Practice Fundamentals 13th National Conference AC of the Anticoagulation Forum Washington DC 25 April 2015 Scott Kaatz, DO, MSc Ann Wittkowsky, PharmD Edith Nutescu, PharmD Terri Schnurr, RN Alison Burnett, PharmD Michael Streiff, MD Nathan Clark, PharmD Practice Fundamentals v  Ann Wittkowsky, PharmD –  Edith Nutescu, PharmD v  Terri Schnurr, RN v  Alison Burnett, PharmD v  Michael Streiff, MD v  Nathan Clark, PharmD –  –  –  –  Full Disclosure •  Speaker honorarium •  •  •  •  •  Janssen Boehringer-Ingelheim Bristol Myer Squibb/Pfizer CSL Behring Daiichi Sankyo •  Consultant •  •  •  •  Boehringer Ingelheim Bristol Myer Squibb/Pfizer Janssen/Johnson and Johnson Daiichi Sankyo •  Board membership (non-profit) •  •  •  •  Thrombosis and Hemostasis Societies of North America AC Forum National Certification Board of Anticoagulation Providers National Blood Clot Alliance Medical and Scientific Advisory Board Practice Fundamentals - Disclosures v  Ann Wittkowsky, PharmD v  Edith Nutescu, PharmD v  Terri Schnurr, RN v  Alison Burnett, PharmD v  Michael Streiff, MD v  Nathan Clark, PharmD How I Handle New Referrals to ACC v  –  2 –  How I Determine Duration of Treatment for VTE – –  How I Improve Patient Adherence –  How I Assure Seamless Transitions of Care –  How I Manage Warfarin With Factor X Levels How I Use VTE Prophylaxis in Pregnancy –  –  No disclosures Janssen Pharmaceuticals No disclosures No disclosures See slide deck No disclosures What is the NCBAP National Certification Board for Anticoagulation Providers 2015 Update "   Established in 1996 "   Mission: Improve the quality of patient care through recognition and promotion of specialized knowledge and skills pertaining to antithrombotic therapy. "   The only national, multi-disciplinary credentialing process à professional recognition and career development, validation "   Introduces a mechanism to implement a consistent standard of care nationwide 1 Multidisciplinary Board of Directors " " " " " " " " "   Wendy Cantrell, PharmD – Henderson, NV   Scott Kaatz, DO – Detroit, MI   Christine Kempton, MD – Atlanta, GA   Laura McDermott, RN – Albuquerque, NM   Lynn Oertel, ANP – Boston, MA   Susan O’Neill, MSN – Staten Island, NY   Lisa Phillips, PharmD – Syracuse, NY   Ryan Schupbach, PharmD – Oklahoma City, OK   Diane Wirth, ANP – Atlanta, GA * As of March 12, 2015 CACP Eligibility, Application & Exam Key requirement for "   Professional Qualification: Active, current United States (or territories) license (RN, NP, Pharmacist - BS or PharmD, PA, MD, DO) "   See Candidate Handbook for details (www.ncbap.org) "   Application and exam are completed online "   Credential must be renewed by exam every 5 years HOW I HANDLE NEW REFERRALS TO ANTICOAGULATION MANAGEMENT SERVICE Ann K Wittkowsky, PharmD CACP FASHP FCCP Clinical Professor University of Washington School of Pharmacy Director, Anticoagulation Services UWMedicine Department of Pharmacy "   ACF Center of Excellence recognition requires having at least one CACP-certified clinician working in the clinic. (US based clinics) "   Become of Center of Excellence http://excellence.acforum.org SATURDAY: Surgery resident enters ACC referral prior to patient’s hospital discharge MEANWHILE: patient is en route to ED with bleeding event MONDAY: ACC front desk clerk cancels referral because patient’s PCP is at another location. Sends In-basket message to attending. THURSDAY: ACC clinic manager gets email from irate attending surgeon WEDNESDAY: Attending surgeon gets in-basket message that referral was cancelled 2 Anticoagulation Clinic Referral Form “I’d like to transfer a patient from my ACC to yours” “Fill out form. Fax to office. Include all information. Leave no blanks. Referrals will not be accepted if any information is missing or if received on wrong form. Referral coordinator will contact you in 72 hours if more information is needed, and will contact patient in 5 business days to set up appointment ” FOR ANTICOAGULATION CLINICS What is your biggest frustration regarding referrals to ACC? 1.  No information (eg: patient appears before referral is received) front desk staff scramble to figure out who he is and…… 2.  Incomplete information on referral form 3.  Inaccurate information about treatment plan (eg: drug, goal INR, duration of therapy) New patient checks into ACC and waits while……. 4. Patient is ineligible for referral to this clinic 5. Provider and patient expect same-day appointment …clinical staff hide in consult rooms. FOR REFERRING PROVIDERS REFERRAL FRUSTRATIONS What is your biggest frustration regarding referrals to ACC? 1. Referral not received and/or processed in a timely manner RECEIVING CLINICS SOLUTION REFERRING PROVIDERS 2. Filling out forms when information is already in the EMR No information Referral not received/processed Incomplete information Information is in EMR! 3.  Expected to know the treatment plan when anticoagulation is not his/her specialty Inaccurate information ACC has the expertise Ineligible patient Confusing eligibility rules same-day appointments not necessary Why no same-day appointments? 4. Confusing rules about which patients are eligible for referral 5.  Not being able to send the patient for a same-day appointment 3 LET’S TALK TO EACH OTHER! RECEIVING CLINICS SOLUTION No information Incomplete information Inaccurate information Ineligible patient REFERRING PROVIDERS Referral not received/processed CLINICIAN to CLINICIAN HAND-OFF same-day appointments not necessary Information is in EMR ACC has the expertise Confusing eligibility rules Why no same-day appointments CASE #1 During phone call After phone call Eligibility/Referring provider Drug and starting dose indication Goal INR Duration of therapy Alternative agents Avoid same-day follow-up Initiate patient education Appointment scheduled enter progress note enter lab orders send referral acceptance letter Rx order by MD Referral order by MD CASE #2 DURING CALL Eligibility/Referring provider Drug and dose Indication Duration Appropriate timing of f/u appt Initiate patient education Appointment scheduled AFTER CALL Enter progress note Enter lab orders Enter referral order for signature Send referral acceptance letter Discharge med order by inpt MD 4 CLINICIAN-TO-CLINICIAN HANDOFF Q: WHAT IF REFERRALS COME BY FAXED FORM OR A COMPUTER/EPIC IN-BASKET MESSAGE? Nursing change of shift PACU to unit ICU to floor Hospital transfers between services Ambulance to ED A: Referral is given to clinician who contacts provider and patient as needed, and queues up the patient for the first appointment Anticoagulation Clinics should “pass the baton” through clinician interaction How I Improve Pa-ent Adherence Deﬁni-ons Prac-ce Fundamentals Terri Schnurr, RN, CCRC schnurt@mcmaster.ca #1 #2 The degree to which a pa-ent follows the instruc-ons, proscrip-ons, and prescrip-ons of his or her doctor The extent to which the pa-ent con-nues the agreed-‐upon mode of treatment, under limited supervision when faced with conﬂic-ng demands, as dis-nguished from compliance or maintenance Meichenbaurn and Turk 1987 The American Heritage® Stedman’s Medical Dic-onary © 2002 5 Pa-ent Case 45 year old male, Rt. upper extremity DVT, Rt. CVC placed a month ago in prepara-on for transplant; currently on disability Pmhx: ESRD, Type 1 diabetes (on insulin since age 13), re-nopathy Meds: Lantus insulin, NovoRapid insulin, Lasix, Tacrolimus, Venlafaxine, Mycophenolate, Oxazepam, Rabeprazole Ques-ons •  How do we ensure that the pa-ent maintains adherence to the treatment plan? •  What is the key to his adherence? •  Are there any barriers? Tx: Innohep x 5 days as well as warfarin (target INR 2.0-‐3.0) Communica-on Avenues for Communica-on •  Pa-ent and doctor •  Pa-ent and nurse •  Pa-ents and their families •  Pa-ents and the environment Pa-ent and Doctor Pa-ent and Nurse •  Trus-ng rela-onship? •  Pa-ent needs to have control; empowerment •  Understanding? •  Par-cipate in their treatment program •  Expecta-ons? •  All ques-ons answered •  Confusion? •  Contacts given •  Comfort level? •  Trus-ng rela-onship with RN •  Ques-ons answered? •  Understanding 6 Pa-ents and their Families Pa-ents and the Environment •  Diﬀerences of opinion regarding level of care? •  Living situa-on – house/apt/re-rement home •  Who has control? •  Mobility – aids? •  Pa-ent is alone? •  Awareness •  Available caregivers? •  Cost? Answers • Key to adherence is eﬀec-ve communica-on • Try to keep barriers to a minimum-‐ work with pa-ent and his family to ﬁnd new ways to achieve goals Thank you ! • Allow pa-ent to have control over his care, which will translate to posi-ve outcomes • Maintain con-nuous contact (as needed) and keep pa-ent engaged. How I Assure Seamless Transi-ons of Care "Perhaps before we begin to talk about building a seam-‐less health delivery system, we should start by perfec-ng a seam-‐full health delivery system." ~ Eric A. Coleman, MD, MPH Prac-ce Fundamentals Allison Burnem, PharmD, PhC, CACP aburnem@salud.unm.edu 7 Discussion Points •  Leveraging the electronic health record (EHR) •  Systemiza-on & integra-on of an-coagula-on processes •  Empowering and suppor-ng pa-ents •  Empowering and suppor-ng clinicians Pa-ent Case •  66 yo M on warfarin admimed from LTCF with spontaneous SAH •  INR on admit 2.79, reversed with PCC and vitamin K •  PMH: COPD, CAD with stent x 4, cervical myelopathy with C3-‐4 fusion, DM, stage 4 CKD, HTN, DVT •  Meds: ASA, insulin, lisinopril, metoprolol, salmeterol/ﬂu-casone, APAP •  Determined that pa-ent had single, provoked DVT 10 months prior arer a spinal procedure performed at another hospital •  Ra-onale for ongoing an-coagula-on= no orders to discon-nue •  Which of the following would have most likely prevented this adverse event? A.  Use of a direct oral an-coagulant (DOAC) rather than warfarin B.  Documenta-on and communica-on of an-coagula-on plan of care C.  Op-mized control of his blood pressure D.  Discon-nua-on of concomitant ASA Leveraging the Electronic Health Record EHR AC Monitoring Form Daily e-‐report iden-ﬁes all admimed pa-ents on treatment an-coagula-on (AC) High INR e-‐alerts sent via EHR to an-coagula-on services to iden-fy AC pa-ents whose treatment is held at admission Electronic pa-ent tracking queue to prevent pa-ents being lost to follow-‐up Comprehensive EHR AC monitoring form •  Includes elements considered necessary for op-mized AC therapy 1,2 •  Informa-on “layered” throughout admission and provides complete “AC info package” for handoﬀ to next care sevng 1) Spyropolous AC, et al. Ann Pharmacother. 2015; 49(1): 113-‐24 2) Nutescu EA, et al. Ann Pharmacother. 2015; 49(1): 125-‐26 Opportuni-es for Improvement Systemiza-on and Integra-on Peri-‐procedural management An-coagula-on Discharge (ACDC) Audits •  Addresses recommended EHR AC elements •  Developed by IPRO, the quality improvement organiza-on (QIO) for New York State •  Available at hmp://qio.ipro.org Deﬁciencies iden-ﬁed with our EHR AC form •  Speciﬁc administra-on -me of last/next dose •  Documenta-on of pa-ent/giver comprehension •  No assessment/documenta-on of fall risk Plan: modify EHR AC form and re-‐measure All pa?ents mee?ng 2 criteria: •  On an?coagulant •  Scheduled for invasive procedure e-‐no?ﬁca?on via EHR to an?coagula?on services for peri-‐op consult •  Pilot project with •  1 procedural clinic (endoscopy) •  1 elec-ve surgery clinic (orthopedic) •  Collabora-on with informa-cs (IT) and OR coordinators •  Facilitate upstream development & communica-on of peri-‐ procedural plan •  ~ 70 consults over 24 months 8 Opportuni-es for Improvement Expand e-‐no-ﬁca-on process to all procedural and surgical clinics Update & standardize screening forms to iden-fy an-coagula-on pa-ents Include direct oral an-coagulants (DOACs) All clinics use same form/process Plan Formally track performance and demand Empowering & Suppor-ng Pa-ents Mul-modal AC educa-on (video, print, verbal) with teachback and demonstra-on AC clinic referrals, appointments & “care gaps” addressed prior to discharge Dosing calendar •  Brand/generic name(s) & strength(s) of ACs •  Time(s) of next dose(s) •  Time/date/loca-on of follow-‐up appointment •  Safety net phone number(s) Conﬁrma-on of aﬀordability & availability of ACs with assistance from case management Use data to pe--on for addi-onal staﬀ Empowering & Suppor-ng Clinicians Completed EHR “AC packet” Accessible to our outpa-ent AC clinic via EHR, so extremely helpful with newly referred AC pa-ents Provides eﬃcient, comprehensive history for our inpa-ent pharmacists if/when pa-ent is re-‐admimed Faxed to outside providers & facili-es at discharge •  Signiﬁcant poten-al for communica-on of key informa-on •  Passive process-‐ we have no staﬀ to call & conﬁrm receipt and understanding •  <5% of recipients call us to conﬁrm receipt of informa-on Pa-ent Case •  66 yo M on warfarin admimed from SNF with spontaneous SAH •  INR on admit 2.79, reversed with PCC and vitamin K •  PMH: COPD, CAD with stent x 4, cervical myelopathy with C3-‐4 fusion, DM, stage 4 CKD, HTN, DVT •  Meds: ASA, insulin, lisinopril, metoprolol, salmeterol/ﬂu-casone •  Determined that pa-ent had single, provoked DVT 10 months prior arer a spinal procedure performed at another hospital •  Ra-onale for ongoing an-coagula-on= no orders to discon-nue •  Which of the following would have most likely prevented this adverse event? A.  Use of a direct oral an-coagulant (DOAC) rather than warfarin B.  Documenta-on and communica-on of an-coagula-on plan of care C.  Op-mized control of his blood pressure D.  Discon-nua-on of concomitant ASA •  Now able to provide “meds-‐to-‐bed” for most pa-ents Opportuni-es for Improvement Standardized Use of Curaspan® automated, encrypted informa-on transmission of transmission system “AC packet” Used by our case managers & familiar to most facili-es and providers Quarterly “community mee-ng” Case management + > 70 regional SNFs, rehabs and home health agencies Collabora-on with state quality improvement organiza-on (QIO) Funding and resources to implement CMS Care Transi-ons Ini-a-ve Increase knowledge of “AC packet” content & mode of transmission Develop culture & processes wherein outside en--es conﬁrm receipt & understanding of AC informa-on Work with QIO & outside en--es to develop tools and processes that will make transmission of “AC packet” is a 2-‐way process between all care sevngs Thank You 9 Disclosures- Michael Streiff, MD Chromogenic factor X activity: A How to Guide Michael B Streiff, MD FACP Associate Professor of Medicine and Pathology Medical Director, Johns Hopkins Anticoagulation Service Johns Hopkins Medical Institutions •  Consulting –  Bio2 Medical –  Boehringer-Ingelheim –  BristolMyersSquibb –  Daiichi Sankyo –  Janssen Pharmaceutical •  Educational Grants –  Sanofi-Aventis –  Covidien •  Research support –  NIH/NHLBI –  PCORI –  Portola The Case of WF The Case of WF •  WF is a 54 yo lawyer with a 5 year history of antiphospholipid syndrome who presents with a new pulmonary embolism after a trip to Costa Rica. His INR is 2.8 (Target INR range 2.5-3.5) •  WF was started on rivaroxaban. 5 weeks later he presented with a new PE. He was switched to LMWH. •  After 4 weeks on Enox 120 mg q12h, he presented with HIT and recurrent PE. Bivalirudin was started and he was transitioned to fondaparinux. •  2 months later he was switched to apixaban 10 mg BID which was followed by recurrent VTE and return to fondaparinux –  What is the best approach to anticoagulation? •  A. Warfarin (INR 3-4) •  B. Rivaroxaban 15 mg BID followed by 20 mg qd •  C. Apixaban 10 mg BID followed by 5 mg BID •  D. LMWH How do Coag tests work? : The activated partial thromboplastin time (aPTT) •  Activated partial thromboplastin time (aPTT) –  Monitors the intrinsic and common pathway –  Sodium citrate – binds calcium in test tube –  Centrifuge – keep only plasma –  Add phospholipids, calcium and XII activator –  Time to clot formation based on light absorption Francis JL, et al. Pharmacotherapy 2004;24:108S-119S. Factor XII activator Phospholipids Ca++ D e t e c t o r L i g h t Courtesy Paula Biscup-Horn How do Coag tests work?: The Prothrombin time (PT) •  Prothrombin Time (PT) –  Monitors the extrinsic and common pathway –  Sodium citrate binds calcium in test tube –  Centrifuge – keep plasma only –  LOTS of phospholipids, calcium, and tissue factor –  Time to clot formation by light absorption Francis JL, et al. Pharmacotherapy 2004;24:108S-119S. Tissue Factor PHOSPHOLIPIDS Ca++ D e t e c t o r L i g h t Courtesy Paula Biscup-Horn PharmD 10 Chromogenic Factor X activity assay Factor Activity 40-20% Corresponds to INR 2-3 Chromogenic substrate pNA Russell Viper Venom Activated Factor X •  Monitoring warfarin in APS –  APS affects 5% of patients with VTE –  Lupus anticoagulant positive in 0.6% of VTE –  LA impact on PT/INR varies with PT reagent Absorbance at 405 nM Factor X + Utility of Chromogenic factor X activity •  Thromborel R (67%), Innovin (2-19%), Neoplastin CI Plus (10%) Thromboplastin C (3%) –  LA can affect POC INR (ProTime POC 10% of APS patients unmeasurable) pNA Factor X activity Mateo J et al. Thromb Haemost 1997; Tripodi A Brit J Haematol 2001; Ortel T JTT 2006; Rosborough T Pharmacother 2004; Perry SL Thromb Haemost 2005 Utility of Chromogenic factor X activity •  Monitoring warfarin in transition from argatroban •  Monitoring warfarin in liver disease •  Monitoring warfarin in dysfibrinogenemia •  Monitoring warfarin in factor VII deficiency XII XI IX VII VIII APTT X V PT II Fibrinogen Alternatives to Chromogenic Factor X assay for LA •  Clot-based Factor II assay- sample dilutions reduce impact of LA •  Prothrombin-proconvertin clotting time- Clotbased assay uses thromboplastin supplemented with factor V and fibrinogen, sample dilution reduces LA impact Fibrin Arpino PA et al. Pharmacother 2005; Kovacs MJ Thromb Haemost 1994; Wool AJ et al. Am J Clin Path 2014 My approach to Chromogenic Factor X assay (CFX) •  Correlate INR and CFX in all patients with lupus anticoagulants •  During transition to warfarin therapy monitor PT/ INR, CFX, D dimer •  Target INR range that correlates with a CFX activity of 20-40% •  Once INR range identified, use INR range routinely and correlate with CFX at least once monthly Back to the case of WF •  WF was bridged back to warfarin with fondaparinux •  I monitored the PT/INR, CFX and D dimer assays •  Target INR range 5-6 correlates to CFX 20-35% •  In the last 8 months he has not had any recurrent VTE or bleeding events. 11 Test Time Questions ? •  The chromogenic factor X assay is useful for –  A. Measuring warfarin in patients with cardiolipin antibodies –  B. Measuring rivaroxaban in patients with lupus anticoagulants –  C. Measuring warfarin in patients with lupus anticoagulants –  D. Helping the lab director pay for his Tesla model S How I Use Prophylaxis During Pregnancy Prac-ce Fundamentals Nathan Clark, Pharm D, FCCP, BCPS nathan.clark@kp.org VTE in Pregnancy •  Venous stasis –  Compression inferior vena cava –  Decreased venous ﬂow velocity •  Vascular injury •  Hypercoagulability –  Increased clovng factors VII, VIII, and X –  Increased von Willebrand factor and ﬁbrinogen –  Decrease in protein S VTE in Pregnancy Thromboembolism remains the leading cause of maternal morbidity in the developed world –  Accounts for 9% of all maternal deaths in the United States (1.1 deaths per 100,000 deliveries) –  Complicates 0.5 to 2 per 1,000 pregnancies American College of Obstetricians and Gynecologists; September 2011; Prac-ce Bulle-n Number 123 Pa-ent Case You are consulted on the following 34 year-‐old female who is 12 weeks pregnant • OB history: gravida 5/para 1 –  1 healthy, happy daughter age 3 (1st pregnancy) followed by 3 miscarriages, all in 1st trimester prior to conﬁrma-on of viability • No personal or family history of VTE • Estrogen OCP use during her 20’s without complica-on • Nonobese, nonsmoker, no drugs or alcohol • Meds: MVI • Labs: heterozygous factor V Leiden, otherwise WNL Which of the following would you recommend for VTE prophylaxis? A. Antenatal prophylac-c dose unfrac-onated heparin (UFH) plus aspirin B. Antenatal therapeu-c dose low-‐molecular-‐weight heparin (LMWH) con-nued postpartum for 6 weeks C. Postpartum prophylac-c dose LMWH only D. Nothing American College of Obstetricians and Gynecologists; September 2011; Prac-ce Bulle-n Number 123 12 How I Use Prophylaxis How I Use Prophylaxis Posi?ve Personal History of VTE No Personal History of VTE Descrip?on Heterozygous FVL or PT 20210 Conﬁrmed Protein C or S deﬁciency Homozygous FVL or PT 20210 Conﬁrmed AT deﬁciency Mul-ple traits An-phospholipid An-body Syndrome (APAS) Antenatal Postpartum Clinical vigilance Clinical vigilance Prophylac-c Yes Prophylac-c or Intermediate Yes Prophylac-c or Intermediate UFH + aspirin 81mg Yes VTE – venous thromboembolism; FVL – factor V Leiden; PT 20210 – prothrombin G202210àA muta-on; AT – an-thrombin; UFH – unfrac-onated heparin Clinical vigilance = thorough pa-ent educa-on and -mely objec-ve inves-ga-on of DVT/PE symptoms Chest 2012;141:e691S-‐e736S American College of Obstetricians and Gynecologists; September 2011; Prac-ce Bulle-n Number 123 hmp://www.guideline.gov/content.aspx?id=25312 accessed 03/24/15 Antenatal An-coagulant Regimens Descrip?on Prophylac-c Intermediate Therapeu-c Drug Dose Heparin 5,000 units q12h Enoxaparin 40mg QD Dalteparin 5,000 units QD Tinzaparin 4,500 units QD Heparin 120 units/kg q12h -trated to mid-‐interval an--‐Xa 0.1 to 0.3 u/ml Enoxaparin 40mg q12h Dalteparin 5,000 units q12h Heparin 200 to 250 units/kg q12h -trated to therapeu-c mid-‐interval an--‐Xa or aPTT Enoxaparin* 1mg/kg q12h Dalteparin* 100 units/kg q12h Tinzaparin* 175 units/kg QD *dose adjusted according to weight gain or an-factor -‐Xa concentra-on An-coagula-on Management Around Labor and Delivery •  Prophylac-c UFH/LMWH can be restarted: –  6 to 12 hours arer vaginal or cesarean delivery –  At least 2 hours arer epidural withdrawal •  Intermediate and therapeu-c UFH/LMWH can be restarted: –  12 hours arer vaginal delivery –  24 hours arer cesarean delivery –  12 hours arer epidural withdrawal American College of Obstetricians and Gynecologists; September 2011; Prac-ce Bulle-n Number 123 Descrip?on Antenatal Postpartum Clinical vigilance Yes Single prior VTE provoked by estrogen or pregnancy Prophylac-c Yes Prior VTE associated with thrombophilia, not receiving long-‐term an-coagula-on Prophylac-c or Intermediate Yes Single prior provoked VTE unrelated to estrogen or pregnancy Unprovoked or mul-ple VTE, not receiving long-‐term an-coagula-on Prior VTE receiving long-‐term an-coagula-on Intermediate Yes Therapeu-c Resume usual therapeu-c an-coagula-on VTE – venous thromboembolism; Clinical vigilance = thorough pa-ent educa-on and -mely objec-ve inves-ga-on of DVT/PE symptoms An-coagula-on Management Around Labor and Delivery •  Consider transi-on from therapeu-c LMWH to UFH around 36 weeks gesta-on •  Consider scheduling for induc-on of labor to facilitate op-mal -ming of an-coagulant withdrawal –  Prophylac-c UFH/LMWH: at least 12 hours –  Intermediate and therapeu-c UFH/LMWH: at least 24 hours American College of Obstetricians and Gynecologists; September 2011; Prac-ce Bulle-n Number 123 Postpartum An-coagulant Regimens •  Postpartum an-coagula-on should con-nue for 6 weeks in pa-ents receiving prophylac-c and intermediate intensity UFH/LMWH –  Resume the antenatal regimen, or –  Transi-on to warfarin (INR 2-‐3) •  Chronically an-coagulated pa-ents should resume therapeu-c an-coagula-on with their usual agent –  Verify if plans for breas•eeding (no DOACs) –  Consider bridge therapy for warfarin re-‐ini-a-on Chest 2012;141:e691S-‐e736S 13 Drugs to Avoid In Pregnancy •  Warfarin* –  Teratogenicity –  Fetal bleeding –  Ok during breas•eeding •  Direct-‐Ac-ng Oral An-coagulants (DOACs) –  No human data –  Risk of fetal bleeding –  Also avoid during breas•eeding •  Fondaparinux** –  An--‐Xa ac-vity in umbilical chord –  Ok during breas•eeding Pa-ent Case You are consulted on the following 34 year-‐old female who is 12 weeks pregnant • OB history: gravida 5/para 1 –  1 healthy, happy daughter age 3 (1st pregnancy) followed by 3 miscarriages, all in 1st trimester prior to conﬁrma-on of viability • No personal or family history of VTE • Estrogen OCP use during her 20’s without complica-on • Nonobese, nonsmoker, no drugs or alcohol • Meds: MVI • Labs: heterozygous factor V Leiden, otherwise WNL Which of the following would you recommend for VTE prophylaxis? A. Antenatal prophylac-c dose UFH plus aspirin B. Antenatal therapeu-c dose LMWH con-nued postpartum for 6 weeks C. Postpartum prophylac-c dose LMWH for 6 weeks only D. Nothing *Can be considered in mechanical heart valve **Can be considered in heparin-‐induced thrombocytopenia How You Should Use Prophylaxis During Pregnancy 14