Pulmonary embolism medical therapy: Difference between revisions
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==Parenteral Anticoagulants | ==Parenteral Anticoagulants | ||
===[[Heparin]]=== | ===[[Heparin]]=== | ||
* Heparin binds to antithrombin and inactivates thrombin, factors IIa, Xa, IXa, XIa and XIIa; binds to heparin cofactor II and inactivates factor IIa; and binds to factor IXa and inhibits factor X activation. | * Heparin binds to antithrombin and inactivates thrombin, factors IIa, Xa, IXa, XIa and XIIa; binds to heparin cofactor II and inactivates factor IIa; and binds to factor IXa and inhibits factor X activation. | ||
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* The apparent biologic half-life of heparin increases from approximately 30 min after an IV bolus of 25 units/kg, to 60 min with an IV bolus of 100 units/kg, to 150 min with a bolus of 400 units/kg. | * The apparent biologic half-life of heparin increases from approximately 30 min after an IV bolus of 25 units/kg, to 60 min with an IV bolus of 100 units/kg, to 150 min with a bolus of 400 units/kg. | ||
* Efficacy of heparin in the initial treatment of [[DVT]] or [[PE]] is highly dependent on dosage. | * Efficacy of heparin in the initial treatment of [[DVT]] or [[PE]] is highly dependent on dosage. | ||
* Initial dosing of IV heparin for VTE is either weight-based (80 units/kg bolus and 18 units/kg/h infusion) or administered as a bolus of 5,000 units followed by an infusion of at least 32,000 units/d. | * Initial dosing of IV heparin for VTE is either weight-based (80 units/kg bolus and 18 units/kg/h infusion) or administered as a bolus of 5,000 units followed by an infusion of at least 32,000 units/d, to achieve aPTT value of 1.5-2.5 of the normal value. | ||
* If heparin is given subcutaneously for treatment of VTE, there are at least two options: (1) an initial IV bolus of 5,000 units followed by 250 units/kg twice daily; or (2) an initial subcutaneous dose of 333 units/kg followed by 250 units/kg twice daily thereafter. | * If heparin is given subcutaneously for treatment of VTE, there are at least two options: (1) an initial IV bolus of 5,000 units followed by 250 units/kg twice daily; or (2) an initial subcutaneous dose of 333 units/kg followed by 250 units/kg twice daily thereafter. | ||
* The dose for [[acute coronary syndrome]] is lower as compared to the treatment of [[DVT]] | * The dose for [[acute coronary syndrome]] is lower as compared to the treatment of [[DVT]] | ||
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* One major advantage of heparin is that the anticoagulant effects can be reversed with IV protamine sulfate. | * One major advantage of heparin is that the anticoagulant effects can be reversed with IV protamine sulfate. | ||
===[[LMWH|Low molecular weight heparin]] | |||
* [[LMWH]] is administered subcutaneously and is available in various forms like Bemiparin, Dalteparin, Danaparoid, Enoxaparin, Nadroparin, or Tinzaparin. | |||
* The recommended doses for treatment of [[PE]]/[[DVT]] are: | |||
** [[Enoxaparin]] : 1 mg/Kg body weight (twice daily). Dose is 30 mg daily for [[VTE]] prophylaxis. | |||
** [[Enoxaparin]] : 1 mg/Kg body weight (twice daily). | |||
** [[Tinzaparin]] : 175 U/Kg body weight (once daily). | ** [[Tinzaparin]] : 175 U/Kg body weight (once daily). | ||
* The doses in case of renal insufficiency are not clear, except Enoxaparin. It is recommended that the dose of [[Enoxaparin]] should be reduced to 50% of the usual dose in patients with a creatinine clearance of <30 mL/min. | |||
**Patient weighing | ===[[Factor Xa Inhibitor|Factor Xa Inhibitors]] | ||
* [[Fondaparinux]] binds to antithrombin and inhibits factor Xa. | |||
* A fixed dose of 2.5 mg daily is used for thromboprophylaxis. In patients with moderate renal insufficiency (creatinine clearance of 30-50 mL/min), dose should be reduced by 50%. | |||
* Recommended dosages for treatment of [[DVT]] or [[PE]] are: | |||
**Patient weighing <50 Kg (110 lb): 5 mg (once daily). | |||
**Patient weighing 50 Kg (110 lb) to 110 Kg (220 lb): 7.5 mg (once daily). | **Patient weighing 50 Kg (110 lb) to 110 Kg (220 lb): 7.5 mg (once daily). | ||
**Patient weighing | **Patient weighing >100 Kg (220 lb): 10 mg (once daily). | ||
==Warfarin== | ==Warfarin== | ||
{{main|Warfarin}} | {{main|Warfarin}} | ||
* The recommended therapeutic INR | * The recommended therapeutic INR during the treatment of [[DVT]] or [[PE]] with warfarin is 2.0-3.0. | ||
==References== | ==References== | ||
Revision as of 19:07, 22 May 2012
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Pulmonary Embolism Microchapters |
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Diagnosis |
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Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores |
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Treatment |
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Follow-Up |
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Special Scenario |
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Trials |
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Case Studies |
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Pulmonary embolism medical therapy On the Web |
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Directions to Hospitals Treating Pulmonary embolism medical therapy |
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Risk calculators and risk factors for Pulmonary embolism medical therapy |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
In most cases, anticoagulant therapy is the mainstay of treatment. For details, visit treatment approach. This chapter discusses the recommended doses.
Treatment Protocol[1]
Stabilize the patient
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Initial Treatment options (≤5 Days)
| |||||||||||||||||||
| Long term treatment (≥3 Month) (INR target, 2.0-3.0) | |||||||||||||||||||
| Extended treatment (Indefinite) (INR target, 2.0-3.0 OR 1.5-1.9) | |||||||||||||||||||
==Parenteral Anticoagulants
Heparin
- Heparin binds to antithrombin and inactivates thrombin, factors IIa, Xa, IXa, XIa and XIIa; binds to heparin cofactor II and inactivates factor IIa; and binds to factor IXa and inhibits factor X activation.
- Unfractionated heparin is mainly used in patients with known renal insufficiency or those who need close monitoring for bleeding, as activated partial thromboplastin time can be checked every 2 hours and doses adjusted.
- The apparent biologic half-life of heparin increases from approximately 30 min after an IV bolus of 25 units/kg, to 60 min with an IV bolus of 100 units/kg, to 150 min with a bolus of 400 units/kg.
- Efficacy of heparin in the initial treatment of DVT or PE is highly dependent on dosage.
- Initial dosing of IV heparin for VTE is either weight-based (80 units/kg bolus and 18 units/kg/h infusion) or administered as a bolus of 5,000 units followed by an infusion of at least 32,000 units/d, to achieve aPTT value of 1.5-2.5 of the normal value.
- If heparin is given subcutaneously for treatment of VTE, there are at least two options: (1) an initial IV bolus of 5,000 units followed by 250 units/kg twice daily; or (2) an initial subcutaneous dose of 333 units/kg followed by 250 units/kg twice daily thereafter.
- The dose for acute coronary syndrome is lower as compared to the treatment of DVT
- The main side effects are heparin-induce thrombocytopenia and osteoporosis.
- One major advantage of heparin is that the anticoagulant effects can be reversed with IV protamine sulfate.
===Low molecular weight heparin
- LMWH is administered subcutaneously and is available in various forms like Bemiparin, Dalteparin, Danaparoid, Enoxaparin, Nadroparin, or Tinzaparin.
- The recommended doses for treatment of PE/DVT are:
- Enoxaparin : 1 mg/Kg body weight (twice daily). Dose is 30 mg daily for VTE prophylaxis.
- Tinzaparin : 175 U/Kg body weight (once daily).
- The doses in case of renal insufficiency are not clear, except Enoxaparin. It is recommended that the dose of Enoxaparin should be reduced to 50% of the usual dose in patients with a creatinine clearance of <30 mL/min.
- Fondaparinux binds to antithrombin and inhibits factor Xa.
- A fixed dose of 2.5 mg daily is used for thromboprophylaxis. In patients with moderate renal insufficiency (creatinine clearance of 30-50 mL/min), dose should be reduced by 50%.
- Recommended dosages for treatment of DVT or PE are:
- Patient weighing <50 Kg (110 lb): 5 mg (once daily).
- Patient weighing 50 Kg (110 lb) to 110 Kg (220 lb): 7.5 mg (once daily).
- Patient weighing >100 Kg (220 lb): 10 mg (once daily).
Warfarin
References
- ↑ Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.