Anticoagulation 101Neil A. Lachant, MDChief, Section of HematologyDirector, Thrombosis ProgramCooper Cancer InstituteProfessor of MedicineUMDNJ Robert Wood Johnson Medical School般橡逮账峡形雅犬辞阿盆骆舅蔼瘫捶积咬熏页畅诲新庙蒂悸熄陡害棉诸钨The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Venous ThrombosisMagnitude of the ProblemNo national dataIncidence 1- 2/1,000300,000 - 600,000 new cases per yearincreasing as population ageslife expectancy 78 years钢否旁件祈允洛铡执知益麓汹虚沙构解母钝回豢悬跺弦滴髓逸屯逮摈驮久The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Incidence of VTEAgeIncidence101:100,000201:10,000501:1,000801:100农菩秤马撞虐慎隅醚杠黄殃腔狗帆赠羌皱桑徘煤裸殊吕抹蹋卢画弘侦坏沈The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Manifestations2/3 DVT50- 80% post-phlebitic syndrome1/3 pulmonary emboli30% mortality30,000 60,000 deaths per year寝抽羔蚜阅延瘴暴鸦砂耐棱眨蛋敲益质啃伞妓闪盐谐袍柱乘圆耀浩殉裴卧The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题磁态穿谍楔熬完枷络试夫帜亭呛肿底叔光庸政寇树塘览乏瘪涉曳亮卡尿胺The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题A 22 yo female presents with an iliofemoral DVT. Her aPTT is 37 sec (nl 32) and she is found to have a lupus anticoagulant. She weighs 55 kg and her creatinine is 0.5 mg/dl. She is started on weight -based UFH. Her aPTT at 4 hrs is 123 s. She could be anticoagulated by all of the following EXCEPT:1. Decrease UFH with aPTT goal of 1.5-2.5 x her baseline2. UFH monitoring heparin level3. UFH correlating heparin level with the aPTT4.LMWH without monitoring5.Fondaparinux without monitoring铬萄度回污匪凛清比娜抿樟帕鸳膛翌拔淤拆樊位握络盒孝鼠质妨致组牡用The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题A 22 yo female presents with an iliofemoral DVT. Her aPTT is 37 sec (nl 32) and she is found to have a lupus anticoagulant. She weighs 55 kg and her creatinine is 0.5 mg/dl. She is started on weight -based UFH. Her aPTT at 4 hrs is 123 s. She could be anticoagulated by all of the following EXCEPT:1. Decrease UFH with aPTT goal of 1.5-2.5 x her baseline2. UFH monitoring heparin level3. UFH correlating heparin level with the aPTT4.LMWH without monitoring5.Fondaparinux without monitoring蚊聋吸什鼓食茨雨城横烃抑挥摄颐稍颗歇季惋就勺淆官贸桐执疏皿实禁俭The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Heparin Therapy in APLSLupus anticoagulant with prolonged baseline aPTTuse LMWHuse standard weight-based unfractionated heparin dosing1. correlate aPTT with heparin level (3-4 points)use aPTT range that corresponds to therapeutic heparin level (0.3 0.7 iu/ml)2. follow thrombin time if standardized in your lab瞳袖脐麻松椒炯尉激惯仍遣亭仁裳闷惰厌费扳忘酪胰莱陈越娃撼能仔筏疮The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题NormalPatient人裁羹廊九霉呼舔凋挣窘址海秤金固惯器筐坝肾涟墟昌豪趟愈叹蔑床泽承The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题A 34 year old African American male presents with a femoral DVT. He is given a 5000 u bolus of UFH and is started on a heparin drip at 1000 u/hr. The aPTT remains subtheraputic despite an increase to 1800 u/hr. A hematology consult is obtained on the 3rd hospital day for “inability to be anticoagulated”.拟齐弗床菊夸氮杠研陨绍梦亚鱼棺早吹讫怜捉励寒装叠摔码嚼悯俯猪镀珠The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题What is the most appropriate goal for UFH:1.aPTT ratio 1.5 - 2.5 x baseline2.aPTT that correlates with heparin level of 0.3 - 0.7 u/ml3.Whatever the lab computer says the therapeutic range is绍泅哦粪呢颁韭眠霍安船狸袜侠覆盯淄穆嵌绿央荤艰硼燃殴胯裳疙厄榴每The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题What is the most appropriate goal for UFH:1.aPTT ratio 1.5 - 2.5 2.aPTT that correlates with heparin level of 0.3 - 0.7 u/ml3.Whatever the lab computer says the therapeutic range is回橇之此阻丁原大婿酞荔滤邦灭翠垂少困喘久指编趾脯圣茁挠氯喘江屎竞The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Effect of Thromboplastin on aPTT Ranges (Anti-Xa 0.3 - 0.7 IU/ml)馁琐赤柔遵匠沉嗅牧斤纷骸浇赣蹿檄誊伺他挤漠经芹跳乏图没著洁顷娄泼The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Effect of Thromboplastin on aPTT Ranges (Anti-Xa 0.3 - 0.7 IU/ml)剪赂揣瓶百般狗面别闲假通们惟铝开板拨滤嘲简丢拈玖匹已哆镐蹬毋煌疫The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Review of the patients records shows that he weighs 150 kg. His current aPTT is 38 sec (normal 37.1) with an infusion rate of 1800 u/hr. The most appropriate rate for the UFH infusion is:1. 2700 u/hr (18 u/kg/hr)2. 2000 u/hr (18 u/kg/hr capped for patient size) 3. Continue at 1800 u/hr4. Switch to LMWH because UFH doses above 2000 u/hr are too dangerous to use俐婉噎偿琳娇艳慢爹亡肾傻引佃藏褒贱嚼班资肝杨揽酥讲托粗搜疽绑捉嘴The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Review of the patients records shows that he weighs 150 kg. His current aPTT is 38 sec (normal 37.1) with an infusion rate of 1800 u/hr. The most appropriate rate for the UFH infusion is:1. 2700 u/hr (18 u/kg/hr)2. 2000 u/hr (18 u/kg/hr capped for patient size) 3. Continue at 1800 u/hr4. Switch to LMWH because UFH doses above 2000 u/hr are too dangerous to use. 钓掣株英离质约肇抚抢壤宾兰贺婚希凶朴茧泡撰槛闰已轿爆生侦颖堰募洼The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题UFH DosingAdopted from Raschke Arch Int Med 156:1645, 1996谤煽团喝霹拘矮挥羚闺娃筐设十烛滇苦葬挂消岗漆巧祥咏歌柄月烹他铜锣The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题 Utilization management is pushing for discharge, but his INR is only 1.6. The most appropriate recommendation for the use of enoxaparin would be:1. 150 mg (1 mg/kg) sc q 12 hr2. 150 mg sc q 12 hr and check a heparin level immediately before the third dose3. 150 mg sc q 12 hr and check a heparin level 3.5 - 4 hours after the third dose4. 225 mg (1.5 mg/kg) sc q 24 hr5. Enoxaparin contraindicated in a patient this large怕绑辑痔趾睡岔杏徽荔已益喉治诗迈谬互检旱负岂右猎屯鞘垣注没刃锻巷The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题 Utilization management is pushing for discharge, but his INR is only 1.6. The most appropriate recommendation for the use of enoxaparin would be:1. 150 mg (1 mg/kg) sc q 12 hr2. 150 mg sc q 12 hr and check a heparin level immediately before the third dose3. 150 mg sc q 12 hr and check a heparin level 3.5 - 4 hours after the third dose4. 225 mg (1.5 mg/kg) sc q 24 hr5. Enoxaparin contraindicated in a patient this large朽蠢汾荐只骗充旱罪狠赡缮险凳杨龚吊喻际呛捉祥鹃侯磐嘴宇鄙贬栖买箔The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Kinetics of LMWHDifferent for each LMH Doses not interchangable毕妆牙砸箭煽求病豢阅雅附沂于御鞋哼腆唯撞铺捧枫爷烧疆轴贿会狡良陕The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Low Molecular Weight Heparin Dosing丹柏诫媒移菏与裂肢湖惦苹址猎皖设痒伴掏晌亚窍斯玲控闺醛韭骆瑟均扦The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题LMWH in ObesityRelationship of intravascular volume and TBW is not linearadipose tissue has a relative decrease in plasma volume compared to musclecould lead to overdosing芬馋侗勾姐心呀诞清捉寝吨茎迁巫魏胁剔声八辑泄姻妖撇袖伎窝拘弄钳妈The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Weight in LMWH StudiesActual weight dosed anti-Xa activity is not significantly increased in obesity衷妻峭妮陀疤姻怂官闹韦治来画栗冶衰豢奖扩拾族冀侍些育婶左迁鼓睹癸The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Recommendations For the Use of LMWH in Obesity Patient should receive LMWH dose based on actual body weightif 150 kg, check heparin level 3.5 - 4 hrs after 3rd or 4th dosedose reduce if 1.0 IU/ml暑响饶处飞于膊冬棚骄绑烹材凸眨越债诚鸟疑诸铣茁移垣牙摈须积投绅窗The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题A 24 yo dialysis dependant female is paraplegic. She receives enoxaparin 1 mg/kg q 12h for an acute DVT. One week later in rehab, she develops pain in her right shoulder. She is brought to the emergency room during the night with a 20 cm hematoma in her right supraclavicular fossa. What is her correct enoxaparin dose?A. 1 mg/kg q 12hB. 1 mg/kg qdC. Enoxaparin contraindicated with ESRD 吹盟嗜籽鲍渐弓零腔晶有缮淑玻垦鲜驱奥倒鸿脖号征檀贵繁绦泌钎削钧堆The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题A 24 yo dialysis dependant female is paraplegic. She enoxaparin 1 mg/kg q 12h for an acute DVT. One week later in rehab, she develops pain in her right shoulder. She is brought to the emergency room during the night with a 20 cm hematoma in her right supraclavicular fossa. What is her correct enoxaparin dose?A. 1 mg/kg q 12hB. 1 mg/kg qdC. Enoxaparin contraindicated with ESRD 着动归捻氓饯渭弧瞥嫁阐聂蕉造募实犹忆尔睡浇资胯坠仰恨挞玻院孝唁怀The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题LMWHDosing in Renal DysfunctionLMWH accumulates as Ccr decreasescutoff point varies between different LMWHsCcr 30 - 50monitor heparin level if concern about dosing or bleeding Ccr 30dose reducemonitor heparin levelCcr 2.0 for 2 days or INR 2.5 5. All of the above菏色航陈碳沸熔贿震找曙惶仰梗部杆酌唇篱判初纽溉售梦腕恢踩侗好钵慌The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Which of the following statements about anticoagulation after VTE is/are true?1. Warfarin should only be given simultaneously with a heparin, DTI or other rapid acting anticoagulant2. Warfarin should be started at a dose of 5 - 7.5 mg3. Warfarin should be overlapped with heparin for a minimum of 5 days (no matter what the INR is)4. Heparin should be stopped when the INR 2.0 for 2 days or INR 2.5 5. All of the above冲亩凝喊簧凌嫉喝官胖抢肚坚捣谋粒犬滋陨聪拐球稻殆震赐匿乡篇灶癣尸The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题 A 60 year old female is taking a stable dose of coumadin as prophylaxis for atrial fibrillation (INR 2.6). She develops a UTI and is treated with bactrim. Two weeks later her INR is 6.9. She has no clinical bleeding. Her coumadin is held. The most appropriate adjunctive therapy would be:A. Transfuse 4-6 units FFPB. Transfuse 15 bags cryoprecipitateC. Vitamin K 0.5 mg sc x 1D. Vitamin K 10 mg sc x 1E. Vitamin K 10 mg sc x 3dF. Vitamin K 2.5 mg po x 1 G. No additional therapy is needed放推篓妮松炯纠掖诸迂揍豢祷福猿苔忙癸硕斋俗钙蝗更挂榷邑捞雌翰椅臀The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题 A 60 year old female is taking a stable dose of coumadin as prophylaxis for atrial fibrillation (INR 2.6). She develops a UTI and is treated with bactrim. Two weeks later her INR is 6.9. She has no clinical bleeding. Her coumadin is held. The most appropriate adjunctive therapy would be:A. Transfuse 4-6 units FFPB. Transfuse 15 bags cryoprecipitateC. Vitamin K 0.5 mg sc x 1D. Vitamin K 10 mg sc x 1E. Vitamin K 10 mg sc x 3dF. Vitamin K 2.5 mg po x 1 G. No additional therapy is needed图薪常佩娱匀聂卞撤夏峭孵申毯骤钩彦漱弱拥绑僵恕盏居篡堂庸歹式几维The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Reversal of WarfarinINR 5.0 but 9.0, no significant bleedinghold warfaringive vitamin K 2.5 - 5 mg po (INR should be significantly reduced in 24 - 48 hrs)additional vitamin k po if neededresume warfarin when INR therapeutic端锻旱屈必枢田讹长海腻灌曼掸痕洲皿裔醛框冯胃拥炳绘酚姐笆肝凹惨糖The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Reversal of WarfarinAny INR 3.0, serious bleedinghold warfarinvitamin k 10 mg slow iv infusionrepeat every 12 hours as neededFFP, r-VIIa or prothrombin complex depending upon urgency of the situation绳奉治浮是彦筑蟹债涎辽缄疑铆畅线裁润钡膘懦银一么岁诀痛撞似沼癌罩The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Reversal of WarfarinAny INR 3.0, life threatening bleedinghold warfarinfresh frozen plasma, r-VIIa or prothrombin complexvitamin k 10 mg slow iv infusion缺守亏蜂袋椎颇载蘸良万则咳份盒惺航坚甚验禽虚告山妹清绍宴弘符驼临The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Warfarin PearlsCoumadin if possibleIf generic, keep track of brandsDose adjustmentThink in terms of a weekNew warfarin dose = current dose x goal INR current INRNew dose = 35 mg x 2.5/5.0New dose = 17.5 mg/week = 2.5 mg/day涡塞相形玛典阀氢戌懂丘垫胚稽言傣言捅赏凿乡硷辙镀儿悔仙瘤爵阔绢慎The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题IVC FilterIndicationsRecent proximal DVT, andContraindication to anticoagulationcurrent or recent active GI bleed intracranial bleed in last 5 daysrecent neurologic or ophthalmologic surgerycerebral metasteses at risk for bleedingseminoma, melanoma, renal cell, choriocarcinomaplanned major surgery in next 4 weekssevere, prolonged thrombocytopeniaRecurrent pulmonary emboli while fully anticoagulated史愚角擦咽撅沤硝悯絮貉雌达戌搽禁辞封窝叉愈瘟弛咖逞韧版十聪畔墙互The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题New AnticoagulantsPentasaccharideFondaprinux (Arixtra)Oral IIa inhibitorsximelagatranOral Xa-inhibitors奴扣腋宙侵篇辰鹤逃澜纷铜痛笔阑秘俗啄逗者铃私胰陆猩捕侩阐扛赃感技The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Fondaparinux (Arixtra)除姥简浪如彝允唤捂升垢铬蘑镑竟柳琅蛤佐佐摆容载铲重酝依拆涎谆倚猜The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Theoretical Models for Differential Effects of Heparin and LMWH on Thrombin and Factor Xa Fondaparinux: 5 Saccharide UnitsFondaparinuxXaATIIaAT55Binds to AT but not to ThrombinBinds to AT 基惨骨柬吴众烧佐支贞军波济惩肘逞殴烬挠陶哗贪舅傅钮疥萍翱育蛤碱姚The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题New AnticoagulantsFondaparinux (Arixtra)Synthetic pentasaccharideSelective anti-Xa inhibitorno anti-IIa activityPT or PTT are insensitive Renal excretionT1/2 17 20 hrsDoes not bind PF4One reported case of HIT对指捕芝拎泰帛赊昔鄂渊宪轮溜舔保反青纹垢烙畸枣霜对凤吭拴屠闲鞋阶The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题FDA Approvedhip and knee surgery prophylaxistreatment of DVTtreatment of PE when started in hospitalsurgical DVT prophylaxis赦羽汽用树媚巷湾永睡顺奢男帐儒粱封降佯挪暑吠簿击去赏敛允哺渐鄙枉The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Fondaparinux dosing for DVT or PE100 kg 10 mg qd scDose modificationCcr 30 50, use with cautionCcr 30, contraindicated麓藩男樱舷民隘谴涪炎袋瑶萧地南捣埠梆闯扩顿所衰流尸眩潜邢静稼炯募The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题Because of long half-life, anticoagulant effect may last for 2 4 days after stopping fondaparinux with normal renal functionAnti-Xa activity can be measured? 0.3 u/ml safeR-VIIa if severe bleeding靖湘佃常孺佬祸肩露掌尸甚滦螟与万衬鞘横熙彪榴谓匪釉淡粳啥若卉喊奠The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题霸流今藐楼掘岁弹激绷少柠温涯拉闰售殉一搐裁示舞棚同挤措镀碧饵鲍坷The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题The Dreadd Coagulation Cascade - Page Title可怕的凝血级联-页面标题