Hematology and Oncology
Venous thromboembolism PROPHYLAXIS options
As a critical care pharmacist, it is crucial to identify patients who require venous thromboembolism (VTE) prophylaxis and those who should avoid it. According to the CHEST Guidelines, prophylaxis is recommended for acutely ill hospitalized medical patients at increased risk of thrombosis (hip replacement, obesity, cancer, advanced age, etc) , unless contraindicate…
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Side Effects
How to REVERSE bleeding due to Pradaxa or Xarelto
As a hospital pharmacist, the new oral anticoagulants are bringing up questions about how to reverse bleeding due to Pradaxa or Xarelto . Antidotes for Pradaxa (dabigatran) or Xarelto (rivaroxaban) are NOT available in many hospitals, like vitamin K for warfarin . But there are things you can do. Stopping the anticoagulant and w…
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Warfarin
When to Rely on WARFARIN Instead of a DOAC
As a clinical pharmacist, you will need to know when and why warfarin is sometimes preferred over a direct oral anticoagulant (DOAC). We’ve seen DOACs ( Eliquis , etc) take the lead for most uses, such as for atrial fibrillation or venous thromboembolism (VTE). But sometimes warfarin is still the go-to. Continue to rely on warfarin for patien…
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DOACs
Ensure appropriate DOAC dosing
As a clinical pharmacist, you are in a key position to prevent direct oral anticoagulant (DOAC) dosing errors. Advocate for a pharmacist-to-dose protocol, recent evidence suggests this can reduce DOAC errors by almost half. Require an indication for DOAC orders and when documenting home DOACs to verify appropriate dosing. And include other key factors within your pr…
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HIT
DOACs are options for treating HIT
As a hospital pharmacist, you will get questions about using direct oral anticoagulants (DOACs) for heparin-induced thrombocytopenia (HIT) . We usually treat HIT with IV argatroban or sometimes IV bivalirudin or subcutaneous fondaparinux ( Arixtra ). Then we transition to warfarin ( Marevan ) once the platelet count recovers, usually 150,000/mm3 or higher. Now there&…
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Stroke
Clinical pharmacology of DOACs
Mechanism of action ㅡ Direct Oral Anticoagulants (DOACs) or Non-Vitamin K Antagonist Oral Anticoagulant (NOACs) are Direct Thrombin Inhibitors (e.g., Dabigatran) and Factor Xa Inhibitors (e.g. Rivaroxaban, Apixaban, Edoxaban) with prothrombinase activity, thus inhibiting the conversion of prothrombin to thrombin, see figure 1 . Thrombin c…
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Dual Antiplatelet Therapy
Limit bleeding risk in patients on triple antithrombotic therapy
How to manage patients on an anticoagulant (warfarin, etc) who also need antiplatelet medications ( aspirin , etc)? ㅡ Many patients end up on " triple antithrombotic therapy " such as warfarin for atrial fibrillation PLUS clopidogrel ( Plavix ) and aspirin after a stent. But bleeding risk is high. One in 50 patients will have a serious bleed in the first…
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Surgery
How to manage direct oral anticoagulants (DOACs) around surgery?!
As a clinical pharmacist, you'll face questions about how to manage direct oral anticoagulants ( Eliquis , etc) around an elective procedure or surgery. Direct oral anticoagulants (DOACs) kick in and wear off faster than warfarin, so they need to be managed differently around procedures. Explain it's okay to continue DOACs for many low-bleeding-risk proced…
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GIT and Liver
Safety of using anticoagulants in patients with cirrhosis
As a hospital pharmacist, you'll see anticoagulants used more often to treat thrombosis in patients with cirrhosis . We're used to thinking of these patients as having an increased bleeding risk due to impaired clotting factor production and thrombocytopenia. But don't consider them "auto-antico…
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Thromboembolism
Simple guide for venous thromboembolism (VTE) prophylaxis after surgery or hospitalization
When is venous thromboembolism (VTE) prophylaxis needed after hospitalization? Not very often . Stay alert for appropriate use. Hip or knee replacement patients Continue to recommend VTE prophylaxis for 14 to 35 days after knee or hip replacement. Recommend using a direct oral anticoagulant (DOAC), such as Eliquis (apixaban) or Xar…
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Oncology
Using DOACs for venous thromboembolism due to cancer
As a clinical pharmacist, you'll continue to see a shift toward direct oral anticoagulants ( Eliquis , etc) for cancer-associated venous thromboembolism (VTE). We're used to seeing these patients on a low-molecular-weight heparin (LMWH), such as enoxaparin ( Clexane ) or warfarin ( Marevan ) as an alternative. But evidence with DOACs is stacking up for VTE du…
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Peripheral Artery Disease
Optimizing medications for peripheral artery disease
How to manage stable peripheral artery disease (PAD)? ㅡ Now that Xarelto (rivaroxaban) is approved for this use. Think of managing peripheral artery disease (PAD) as similar to coronary artery disease . Plaque buildup puts peripheral artery disease (PAD) patients at high risk of complications, such as cardiovascular (CV) events or limb amputation. And they may devel…
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Hematology and Oncology
Note on treating venous thromboembolism (VTE)
Discover key insights into managing venous thromboembolism (VTE) with our concise guide. From preferred anticoagulants to treatment duration and recurrence management, we unravel critical considerations for optimal patient care. Which anticoagulant is preferred? How long should anticoagulation be used? When might a low-dose DOAC be considered long-term? …
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Direct Oral Anticoagulants
Antiplatelets for arterial clots and anticoagulants for venous clots
It can be tricky to know when to recommend an antiplatelet, an anticoagulant, or both... These are some important questions to know the difference between antiplatelet and anticoagulant, and when to use each other... What Are Antiplatelets and Anticoagulants? Antiplatelets : Medications like aspirin, clopidogrel (Plavix), and ticagrelor (Briliq…
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