It used to be SOOO much more complicated, but since we entered the era of the #DOACs, #lifeisgood! #Physicians #nurses #pharamcists all work together to make it happen, and all can earn CE/#CME here! @AlexSpyropoul @scottkaatz @RenatoDLopes1 @GenoMerli @aakonc @vic_tapson pic.twitter.com/HK1Qz0NUBS
— cardio-met (@cardiomet_CE) December 13, 2021
2) This program is supported by an educational grant from Bristol Myers Squibb & its Alliance partner Pfizer, Inc., & is intended for healthcare professionals. Faculty disclosures are listed at https://t.co/gvXca4G9Xm. Earn credit from prior programs at https://t.co/U6Mo1oSwIh.
— cardio-met (@cardiomet_CE) December 14, 2021
4) At least we didn’t have to check #PTTs while waiting for the #INR to bump. Rare patients even stayed entirely on enoxaparin. Oncology patients with #VTE might stay long-term on #dalteparin. But the big advance came with the advent of #NOAC (now #DOAC) therapy for #VTE.
— cardio-met (@cardiomet_CE) December 14, 2021
6) Two more alternatives to enox+warfarin, #dabigatran & #edoxaban, were also approved by #FDA, but only after a lead-in (usually 5 days) with enox or UFH. Effective, safe, but NOT monotherapy, not as convenient. Could still–maybe–be outpatient, but only with self-injection.
— cardio-met (@cardiomet_CE) December 14, 2021
8) Want to check out the pivotal trials?#dabigatran: https://t.co/RMaHn2TDP9#edoxaban: https://t.co/diBqrhnCGY#rivaroxaban: https://t.co/7vrnEvBsR9 and https://t.co/zbddANSlcf#apixaban: https://t.co/9VAVPR8iUj
— cardio-met (@cardiomet_CE) December 14, 2021
10) … less diet and drug interactions, and do not require regular monitoring (https://t.co/QdYbZinpbh). Due to their rapid onset of action, initial bridging with SQ #LMWH is also not routinely required. In addition, real-world data have demonstrated that the bleeding risk …
— cardio-met (@cardiomet_CE) December 14, 2021
12) This applies particularly to patients with hepatic or renal impairment & other concerns such as cancer or antiphospholipid syndrome. Patents at extremes of body weight, whose adherence is questioned, or who have recurrent VTE or have had high-risk #PE in the past.
— cardio-met (@cardiomet_CE) December 14, 2021
14) Talk about “ahead of his time”: in 1998 @PhilWellsMD1 published “Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection” and showed . . .
— cardio-met (@cardiomet_CE) December 14, 2021
16) So certainly with oral monotherapy we should be able to safely manage MOST DVT from the #emergencydepartment or the #observationunit. For example, in #AMPLIFY (see https://t.co/955DCPMene) mean hospital LOS for VTE patients treated with #apixaban was 0.57 days.
— cardio-met (@cardiomet_CE) December 14, 2021
18) Still, it’s not SO easy. Patients with a serious diagnosis (as any but the most trivial DVT often is) must have appropriate follow-up arranged and must be educated on the importance of adherence to #antithrombotic therapy. (This applies after inpatient admission, too.)
— cardio-met (@cardiomet_CE) December 14, 2021
20) . . . for quick disposition, planning must be in place for the required dose transition after initiation. So tell me, on what days does the dose transition for #apixaban and #rivaroxaban, respectively, occur in the management of #VTE?
— cardio-met (@cardiomet_CE) December 14, 2021
22) Welcome back! We are talking rapid disposition of #acute #VTE with #antithrombotic #monotherapy. So far we have focused on #DVT, but today we’ll get to early d/c of #PE also. This is your ONLY source for CE/#CME-accredited, serialized education on Twitter! I am @md_pollack.
— cardio-met (@cardiomet_CE) December 15, 2021
24) Both drugs offer “starter packs” which could be a mixed blessing–outstanding for after-hours dispensing and who doesn’t like a blister pack to improve compliance?? But don’t send that patient home without arranging f/u for him/her before that transition date!
— cardio-met (@cardiomet_CE) December 15, 2021
26) By label, #apixaban requires no dose adjustment for patients with renal impairment, including those with end-stage renal disease (ESRD) on dialysis, for the treatment of #VTE and reduction in the risk of recurrent VTE following initial therapy.
— cardio-met (@cardiomet_CE) December 15, 2021
28) … #clinicians in 🇺🇸 are OK with doing it. But direct discharge home from #emergencydepartment after a diagnosis of acute #pulmonaryembolism? That has created much more 🫀burn. Why? Because #PE is a more immediate life threat, because #PE is usually …
— cardio-met (@cardiomet_CE) December 15, 2021
30) … inform who should NOT go 🏡directly from the ED. Your patient should have an sPESI score (see https://t.co/rwewzP4BBY and calculate score at https://t.co/oBoc7yRQzE) of ZERO before you consider home care and careful follow-up. Your patient should NOT have …
— cardio-met (@cardiomet_CE) December 15, 2021
32) … ischemic 🫀 , chronic lung, or liver or renal disease, thrombocytopenia, or cancer), ●abnormal mental status or lack of good home support, or ●worrisome concomitant #DVT (a high clot burden may the risk of death or warrant additional therapy).
— cardio-met (@cardiomet_CE) December 15, 2021
34) https://t.co/DUE9ILZ3Wn: open label trial of 344 patients w/symptomatic PE & low risk of 🪦 randomized to inpatient IV #UFH+#warfarin or outpatient #LMWH+#warfarin. Outpatients had sl higher rate of recurrent VTE (0.6% v 0%) & major bleeds (1.8% vs 0%) at 90d, NS.
— cardio-met (@cardiomet_CE) December 15, 2021
36) At three months, there were no bleeding events, recurrent VTE, or 🪦. Also, https://t.co/VXiMDSMFxF: prospective analysis, 525 PE pts d/c’d early on rivaroxaban; 0.6% developed symptomatic non-fatal VTE recurrence at 3 months follow-up and bleeding rates were low (1.2%).
— cardio-met (@cardiomet_CE) December 15, 2021
38) Mark your response and return tomorrow for the answer, a wrap-up of this program, and your link to FREE CE/#CME—#physicians #nurses #Pharmacists. Nod to @RosovskyRachel @FoozFlower @ProfMakris @EfaviRENZO @EBondarsky @GenoMerli @NotoriousS1Q3T3 @geek_md @ThromboAdviser
— cardio-met (@cardiomet_CE) December 15, 2021
40) I am @md_pollack and as to yesterday's poll: the answer is B. We'll look at the Hestia criteria, but the significance here is that instead of focusing just on NOT admitting acute #PE for safety or medicolegal concerns, we're looking for even better ways to ID good candidates.
— cardio-met (@cardiomet_CE) December 16, 2021
42) Hestia criteria: https://t.co/7weH0kc7ht; calculator at https://t.co/2UTWIoLdIg.
— cardio-met (@cardiomet_CE) December 16, 2021
Now look at https://t.co/VecoW958cX, in which Hestia and sPESI were compared. Bottom line: For triaging PE patients, the Hestia rule strategy had similar safety & effectiveness as w/ sPESI. pic.twitter.com/CTPX7Z6VRC
44) Must #PE be definitively ruled out in patients with #DVT being considered for wholly outpatient #antithrombotic care? This question has bona fide historical origins, as "back in the day," one of the EXCLUSION 🚫criteria for d/c from the #ED with #DVT (in those days not . . .
— cardio-met (@cardiomet_CE) December 16, 2021
46) … and going north. What we've learned is that if the patient isn't sufficiently symptomatic either to warrant admission for symptoms or to score not-low-risk on sPESI or Hestia, then it shouldn't block early discharge.
— cardio-met (@cardiomet_CE) December 16, 2021
48) And that's it! You just earned 0.5h CE/#CME credit! Claim it at https://t.co/e8tjIDJcfN. I am @md_pollack. FOLLOW US for more FREE accredited #tweetorials from expert authors! Also check out our companion CE/#CME feed from @ckd_ce! @MedTweetorials #FOAMed #CardioTwitter
— cardio-met (@cardiomet_CE) December 16, 2021