1 / 36

Update in Hospital Medicine

Update in Hospital Medicine . October 26, 2012 Amy O’Linn, D.O. Clinical Associate, Department of Hospital Medicine olinna2@ccf.org. Fairview Hospital. 450 beds. Disclosures. None. Methods.

amma
Download Presentation

Update in Hospital Medicine

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Update in Hospital Medicine October 26, 2012 Amy O’Linn, D.O. Clinical Associate, Department of Hospital Medicine olinna2@ccf.org

  2. Fairview Hospital 450 beds

  3. Disclosures • None

  4. Methods • Reviewed literature (primary studies and guidelines) relevant to hospital medicine from the past 12 months • Summarized most relevant studies

  5. 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

  6. 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.

  7. Which treatment would you choose? • 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

  8. Which treatment would you choose? 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

  9. Rivaroxaban alone to treat PE • Presented at ACC in March • Randomized, open-label, event-driven, 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.

  10. EINSTEIN-PE Outcomes Buller HR et al. NEJM 2012: 366(14), 1292.

  11. “What about me?”The patient’s voice • ACCP February 2012: Antithrombotic Therapy and Prevention of Thrombosis, 9th edition Evidence-Based Clinical Practice Guidelines. MacLean S et al. CHEST 2012: 141(2) (Suppl): e1S-e23S.

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. 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.

  17. 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.

  18. Which treatment would you choose? • 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

  19. You grab a cup of coffee… • .. And you run into an orthopedic colleague. • Is Rivaroxaban FDA-approved for post-TKR DVT prevention? • Yes • No

  20. You grab a cup of coffee… • Is Rivaroxaban FDA-approved for post-TKR DVT prevention? YES

  21. Options for VTE prevention post-TKR/THA Rivaroxaban Apixaban (Europe) Aspirin (reserve) Intermittent pneumatic compression • Coumadin • Low-dose unfractionated heparin • Fondiparinux • Pradaxa (Europe)

  22. 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?

  23. What’s your reaction? • You do nothing. High sugars have nothing to do with mortality. • You add sliding scale. • Stop metformin, add long-acting insulin and prandial insulin. • Continue the metformin.

  24. Example of Basal-bolus insulin in the mgmt of non-critically ill DMII pts Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38..

  25. Example of Basal-bolus insulin in the mgmt of non-critically ill DMII pts Umpierrez GE et al. J of Clin Endocrin & Metab, January 2012, 97 (1):16–38.

  26. What’s your reaction? You do nothing. High sugars have nothing to do with mortality. You add sliding scale. Stop metformin, add long-acting insulin and prandial insulin. Continue the metformin.

  27. Case Presentation Nurse pages you: Mrs. Smith is a medical patient with pyelonephritis refusing her SQ heparin for DVT prophylaxis.

  28. The value of VTE prophylaxis 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.

  29. The OUTs and INs OUT IN FEV1/FVC <0.70 Never smoker COPD Good early sepsis care (fluids, Abx) • FEV1(Vestbo J et al. Global 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

  30. The OUTs and INs OUT IN In stable pt, blood transfusion Hg <8 Normal Saline to prevent contrast nephropathy • 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 medium-induced nephropathy: a RCT. Europ Heart J (2012); 33, 2071.)

  31. Readmissions • Reacting to 20% readmission rate, Medicare is reducing reimbursements for those hospitals that have high readmission rates.

  32. 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

More Related