Transcript Internal medicine Case Presentation

Auto Anti-coagulation and VTE
Prophylaxis
Hilary Rowe, BScPharm
VIHA Pharmacy Resident 2009-10
Internal Medicine Rotation
November 5th, 2009
Outline
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Objectives
Patient Case
Background
Clinical Question
Review of Evidence
Recommendation
Monitoring
Objectives
• Review pathophysiology for auto anticoagulation & clinical presentation
• Discuss evidence of auto anti-coagulation
• Discuss therapeutic options for VTE
prophylaxis
Mr. JE
• ID: 33 yo Caucasian male, ht 170cm, wt
55kg
• CC: ER by ambulance Sept 1/09 for
weakness & falls-jaundice, ascites
• HPI Oct 19/09: Small esophageal
varices, ascites
• PMHx: chronic lower back pain, alcohol
abuse x 14 years
Mr. JE
• Meds PTA: None
• Allergies: None
• SH: Homeless, estranged from family,
smoker (30 pack yr hx), drinks 26 oz
(780mL) vodka a day x 14 yrs
• Discharge Plan: To family
Review of Systems
System
CNS
Findings
•Alert and Oriented x 3
•Difficulty sleeping in
hospital
HEENT
Unremarkable
Psych
Anxiety, headache, seizures
Medications
Zopiclone
3.75 mg at hs
prn
CIWA protocol
Review of Systems
System Findings
Resp
Unremarkable
Cardio
Unremarkable
GI
•No hematemesis,
•FOB neg x 3
•Endoscopy small
esophageal varices
Medications
Nadolol 40mg od
Review of Systems
System
Findings
Medications
Liver
•Alcoholic liver cirrhosis
•Ascites
•Negative paracentesis
cultures
•Furosemide
100mg daily
•Spironolactone
100mg bid
GU
•SrCr 76
•CrCl 95ml/min
Review of Systems
System
Heme
Findings
•↓ Hgb 101, MCV 98, ↑ RDW
21.4, ↓ Plt 92
•Iron 8 ↓ , ferritin 50, B12 535,
RBC folate 1134
•↑ INR 1.9, ↑ Tbili 361, ↓Alb
25, ↑ GGT 78, ALP 129,
↑
AST 81
Fluids & ↓ Na 125, K+ 4.3, ↓ Cl 89
Lytes
Medications
•Fe fumarate
600mg at hs
•Multivitamin
daily
Medical Problems List
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Alcohol addiction
Alcoholic cirrhosis
Ascites
Esophageal varices
Anemia of chronic disease & iron
deficiency anemia
• Chronic lower back pain
DRP’s
• JE is at increased risk of COPD, CVD
and cancer secondary to smoking,
requiring tobacco cessation counseling
• JE has a mixed anemia secondary to
iron deficiency and anemia of chronic
disease, requiring monitoring of his
anemia therapy
DRP’s
• JE is at an increased risk of VTE
requiring assessment of his need for
DVT prophylaxis despite his elevated
INR of 1.9
Alcoholic Liver Cirrhosis
• Decrease in pro-coagulants
– Can’t make II, VII, IX, X
• Decrease in anti-coagulants
– Can’t make Protein C, S & antithrombin III
• PT & INR measures activity of procoagulants and doesn’t capture
changes in anti-coagulants
• PT does not predict bleeding risk
Risk Factors For VTE
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Recent surgery or major trauma
Immobility or paralysis
Malignancy
Previous VTE
>80 years
Smoking
Varicose veins
Inherited or acquired thrombophilia
CTU Discussion
Rounds
• Team discussed that patient had been
in hospital for a significant amount of
time and might need VTE prophylaxis
• Team wanted to know if his elevated
INR of 1.9 would protect him?
Clinical Question
P
33 year old male with an elevated INR
secondary to alcoholic liver disease
I
VTE Prophylaxis
C
No VTE Prophylaxis
O
Reduce the risk of DVT and PE
Reduce morbidity and mortality
Decrease hospitalization
Search Strategy
• PubMed, Embase, Google
• Search terms:
– Liver cirrhosis
– Risk of Thromboembolism
– DVT, Pulmonary embolism
– Auto anticoagulation
• Found
– 2 retrospective case control studies
Northup et al. Am J Gastroenterol 2006
Retrospective matched case control study
Design
1993-2001
•Patients from all admissions (medical, ICU,
P
surgical) with cirrhosis assessed for diagnosis
of VTE during hospitalization
•Patients with an elevated prothrombin time
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and INR from cirrhosis with a VTE
•Patients with an elevated prothrombin time
C
and INR from cirrhosis without a VTE
•VTE in cirrhosis patients: DVT, PE & both
O
•Serum albumin
Northup et al. Am J Gastroenterol 2006
Inclusion & exclusion:
•Patients from all admissions, (medical, ICU,
surgical) with cirrhosis assessed for diagnosis
of VTE during hospitalization
•Matched with a cirrhotic patient with the same
gender, age, race, # comorbidities, presence of
cancer, occurrence & type of surgery
•Excluded if previous VTE or portal vein, splanic
vein, mesenteric vein or central line VTE
Northup et al. Am J Gastroenterol 2006
•Lower albumin in patients with VTE
*38-53g/L normal, 1g/dL=10g/L
•Elevated INR did not protect patients from VTE
Northup et al. Am J Gastroenterol 2006
Results:
•VTE in cirrhosis patients 113/21,000 (0.5%)
-74/113 (65.5%) DVT
-22/113 (19.5%) PE
-17/113 (15%) Both DVT & PE
-Serum albumin independently predicts VTE
(p<0.001, OR 0.24 95% CI 0.10-0.55)
Northup et al. Am J Gastroenterol 2006
Limits:
•Retrospective
•No “gold standard” for VTE diagnosis so events
could have gone undetected
•Small sample size = higher type II error
•Factors that may have been unmatched
•21% had prophylaxis (33% medically, rest SCD’s)
•Did not discuss # in each group who got
prophylaxis
Northup et al. Am J Gastroenterol 2006
Conclusions
• Deficiencies of antithrombin III, protein C &
protein S are associated with ↑ risk of VTE
• Serum albumin may be indicator for level of
proteins made by liver such as Antithrombin
III, protein C & S
↑ INR does not decrease risk of VTE
Sogaard et al. Am J Gastroenterol 2009
Design Retrospective case control study 1980-2005
P
•Patients with a discharge diagnosis of DVT or
PE
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•Patients that developed a VTE
C
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•Patients that didn’t develop a VTE
•Assessed association between liver disease &
overall risk of VTE and unprovoked VTE
Sogaard et al. Am J Gastroenterol 2009
• Unprovoked VTE=patient without diagnosis of
cancer before or within 90 days of VTE, or
diagnosis of fracture, trauma, surgery,
pregnancy 90 days before VTE
• Each case matched with 5 population
controls without a VTE by age, gender,
county
• Patients with several VTE’s had their first
event used
Sogaard et al. Am J Gastroenterol 2009
Sogaard et al. Am J Gastroenterol 2009
Results
• 20% (99,444/496,872) had a VTE
• 22% (67,519/308,614) had unprovoked VTE
Sogaard et al. Am J Gastroenterol 2009
Limits
• Retrospective
• Relied on coding of Danish nationwide
registry for diagnosis of VTE
• No data on lifestyle factors
• Declining risk of VTE in past 10 years
– Is this due to prophylaxis?
Sogaard et al. Am J Gastroenterol 2009
Conclusion
• Both cirrhotic and non-cirrhotic liver
disease are risk factors for VTE
Goals of Therapy
Patients Goals
• Abstinent from alcohol
Team Goals
• Prevent VTE
• Prevent hospitalization
• Decrease morbidity & mortality
• Minimize adverse drug events
• Keep patient abstinent (quality of life)
• Find housing (quality of life)
Therapeutic Options
•No DVT prophylaxis
•Sequential compression devices
•Heparin 5000 units sc bid
•Dalteparin 5000 units sc daily
Recommendation
• Dalteparin 5000 units subcutaneous daily
• Try to mobilize patient as soon as possible
• Initiate smoking cessation counseling
Monitoring
Adverse Events
Monitor
Who
When
How Long
Pain &
bruising at inj
site
Bleeding-in
urine, bowel,
nose etc.
Patient
After inj
Daily while
on therapy
Patient &
nurse
Daily-after
urination,
bowel
movements
etc.
Daily while
on therapy
Monitoring
Efficacy
Monitor
Who
When
How Long
Shortness of Patient &
breath
Physician
Daily
Duration of
therapy
Pain in the
legs
Redness &
Swelling in
legs
Daily
Duration of
therapy
Duration of
therapy
Patient &
Physician
Patient &
Physician
During
physical
exam
summary
Summary
Question: Does elevated INR protect patient
from a VTE?
Answer:
• ↑ INR does not decrease risk of VTE
• ↓ albumin independently predicts VTE risk
Future:
• Study VTE prophylaxis in this population &
predict benefit & risk of bleed
Questions?
References
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Northup PG, McMahon MM, Ruhl AP et al. Coagulopathy does not fully
protect hospitalized cirrhosis patients from peripheral venous
thromboebolism. Am J Gastroenterol 2006;101:1523-28.
• Sogaard KK, Horvath-Puho E, Gronbaek H et al. Risk of venous
thromboembolism in patients with liver disease: a nationwide
population-based case-control study. Am J Gastroenterol
2009;104:96-101.