Thread by @cardiomet_CE

Don’t miss a new accredited #tweetorial launching TOMORROW here on @cardiomet_CE. #Emergencymedicine #thrombosis researcher @md_pollack will be discussing safe, effective management of selected patients with venous thromboembolism (#VTE) from the #emergencydepartment.

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

1) Welcome to a #tweetorial on the safe and effective management of acute venous #thromboembolism (#VTE) directly from the #emergencydepartment. This program is accredited for 0.50 credits for #physicians #nurses #pharmacists by @academiccme! I am @md_pollack.

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 cardiometabolic-ce.com/disclosures/. Earn credit from prior programs at cardiometabolic-ce.com.

3) So @md_pollack became interested in #VTE when the only accepted treatment was IV unfractionated heparin (#UFH) as a bridge to #warfarin therapy. What a pain--for providers and patients! Then along came #LMWH, and the favored recipe became #enoxaparin as a bridge to warfarin.

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.

5) From comparison to enox+warfarin, #FDA approved #apixaban and #rivaroxaban as alternatives, and either could be used as #antithrombotic #monotherapy, WITHOUT a need for monitoring . . . though dose adjustments, primarily for #renal function, might be required.

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.

7) The REAL advantage of antithrombotic MONOTHERAPY, at least to us in #emergencymedicine (& payors!), was the potential for wholly #outpatient treatment of VTE. If you don't need injections, then maybe you don't need a hospital bed! That's the case for #apixaban & #rivaroxaban.

8) Want to check out the pivotal trials?
#dabigatran: nejm.org/doi/full/10.10…
#edoxaban: nejm.org/doi/full/10.10…
#rivaroxaban: nejm.org/doi/full/10.10… and nejm.org/doi/full/10.10…
#apixaban: nejm.org/doi/full/10.10…

9) So this became a risk stratification exercise. Could patients suitable for discharge home on oral #antithrombotic #monotherapy be safely identified? For #DVT without #PE, this proved not to be so difficult. DOACs have more predictable pharmacokinetics and pharmacodynamics ...

10) ... less diet and drug interactions, and do not require regular monitoring (pubmed.ncbi.nlm.nih.gov/24946813/). 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 ...

11) ... profile with DOACs is non-inferior, and in some cases superior to warfarin (nejm.org/doi/full/10.10…; nejm.org/doi/full/10.10…; pubmed.ncbi.nlm.nih.gov/27550177/). Still, appropriate consideration & patient education regarding treatment is required.

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.

13) Very large clot burden or #iliofemoral clots may warrant at least short-term inpatient care. It is NOT necessary to perform a #CTscan of the lungs to exclude #PE before outpatient #DVT management as long as the patient is not manifesting acute pulmonary symptoms or hypoxia.

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 . . .

15) . . . "patients can safely and effectively perform home self-injection under the supervision of a hospital-based nurse. Injections at home by a homecare nurse are similarly effective." See pubmed.ncbi.nlm.nih.gov/9738611/

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 ahajournals.org/doi/10.1161/JA…) mean hospital LOS for VTE patients treated with #apixaban was 0.57 days.

17) Seems the rest of 🌎was way ahead of 🇺🇸 in keeping DVT out of the hospital. You saw 🇨🇦 from @PhilWellsMD1 back in #14. Down under 🇦🇺 onlinelibrary.wiley.com/doi/full/10.10… reported marked reduction in hospital & hospital-in-the-home DVT admissions compared to the prev 30 months (p < 0.001).

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.)

19) The complications of even "uncomplicated #DVT" include #clot extension, #pulmonary #thromboembolism, and #postthrombotic syndrome. Patients must understand that great meds don't work if they aren't taken as directed! And while the #monotherapy #DOACs are ideal . . .

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?

21) Mark your answer and return tomorrow to continue this discussion! #hematology #Cardiotwitter #isth @NATFthrombosis #FOAMed @connors_md @Clotmaster @SnayCardsPharmD @AlexSpyropoul @couminator @beaverspharmd @VietHeartPA @Lross246 @ThromboAdviser @radcliffeVASCU @baileyannRN