Hematology and Oncology Book

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Anticoagulation in ThromboembolismAka: Pulmonary Embolism Anticoagulation, Deep Vein Thrombosis Anticoagulation, PE Anticoagulation, DVT Anticoagulation

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  1. See Also
    1. Deep Vein Thrombosis
    2. Pulmonary Embolism
  2. Disposition
    1. Pulmonary Embolism
      1. Inpatient Anticoagulation
    2. Deep Vein Thrombosis
      1. Inpatient or outpatient management depending on risk
      2. See Deep Vein Thrombosis
  3. Consider Thrombophilia work-up
    1. See Thrombophilia
    2. Reserve blood for tests prior to Anticoagulation
  4. Select form of Heparin
    1. Standard Heparin
      1. See Weight based Heparin nomogram for dosing
    2. Low Molecular Weight Heparin
      1. See Low Molecular Weight Heparin for dosing
      2. Efficacy
        1. Equivalent to standard Heparin in non-massive PE
          1. Quinlan (2004) Ann Intern Med 140:175
          2. Mismetti (2005) Chest 128:2203
      3. Enoxaparin (Lovenox) 1 mg/kg twice daily or
      4. Enoxaparin (Lovenox) 1.5 mg/kg once daily or
        1. Single daily dosing not recommended for home use
      5. Tinzaparin (Innohep) 175 anti-Xa IU per kg daily
        1. Dose (ml): (weight in kg) x 0.00875 ml/kg daily
  5. Start Warfarin (Coumadin) concurrent with Heparin
    1. Contraindicated in pregnancy
      1. See DVT in Pregnancy
    2. Start Warfarin at 5 mg PO daily on Day 1-2
      1. See Warfarin for further dosing information
      2. Study: 10 mg start was therapeutic 1.4 days earlier
        1. Kovacs (2003) Ann Intern Med 138:714
    3. Check INR in 3-5 days
    4. Therapeutic INR: 2.0 to 3.0 IU
      1. Continue Heparin until INR is therapeutic
  6. Duration of Anticoagulation
    1. Symptomatic isolated calf vein thrombosis: 6-12 weeks
    2. Low risk patient: >3 months
      1. First episode or
      2. Reversible thromboembolism risk
    3. First idiopathic DVT or PE: >6 months
      1. New guidelines suggest using only 3 months of initial therapy
      2. At three months triage to stop or use longterm Anticoagulation based on risk
    4. Recurrent DVT or PE: >12 months
    5. Thrombophilia: >12 months and consider life-long
  7. References
    1. Hyers (2001) Chest 119:176S

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