Am Fam Physician. Martin K, Beyer-Westendorf J, Davidson BL, et al. Low-molecular-weight heparin is recommended as the anticoagulant of choice in patients with cancer and venous thromboembolism; however, direct oral anticoagulants may be appropriate in select situations. 5. Version 1.2019. American Academy of Family Physicians (AAFP) guidelines recommend the use of oral anticoagulants with a CHADS2 score higher than 1.19 These guidelines also allow for anticoagulation in patients with a CHADS2 score of 1 in certain circumstances.19 The recently published American Heart Association (AHA) /American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines recommend a direct oral anticoagulant over vitamin K antagonists, unless the patient has moderate-to-severe mitral stenosis or a mechanical heart valve.20 Anticoagulation is recommended for male patients with a CHA2DS2-VASc score of 2 or higher and female patients with a CHA2DS2-VASc score of 3 or higher. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.
Antimicrobials Ciprofloxacin Clarithromycin (Biaxin) Erythromycin Fluconazole (Diflucan) Isoniazid Metronidazole (Flagyl) Trimethoprim/sulfamethoxazole Voriconazole (Vfend) Cardiovascular* Amiodarone Fluvastatin (Lescol) Gemfibrozil (Lopid) Lovastatin (Mevacor) Complementary and alternative medicine Devil's claw Garlic Ginkgo biloba Miscellaneous Alcohol (acute ingestion) Phenytoin (Dilantin) Sertraline (Zoloft). Mentias A,
Chest. If the patient's INR becomes subtherapeutic or supratherapeutic, the frequency of monitoring should be increased until the INR stabilizes again. Lane DA, / afp Standard treatment involves systemic chemotherapy with cisplatin-containing regimens, followed by surgical resection of residual neoplasm if a positive response is achieved. Andexanet alfa for acute major bleeding associated with factor Xa inhibitors. et al. Mahaffey KW, Mahaffey KW, Antithrombotic therapy for atrial fibrillation. AFP is the major glycoprotein of fetal serum and resembles albumin in molecular weight, amino acid sequence, and immunologic characteristics.
Liu A, ; However, an investigation of serum markers of angiogenesis demonstrated that levels observed in pregnancies with and without evidence of placenta accreta were similar.35, VINCENT ARLET, JEAN OUELLET, in Surgical Management of Spinal Deformities, 2009. et al. Most of the recommendations are based on the 10th edition of the American College of Chest Physicians (ACCP) guidelines on antithrombotic therapy for VTE disease (Table 1).1–5, Suggest initiating aspirin to prevent future VTE in patients with an unprovoked DVT or PE who decide to stop anticoagulation (grade 2B), Aspirin should not be considered a substitute for anticoagulation but is suggested for patients who wish to stop therapy and not pursue lifelong anticoagulation following an unprovoked DVT or PE, Recommended for outpatient treatment of non–cancer-associated provoked or unprovoked VTE over vitamin K antagonists (grade 2B) and LMWH (grade 2C), Simplification of anticoagulation management: no need for frequent dosage adjustments or international normalized ratio monitoring Andexanet alfa (Andexxa) is available to reverse apixaban (Eliquis) and rivaroxaban (Xarelto), and idarucizumab (Praxbind) is available to reverse dabigatran (Pradaxa), Recommended for outpatient treatment of cancer-associated provoked or unprovoked VTE over direct oral anticoagulants (grade 2C) and vitamin K antagonists (grade 2B), Two studies have demonstrated a reduction in recurrence of VTE in patients with cancer treated with a direct oral anticoagulant (e.g., rivaroxaban, edoxaban [Savaysa]) compared with LMWH (e.g., dalteparin [Fragmin]); however, the studies also demonstrated an increased risk of bleeding, specifically in patients with esophageal or gastroesophageal cancer 4,5 CHEST guidelines have not been updated in response to these studies*, Suggest care at home or early discharge for patients with low-risk PE who have adequate home support (grade 2B), Criteria: clinically stable; no recent bleeding, no advanced renal disease, no advanced hepatic disease, no thrombocytopenia (< 70 × 103 per μL [70 × 109 per L]); adequate support at home and ability to adhere to regimen; patient feels comfortable with home care; no evidence of right ventricular dysfunction; normal cardiac biomarkers Pulmonary Embolism Severity Index may be used to help stratify risk, Suggest changing to LMWH if recurrence while on vitamin K antagonists or direct oral anticoagulants (grade 2C) If recurrence while on LMWH, suggest increasing dose by one-fourth to one-third (grade 2C), If unable to increase intensity, consider insertion of an inferior vena cava filter, Low-risk subsegmental PE without proximal DVT, suggest surveillance instead of anticoagulation (grade 2C), suggest anticoagulation if higher risk of recurrence (grade 2C), Factors associated with true subsegmental PE compared with a false-positive result on computed tomography: high-quality imaging; multiple filling defects; defects in proximal subsegmental vessels; multiple images with same defect; defect surrounded by contrast; symptoms consistent with PE; multiple views with defect; high pretest probability for PE; positive unexplained d-dimer assay results Factors associated with high risk of progression or recurrence: hospitalized patients; immobility or reduced mobility; cancer; unprovoked; low cardiopulmonary reserve; severe symptoms that cannot be explained otherwise All patients should be evaluated for DVT by ultrasonography of lower extremities; additional testing to rule out DVT is indicated for patients with signs or risk of an upper extremity DVT or a central-line–associated DVT. Our Right to Heal highlights the powerful personal and professional experiences of Black Canadian women fundraisers.
Dowlati A, Accessed May 2, 2019. https://www.pradaxa.com, 10. January CT, Wann LS, Calkins H, et al. Hokusai VTE Cancer Investigators. Accessed May 2, 2019. https://www.bevyxxa.com/wp-content/uploads/2017/11/bevyxxa-betrixaban-capsules-prescribing-information-pdf, Eliquis (apixaban) tablets, for oral use [prescribing information]. Mazurek M,
Although LMWH has a similar bleeding risk and lower heparin-induced thrombocytopenia risk compared with unfractionated heparin, a patient with a history of heparin-induced thrombocytopenia should not take LMWH.1, Enoxaparin (Lovenox) 1 mg per kg subcutaneously every 12 hours or 1.5 mg per kg subcutaneously every 24 hours, Enoxaparin 1 mg per kg subcutaneously every 24 hours if CrCl < 30 mL per minute per 1.73 m2 (0.50 mL per second per m2), ASH guidelines suggest not routinely monitoring anti–factor Xa levels forpatients who are obese or those with renal impairment, Unfractionated heparin and LMWH considered equally effective and safe Unfractionated heparin may be better for patients with high bleeding risk because of short half-life and reversibility Unfractionated heparin may be favorable in patients with CrCl < 30 mL per minute per 1.73 m2 LMWH has lower incidence of heparin-induced thrombocytopenia but should not be used in patients with previous episode, Dalteparin (Fragmin) 200 units per kg subcutaneously once daily, Use with caution and monitor anti–factor Xa levels in patients with CrCl < 30 mL per minute per 1.73 m2, Fondaparinux (Arixtra) Weight < 110 lb (50 kg): 5 mg subcutaneously daily Weight 110 to 220 lb (50 to 100 kg): 7.5 mg subcutaneously daily Weight > 220 lb: 10 mg subcutaneously daily, Use with caution in patients with CrCl 30 to 50 mL per minute per 1.73 m2 (0.50 to 0.83 mL per second per m2) Contraindicated in patients with CrCl < 30 mL per minute per 1.73 m2, Routine monitoring not suggested; if elected for monitoring, use anti–factor Xa levels with fondaparinux as the reference standard for the assay, LMWH and fondaparinux have comparable effectiveness and safety Longer half-life for fondaparinux is advantageous (daily dosing) and potentially troublesome (adverse effects and lack of reversibility) Although not U.S. Food and Drug Administration approved for heparin-induced thrombocytopenia, fondaparinux has been used for the management of these patients.
Dabigatran versus warfarin in patients with atrial fibrillation [published correction appears in. et al. Select drug-drug interactions that are considered to potentiate or inhibit the effects of vitamin K antagonists are listed in Table 4.8 When an interacting drug is initiated or discontinued, more frequent INR checks are recommended. Secondary versus primary stroke prevention in atrial fibrillation. (Or your team.) ;
2013;11(9):1647–1654. et al.
Savaysa (edoxaban) tablets, for oral use [prescribing information].
Liu A, Andexanet alfa (Andexxa) is a genetically modified variant of factor Xa that binds and sequesters factor Xa inhibitors. An advantage to evening administration is the ability to adjust or hold the dose the same day that the INR result becomes available. Pradaxa (dabigatran etexilate mesylate) capsules for oral use [prescribing information]. Direct oral anticoagulants should be used as first-line agents for the treatment of venous thromboembolism and the prevention of stroke in patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc score of 2 or higher in men and 3 or higher in women. Blood Adv.
/ Vol. Monitoring should then be decreased to twice weekly until the INR is within the therapeutic range, then decreased to weekly, every other week, and finally monthly.4 The ACCP guidelines recommend INR monitoring once every 12 weeks for patients who are stable (defined as at least three months of consistent results with no required adjustment of vitamin K antagonist dosing). Apixaban versus warfarin in patients with atrial fibrillation. https://www.aafp.org/afp/2013/0415/p556.html, 37. du Breuil AL,
The search included meta-analyses, randomized controlled trials, clinical trials, clinical guidelines, and reviews.
et al. In one institution, the percentage of patients necessitating shunt placement was reduced when stricter criteria were used, including permissive mild ventricular dilatation and the presence of symptomatic hydrocephalus (Chakraborty et al., 2008). All rights Reserved. Bloomfield HE, 2005;71(10):1979–1982.https://www.aafp.org/afp/2005/0515/p1979.html. Milling TJ Jr, This content is owned by the AAFP. From: Medical Management of the Thoracic Surgery Patient, 2010, Michael D. Klein, in Pediatric Surgery (Seventh Edition), 2012, Elevated alpha fetoprotein (AFP) in both maternal serum and amniotic fluid and elevated amniotic fluid acetylcholinesterase (AChE) have been correlated with abdominal wall defects when there is no myelomeningocele.96 In a study of 23 pregnancies with gastroschisis and 17 with omphalocele, second-trimester serum AFP was 9.42 times greater than normal in gastroschisis and 4.18 times normal in omphalocele.97 Another study found elevated amniotic fluid AFP in 100% of pregnancies with gastroschisis and in only 20% of those with omphalocele. The Hokusai VTE cancer trial evaluated dalteparin with edoxaban in patients with active cancer.3 The primary outcome (recurrent VTE and/or major bleeding) did not differ between treatment groups (P = .006 for noninferiority).3 There was a decrease in recurrent deep venous thrombosis in favor of the edoxaban group (3.6% vs. 6.7%; HR = 0.56; CI, 0.32 to 0.97) but an increase in major bleeding in that group (6.9% vs. 4.0%; HR = 1.77; 95% CI, 1.03 to 3.04).3 Gastrointestinal malignancy was also found to be a risk factor of increased gastrointestinal bleeding when using a direct oral anticoagulant vs. LMWH.3 Therefore, direct oral anticoagulants should be used with caution in patients with cancer who have a history of gastrointestinal malignancy or bleeding. Chaudhury P, 2018;36(20):2017–2023.
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