1b) Our expert author is #pharmacist Craig Beavers, PharmD @beaverspharmd CV Clinical Pharmacy Specialist @UK_COP, and Immediate Past Chair of the @ACCinTouch #ACCCVT Section pic.twitter.com/WTJUabPoQM
— cardio-met (@cardiomet_CE) November 22, 2022
3) 🧠-starting case: 67♂️ taking apixaban 5mg twice daily for 1 mo for #LV thrombus presents with #AMS and found to have #ICH on CT. Last known well 1 hour ago; last dose 4 hours ago. pic.twitter.com/pNxj0fBafa
— cardio-met (@cardiomet_CE) November 22, 2022
5a) Well, the nihilist in me says none of the above! With that scan in a pt with a seemingly reliable history of apixaban use, I don't need to wait around for a test that doesn't quantify magnitude of #anticoagulation on #DOAC therapy. But I asked, so . . .
— cardio-met (@cardiomet_CE) November 22, 2022
6) Briefly, how common is major bleeding with #DOACs? The rate can be up to 4⃣% when pooling the data across populations.
— cardio-met (@cardiomet_CE) November 22, 2022
See 🔓https://t.co/LhgUqeIP31
8) Thus, efficient management is critical and knowing proper assessment is key for success! Appropriate downstream treatment, which includes #reversal agents and supportive care, require proper assessment pic.twitter.com/dp7uR4iKwN
— cardio-met (@cardiomet_CE) November 22, 2022
10) The 4 high-level categories: H&P, identification of source, defining severity, & laboratory evaluation. My adaption of this can be found Figure 1 in this amazing article: https://t.co/L3FwEItM7l
— cardio-met (@cardiomet_CE) November 22, 2022
So…we are key things details need to be grabbed in the H&P? Comment below.
12) 💊?s:
— cardio-met (@cardiomet_CE) November 22, 2022
-Agent/dose?
-Last dose given?
-Overdose?
-Renal/hepatic disease?
14) Of course, ⬇️#renal/#hepatic function extends these ⏱️ pic.twitter.com/6CNYxAAs4g
— cardio-met (@cardiomet_CE) November 22, 2022
16) Identification of source: Of course the H&P will help, but use of diagnostic imaging may also be needed to establish & confirm. Typically, this would include, but not limited to, non-contrast CT for #ICH, #endoscopy for GI bleeds, and potential #ultrasound/#echocardiography pic.twitter.com/ZhMJTpaG1h
— cardio-met (@cardiomet_CE) November 22, 2022
18a) Finally, lab assessment…do you recall? Which of these three #DOACs is least impacted by renal clearance?
— cardio-met (@cardiomet_CE) November 22, 2022
a. Apixaban
b. Edoxaban
c. Rivaroxaban
19a) Remember our case from tweet 3? 67♂️ taking #apixaban who presents with #AMS + #ICH on #CT. Last known well 1h ago; last dose 4h ago.
— cardio-met (@cardiomet_CE) November 22, 2022
In terms of coagulation assessment, let’s get a brief review of our options (ref https://t.co/wbsmZm6Y2f): pic.twitter.com/JADuSu78qt
19c) The 2021 International Council for Standardization in Haematology (ICSH) Recommendations for Laboratory Measurement of DOACs provide a great overview: https://t.co/lfshpJu0nG
— cardio-met (@cardiomet_CE) November 22, 2022
👉Fig 1 ➡️ concentration effect on lab assay. Dashed orange area ➡️⬆️variability in assessment: pic.twitter.com/Axy6v8XMUI
21) ISCH recommendations in #bleeding 🩸🩸🩸🩸 (with caveat): pic.twitter.com/jU6IzXVWew
— cardio-met (@cardiomet_CE) November 22, 2022
23)
— cardio-met (@cardiomet_CE) November 22, 2022
🩸In acute bleeding: Coag testing is not used for determining anticoag status if pt on #DOAC & significant bleeding occurring
🩸Prolonged coags can be helpful to determine residual effect but not to withhold treatment, given lack of true assays & therapeutic cutoffs
25) 🔑 points:
— cardio-met (@cardiomet_CE) November 22, 2022
🩸No data support adjusting dose of reversal agent #andexanet_alfa based on severity/location of bleed, anti-Xa levels, or other clinical characteristics.
🩸In pts on aFXa #DOACs with life-threatening bleed, do not delay giving therapy for lab results.
26b) In THIS patient, choose D. In perhaps a less severe case, such as a #GI_bleed with some response to fluid resuscitation, B (calibrated to #apixaban) would be best! pic.twitter.com/BVF1oHKkbq
— cardio-met (@cardiomet_CE) November 22, 2022
28) A team of #hematology, #cardiovascular, #emergency_medicine, #pharmacists, #nursing, lab, and imaging should help develop an anticoagulation reversal protocol/guideline to help drive appropriate decision making considering the 4 pillars of assessment discussed above.
— cardio-met (@cardiomet_CE) November 22, 2022
30) Take home messages: pic.twitter.com/Krcjjq1iNP
— cardio-met (@cardiomet_CE) November 22, 2022
31) That's it! Now go claim your 0.5h 🆓CE/#CME at https://t.co/mQGE1VsSmR and FOLLOW US for more expert-led #accredited #tweetorials–the only programs delivered wholly on Twitter!
— cardio-met (@cardiomet_CE) November 22, 2022
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