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Update in Hospital Medicine
October 26, 2012
Amy O’Linn, D.O.
Clinical Associate, Department of
Hospital Medicine
[email protected]
Fairview Hospital
450 beds
Disclosures
• None
Methods
• Reviewed literature (primary studies
and guidelines) relevant to hospital
medicine from the past 12 months
• Summarized most relevant studies
Talk 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 Presentation
• ED calls: 72 year old man who was
recently diagnosed with bladder cancer
presents with acute shortness of
breath, CT PE protocol diagnoses a
right sided pulmonary embolus.
Which treatment would you
choose?
1)
2)
3)
4)
5)
6)
7)
LMWH SQ to VKA (warfarin) PO
Long-term LMWH (enoxaparin)
Dabigatran (Pradaxa) PO alone
Rivaroxaban (Xarelto) PO alone
Apixaban (Eliquis) PO alone
Fondaparinux (Arixtra) SQ daily
Idrabiotaparinux SQ weekly
Which treatment would you
choose?
1)
2)
3)
4)
5)
6)
7)
LMWH SQ to VKA (warfarin) PO
Long-term LMWH (enoxaparin)
Dabigatran (Pradaxa) PO alone
Rivaroxaban (Xarelto) PO alone
Apixaban (Eliquis) PO alone
Fondaparinux (Arixtra) SQ daily
Idrabiotaparinux SQ weekly
Rivaroxaban alone to treat PE
• Presented at ACC in March
• Randomized, open-label, eventdriven, noninferiority trial
• 4832 patients w/ acute symptomatic
PE
• Rivaroxaban (15 mg BID x 3 weeks,
followed by 20 mg qday) v. standard
therapy with enoxaparin --> VKA for
3, 6, or 12 months
Buller HR et al. NEJM 2012: 366(14), 1292.
EINSTEIN-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 7 (0.3)
site- no. (%)
26 (1.1)
Clinically relevant
nonmajor bleeding
episode- no. (%)
235 (9.8)
228 (9.5)
Buller HR et al. NEJM 2012: 366(14), 1292.
“What about me?”
The patient’s voice
• ACCP February 2012: Antithrombotic
Therapy and Prevention of Thrombosis,
9th edition Evidence-Based Clinical
Practice Guidelines.
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
MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
One selection Summary of
Results
• Arnsten et al. 1997
• 132 (43 noncompliant and 89 compliant)
warfarin patients
• Case-control study
• Telephone interviews
• VTE/AF prophylaxis
MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
One selection Summary of
Results (cont’d)
• “53% of noncompliant and 31% of
compliant individuals reported that
warfarin affected their lifestyle. 30%
and 15% respectively, reported that
warfarin restricted physical activity;
49% and 30% worried about bleeding
complications while taking warfarin,
and 60% and 34% reported that regular
blood testing was problematic.”
MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
Summary
• Values and preferences vary from
person to person.
• Uncertain “average patient” values.
• Higher disutility on stroke than GIB.
• Much higher disutility on stroke than
treatment burden.
MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.
CHEST Antithrombotic
Guidelines (Continued)
• Acute isolated distal DVT? Serial
ultrasound (Grade 2C).
• Anticoagulate empirically if high
suspicion for PE (if low suspicion,
can wait for test) (Grade 2C).
• Early ambulation in acute DVT (Grade
2C).
Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.
CHEST Antithrombotic
Guidelines (Continued)
• Proximal DVT or PE provoked by
surgery or nonsurgical transient RF:
recommend A/C x 3 months (Grade
1B).
• Unprovoked proximal DVT or PE with
low/mod bleeding risk: suggest
extended A/C therapy (Grade 1B, 2B).
If high bleeding risk, then 3 mos
(Grade 2B).
Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.
CHEST Antithrombotic
Guidelines (Continued)
• Early discharge in patients with
low-risk PE whose home
circumstances are adequate
(Grade 2B).
• In cancer patients with VTE,
LMWH long-term recommended
over LMWH to coumadin (Grade
2B).
Kearon C et al. CHEST 2012: 141(2) (Suppl): e419S-e494S.
Which treatment would you
choose?
1)
2)
3)
4)
5)
6)
7)
LMWH SQ to VKA (warfarin) PO
Long-term LMWH (enoxaparin)
Dabigatran (Pradaxa) PO alone
Rivaroxaban (Xarelto) PO alone
Apixaban (Eliquis) PO alone
Fondaparinux (Arixtra) SQ daily
Idrabiotaparinux SQ weekly
You grab a cup of coffee…
• .. And you run into an orthopedic
colleague.
• Is Rivaroxaban FDA-approved for postTKR DVT prevention?
1) Yes
2) No
You grab a cup of coffee…
• Is Rivaroxaban FDA-approved for postTKR DVT prevention?
YES
Options for VTE prevention
post-TKR/THA
• Coumadin
• Low-dose
unfractionated
heparin
• Fondiparinux
• Pradaxa (Europe)
•
•
•
•
Rivaroxaban
Apixaban (Europe)
Aspirin (reserve)
Intermittent
pneumatic
compression
Case Presentation
89 woman s/p R total knee replacement
this morning.
Pt has h/o HTN, CKD III.
Blood sugar 250.
Previously taking metformin at home.
You are consulted for medical
management.
What do you do?
What’s your reaction?
1) You do nothing. High sugars
have nothing to do with
mortality.
2) You add sliding scale.
3) Stop metformin, add longacting insulin and prandial
insulin.
4) Continue the metformin.
Example of Basal-bolus insulin in the
mgmt 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..
Example of Basal-bolus insulin in the
mgmt of non-critically ill DMII pts
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)
Insulinsensitive
Usual
Insulinresistent
>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
Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38.
What’s your reaction?
1) You do nothing. High sugars
have nothing to do with
mortality.
2) You add sliding scale.
3) Stop metformin, add longacting insulin and prandial
insulin.
4) Continue the metformin.
Case Presentation
Nurse pages you: Mrs. Smith is a
medical patient with
pyelonephritis refusing her SQ
heparin for DVT prophylaxis.
The 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 Intern
Med; 2011; 155:625-632.
The OUTs and INs
OUT
IN
• FEV1 (Vestbo J et al. Global
• FEV1/FVC <0.70
• Never smoker COPD
• Good early sepsis care
(fluids, Abx)
strategy for the diagnosis,
management and prevention
of chronic obstructive
pulmonary disease: GOLD
executive summary. Am J
Respir Crit Care Med 2012
Aug 9)
• “emphysema”
• “chronic bronchitis”
• Xigris
The OUTs and INs
OUT
• Liberal blood
transfusions (Carson JL, et
al. Red Blood Cell Transfusion
Guideliness from AABB, Ann
Intern Med 26 March 2012.)
• Confusing ways to
write sodium bicarb
(Klima T, et al. Sodium chloride
vs. sodium bicarbonate for the
prevention of contrast mediuminduced nephropathy: a RCT.
Europ Heart J (2012); 33, 2071.)
IN
• In stable pt, blood
transfusion Hg <8
• Normal Saline to
prevent contrast
nephropathy
Readmissions
• Reacting to 20% readmission rate,
Medicare is reducing reimbursements
for those hospitals that have high
readmission rates.
Teach Me Back
• Rivaroxaban
• ACCP guidelines
value patient
preferences and
suggest weighing
risk of bleeding
with VTE in every
case.
• Sugars are
important
• Universal VTE
prophylaxis is not
recommended.
• Conservative
blood mgmt.
• NS for kidneys