EM:RAP Emergency Medicine: Reviews and Perspectives

2012  ›  December Episode

Clotting Problems

So many anticoagulants. So little time! 

Contributors

  • Tom Deloughery, MD
  • Rob Orman, MD

Comments on Clotting Problems

Scott W., M.D.

Do you have social workers in the ED arrange with pt's inurance company/pharmacy to make sure they can get the LMW heparin (isn't it still very expensive)? What do you do for the uninsured? Do you have the ER nurses do the injection teaching?

Rob O

Hi Scott-
For insured patients, we write a script for a five day supply. For an uninsured patient who cannot afford the drug, we have our social workers arrange for the hospital to fill the prescription before the patient leaves.
As far as instruction, there is a video that explains the process and then the nurses make sure that the patient or family member can administer the drug. So instruction comes from two different sources-video tutorial and nurse education.

Scott W., M.D.

Thanks Rob. BTW...enjoy your segments hope you meet some great docs in Colorado to continue the series.

Mazdak M., Dr

Could you please give me a time frame for DVT treatment duration according to the most common underlying conditions , and the veins which are involved , Thx

Andrea W., M.D.

I'm interested to hear if anybody else is using Rivaroxaban instead of Warfarin for treatment of DVT. I've started having the discussion and offering it to patients that I'm going to send home with DVT, and I'm finding that even with the increased cost, patients are overwhelmingly choosing Rivaroxaban. I'm guessing it's because they don't like the idea of all the drug monitoring that has to go into Warfarin use, and the number of drug interactions.
Does anybody else think the idea of not using these drugs because they aren't "reversible" is silly? Warfarin doesn't really "reverse" with vitamin K for up to 24 hours, and even with FFP you don't ever get complete reversal. LMWH isn't reversed that well with protamine, but nobody hesitates to use it. We've been using drugs that can't be completely reversed immediately for years without complaint . . . and yet some of the docs I work with are using this argument for why we shouldn't use them. There's some new data coming out that says PCC works to reverse Rivaroxaban, but I haven't had the chance to really look at it yet. Share your thoughts? Thank you!

Patrick S., M.D.

Do NOT engage Dr. Deloughery in any competition involving Broca's center.

You will get lapped.

Patrick B.

Apologize haven't listened to this episode but have you guys covered calf vein (non muscle vein) DVT. Had a bounceback (colleague gave tapered triple/double up OCP's to a 40yo obese female) who presented mildly symptomatic with below knee DVT, clearly provoked....tough call on therapy!

Rob O

Hi Patrick,
I think you question may be answered in the episode.

There are several options, none of which are clearly wrong or right. They include (stopping the med) + serial US to see of the clot resolves. Short term anticoagulation and recheck for clot resolution, 3 months of anticoagulation. Some centers are treating calf clots with oral Xa inhibitors for a few weeks. In a case like this, a provoked clot, I would discuss options with the patient but lean toward serial ultrasounds.

Sean G., M.D.

Rob or Tom, could either of u give me what the superficial phlebitis treatment guide lines are derived from? Specifically I mean the use of enoxiparin for large (>7cm) or proximal (upper half of the thigh)? Is there evidence that proves this tx is superior to hot packs NSAIDS and elevation? I was curious because none of the papers I saw referenced for this segment seemed to address this. I was wondering where those guidelines came from. I have been using them, but some docs(IM) dont and I would like to site the reference if there is one.

Rob O

Hi Sean, here is Tom's reply to your question on length of superficial
Clot...
Three key trials
· Arch Intern Med. 2003 Jul 28;163(14):1657-63. A pilot randomized double-blind comparison of a low-molecular-weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis
o NSAIA offered some benefit, LMHW worked better and not difference between high and low dose. Tx 10-12 days
· J Thromb Haemost. 2005 Jun;3(6):1152-7. High vs. low doses of low-molecular-weight heparin for the treatment of superficial vein thrombosis of the legs: a double-blind, randomized trial.
o No difference between high and low dose LMWH in STP
· N Engl J Med. 2010 Sep 23;363(13):1222-32. Fondaparinux for the treatment of superficial-vein thrombosis in the legs.
o Fonda for 42 days worked. If you look at data most benefit in first 10 days
My take on this data is that 1) most patients with big painfully STP benefit from LMWH/Fonda, 2) you need only prophylactic dosing, and 3) although the “big” trial used 42 days, the arch IM trial showed that just 10 days worked in most patients and the NEJM trial also showed most benefit early one. However most studies use 5cm instead of 7cm as the length cut-off – I must have been thinking of the 7 dwarfs or something……

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