must enter in the date of the diagnostic test that gave the confirmation.
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Warfarin
Anticoagulant effect (VII, IX)
vs.
Antithrombotic effect (X, II)
Anticoagulant effect can be seen within 2 days
Antithrombotic effect takes minimum of 4-5 days due to the t ½ of prothrombin (24-48 hours)
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Warfarin
• Current ACCP guidelines recommend 5-10 mg initial dosing In the elderly, patients who are debilitated, malnourished, have
CHF, liver disease or recent surgery or who are taking medications which increase sensitivity to warfarin - initial dose should be ≤ 5 mg
• Hospitals patients should RARELY receive more than 5 mg initial coumadin dosing
• Higher initial doses may be suitable for stable, healthy outpatients
• Monitoring should begin after 2-3 doses • 5 mg vs. 10 mg initial dose debate
Early INR changes are due to FVII depletion Minimum of 4-5 days are required to deplete FX and FII
Chest 2008;133(3Suppl):454-545.
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Warfarin Follow Up Appointment
All patients discharged on Warfarin:
• Discharge instructions must include an appointment for Warfarin follow up monitoring.
• Discharging provider enters this information in the follow up section on patient profile (CMC) which has a new option specific to Warfarin follow up.
• Includes: The clinic or physician that will cover the follow up monitoring
• (UH “Coumadin Clinics” are now called “Anticoagulation Monitoring Services”
Phone number Date next PT/INR is due
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Anticoagulation Monitoring Service
AKA – Coumadin Clinic
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Anticoagulation Monitoring Service Referral
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AMS Referral
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Anticoagulation Monitoring Service Referral
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Anticoagulation Monitoring Service
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Therefore – engage the PCP early and often
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Anticoagulation Management
• Must document and “manage” all aspects of anticoagulation
• Minimum of 5 days overlap required
• INR max 3 days after starting therapy
• Min every 2 days during the transition
• Need 2 checks the week following
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Anticoagulation Monitoring Service
• Monitor anticoagulation for a MANAGING PHYSICIAN Nurse driven protocol following the orders of the physician
• We ARE NOT responsible for the patient until the first visit – usually 3-5 days after dc If the visit is delayed someone else needs to be monitoring If the visit is missed someone else is responsible
• We do NOT dose adjust without orders• Expectations are that the orders are followed – any
desirable adjustments may be made and will be followed Ie shorter or longer intervals for management
• If warfarin or lovenox etc are required the managing physician must be engaged We will facilitate referrals for the physician with the pharmacy
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Warfarin Follow Up Appointment
All patients discharged on Warfarin:
• Discharge instructions must include an appointment for Warfarin follow up monitoring.
• Discharging provider enters this information in the follow up section on patient profile (CMC) which has a new option specific to Warfarin follow up.
• Includes: The clinic or physician that will cover the follow up monitoring
• (UH “Coumadin Clinics” are now called “Anticoagulation Monitoring Services”
Phone number Date next PT/INR is due
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Conclusions
• On admission ALL patients require DVT risk assessment and prophylaxis orders
• Heparin when required - use the order sets High dose vs. Low dose
• Anti-Xa monitoring is the UHCMC standard for adult patients
• Discharge on anticoagulation requires effort PCP contact for follow up AMS referral Interim plan for delays in presentation to the AMS ****LMWH or other anticoagulants may require pre-
authorization so request SW/pharmacy approvals early