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Coagulation Disorders

Terms in this set (22)

age (doubles with decade > 50)
History of VTE (Strongest)
Drug Therapy (estrogen, contraception)

Venous stasis (MI, CHF, immobility, paralysis, A-Fib, LV dysfunction)

Vascular Injury (catheter, trauma, surgery)

Hypercoagulability (C and S deficiency, antithrombin deficiency, malignancy)
What are the RF's for VTE?
. C resistant/ 5 mutation - C degrades factor V which helps stop coagulation cascade. In this mutation, factor V is resistant to protein C

. Prothrombin Mutation - increased levels of prothrombin = more clotting

. S deficient - Protein S activates protein C

. Antithrombin deficient - antithrombin inactivates factors X and II
Hypercoaguable disorders

Hereditary:
. C resistant/ 5 mutation -
. Prothrombin Mutation -
. S deficient -
Antithrombin deficient -
. Pregnancy - increased levels of estrogen

. Antiphospholipid antibodies - antibodies
activate coagulation cascade and inactivate
protein C and S

. Drug therapy - estrogens

. Cancer - cancer
Hypercoaguable disorders

Acquired
. Pregnancy -
. Antiphospholipid antibodies -
. Drug therapy -
. Cancer -
thrombosis is a common cause of death in cancer pts

risk increases in hospitalized pts

increased mortality
increased risk
increased risk of bleeding with long-term anticoagulation
Clinical impacts of VTE and Cancer
Digestive cancer: pancreas, liver, stomach, esophagus

Brain
Leukemia/lymphoma

Higher stage
Histology - adenocarcinoma
Highest in first 3-6 months after cancer diagnosis
What are the highest risk factors in cancer pts?
calf or leg swelling
leg pain
warmth
edema
erythema
palpable vein
Homans sign
Signs of DVT
dyspnea
tachypnea
tachycardia
hemoptysis
chest pain
cough
Signs of PE
D-dimer (0-250)

elevated in presence of clot
DVT / PE lab diagnostics
Duplex ultrasonagraphy
- can measure rate and blood flow and visualize clot / can't reliably detect small clots in distal veins

Contrast Venography (GOLD)
- can see entire venous system
- contraindicated in nephrotoxicity or dye allergy
DVT Testing
Non-Invasive

Invasive
ventilation perfusion
- preferred in pts with renal insufficiency or allergies to dye

Contrast CT
- uses contrast dye so unsuitable for pts with poor renal function

****
Pulmonary angiography (GOLD)
- contraindicted in pts with renal dysfunction and dye allergy
PE Testing
Non-Invasive


Invasice
Indication: DVT +/- PE

Dose: 80 u/kg IV bolus + 18u/kg/hr IV

Comment: titrate to goal aPTT
Treatment
UFH

Indication:
Dose:
Comment:
Indication: Acute DVT w/o PE

Dose: 1mg/kg SC q12h

Comment: CrCl < 30 = 1mg/kg SC once daily
Treatment
Enoxaparin (outpatient)

Indication:
Dose:
Comment:
Indication: DVT +/- PE

Dose: 1mg/kg SC q12h OR
1.5mg/kg once daily

Comment: CrCl < 30 = 1mg/kg SC once daily
Treatment
Enoxaparin (Inpatient)

Indication:
Dose:
Comment:
Indication: VTE in cancer

Dose: 200u/kg SC QD x 1 month, THEN 150u/kg SC QD x 5 months

Comment: CrCl < 30 = Anti Xa level target is 0.5-1.5
Treatment
Dalteparin

Indication:
Dose:
Comment:
Indication: DVT or PE

Dose:
< 50kg = 5mg SC QD
50-100kg = 7.5mg SC QD
> 100kg = 10mg SC QD

Comment: < 30 mL/min = contraindicated
Treatment
Fondaparinux

Indication:
Dose:
Comment:
5mg QD with goal INR = 2-3
normal starting dose for warfarin?
UFH - aPTT or anti- Xa (0.3-0.7)

LMWH (enoxa or dalte) - Anti-Xa (0.5-1)

Fondaparinux - none

Warfarin - INR 2-3

DOACs - none
Monitoring:

UFH -
LMWH (enoxa or dalte) -
Fondaparinux -
Warfarin -
DOACs -
LMWH x at least 6 months

Second episode of recurrent = indefinite
Prevention of recurrent VTE
NTI
Frequent monitoring
potential interactions with drugs and food
frequent interruptions due to procedures
warfarin resistance
What are the disadvantages or warfarin in cancer?
Body weight adjusted dosing
no lab monitoring
predictable response
rapid onset of action

has less recurrence of VTE and less bleeding
What are the advantages of LMWH over warfarin in cancer?
initial = rivaroxaban

Long term = edoxaban or rivaroxaban for at least 6 months
How would we use DOACs?
5 days of parenteral then switch to DOAC for at least 6 months
Edoxaban or dabigatran with UFH/LMWH
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