2) When we think about “special populations” in #VTE, we think weight, age, and #cancer status. @aakonc already addressed the last of those (earn credit still at https://t.co/1J0Rd9gKDX). Learn the rest here! Hello to @ProfMakris @bhwords @MiddeldorpS @fniainle @AliTaherMD
— @CKD_ce (@ckd_ce) June 29, 2022
4) Treatment options for #VTE include initial use of heparin (usually low molecular weight heparin, #LMWH) overlapping with #warfarin, or initial LMWH switching to direct oral anticoagulant (#DOAC) or DOAC monotherapy. For most patients DOACs are the treatment of choice. pic.twitter.com/PJK22cIxMZ
— @CKD_ce (@ckd_ce) June 29, 2022
6) Why limited data at extreme subgroups? Unfortunately these patients are under-represented in Ph3 clinical trials (lower proportion in population, exclusion criteria, recruitment bias). Under-representation = lack of confidence in treatment options for those subgroups pic.twitter.com/FhNMixhrJ3
— @CKD_ce (@ckd_ce) June 29, 2022
8) Worldwide obesity is on the rise & is a risk factor for VTE. According to the WHO, it has nearly tripled since 1975. We are more likely to see obese patients in the thrombosis clinic as seen in the BMI histogram from the FIRST registry of UK VTE cases. pic.twitter.com/OQBCDdrCQU
— @CKD_ce (@ckd_ce) June 29, 2022
10) What does the guidance say? The @ASH_hematology 2020 VTE treatment guidelines suggest: home treatment over hospital, DOACs over VKA (without a particular DOAC preference), for 3-6 months, & suggest against routine use of compression stockings.
— @CKD_ce (@ckd_ce) June 29, 2022
🔓https://t.co/1ECMgy37jt pic.twitter.com/l1VuUNNfnh
12) Rivaroxaban is the best studied #DOAC in obesity. Post-hoc analysis of VTE pts with BMI >35 in EINSTEIN showed no sig diff in recurrent VTE/major bleeding bet rivaroxaban & warfarin. Several observational studies also show no difference in outcomes.
— @CKD_ce (@ckd_ce) June 29, 2022
🔓https://t.co/TUGDu28esZ
14) Here is the summary of efficacy and safety outcomes in VTE treatment clinical studies comparing DOACs with VKA in obese patients. (Modified from 🔓https://t.co/TGjOuTA1j4) pic.twitter.com/GoQ5cG8w6e
— @CKD_ce (@ckd_ce) June 29, 2022
16) Let’s return to our patient with proximal DVT. He weighs 130 kg and has a busy job as an investment banker. What would you treat him with?
— @CKD_ce (@ckd_ce) June 29, 2022
18) Welcome back!! @AryaRoopen is leading us through a first-rate program on managing #VTE at extremes of weight & in the face of⬇️#renal function. You are earning CE/#CME 🇺🇸🇪🇺🇨🇦🇬🇧. Please follow us for more #accredited #tweetorials!
— @CKD_ce (@ckd_ce) June 30, 2022
20) Correct answers include rivaroxaban apixaban & warfarin. The 2021 @ISTH SSC guideline for #VTE pts w/BMI >40 or BW>120 kg recommends standard doses rivaroxaban or apixaban. Dabigatran or edoxaban are advised against due to lack of supporting data.
— @CKD_ce (@ckd_ce) June 30, 2022
🔓https://t.co/MN2qfFBDiu pic.twitter.com/jizYbifU6A
22a) Previous guidance suggested monitoring DOAC levels in obesity. Therapeutic targets are not known & there is insufficient evidence to make clinical decisions or dose adjustments based on DOAC levels. The 2021 @isth guidance suggest against routine monitoring in this setting.
— @CKD_ce (@ckd_ce) June 30, 2022
23) An interesting situation might arise if an obese patient on DOAC requires bariatric surgery, which might alter bioavailability. Data are scant and limited to small PK studies with little outcome information. pic.twitter.com/73CPwiDhYc
— @CKD_ce (@ckd_ce) June 30, 2022
25a) It is increasingly common to see underweight patients that need treating for VTE. Prevalence of underweight among adults varies from 2% to 23% globally (WHO). Underweight patients might have other morbidities and have worse outcomes in hospital settings and higher mortality.
— @CKD_ce (@ckd_ce) June 30, 2022
26) There is little evidence to inform dosing #DOACs in #underweight cases. SPCs for DOACs & #VTE treatment guidelines do not help. Over-anticoagulation & bleeding risk are an obvious concern. With DOAC #monotherapy this risk might be highest in the initial treatment period. pic.twitter.com/D8L94lzSn7
— @CKD_ce (@ckd_ce) June 30, 2022
28) Guidance? Data from dabigatran studies are scant. Rivaroxaban EINSTEIN data only included 2% underweight patients; outcomes not separately evaluated. Peak plasma riva levels are higher in underweight patients but clinical significance is uncertain. 🔓https://t.co/vTIA7j3bUA pic.twitter.com/4kc19zfulw
— @CKD_ce (@ckd_ce) June 30, 2022
30) The #Edoxaban phase 3 #VTE trial recruited 13% patients <60 kg, who received half dose of edoxaban. Separate outcome data are not available so no conclusion can be reached. In contrast, safety & efficacy of weight-based dosing for #LMWH is well established.
— @CKD_ce (@ckd_ce) June 30, 2022
32) Coming back to the case, there is no single right answer. All options are valid: warfarin, standard dose rivaroxaban or apixaban, half dose edoxaban. The loading period of higher intensity anticoagulation with rivaroxaban or apixaban might be a concern.
— @CKD_ce (@ckd_ce) June 30, 2022
34) My preference (@AryaRoopen) then would be for 5 days of LMWH followed by half dose edoxaban (30 mg od). Since this is a provoked event 3-6 months of anticoagulation would suffice.
— @CKD_ce (@ckd_ce) June 30, 2022
Please RETURN TOMORROW to wrap up this program and grab your FREE CE/#CME! pic.twitter.com/68tsO6dUp0
36) #CKD is a global health concern, affecting 11-13%, the majority stage 3.
— @CKD_ce (@ckd_ce) July 1, 2022
CKD is associated with an increased risk of cardiovascular disease including VTE.
See https://t.co/OiH9L760eE and also more #accredited #tweetorials from @ckd_ce! pic.twitter.com/SpecLGuo9n
38) He would need initial anticoagulation 3-6mo & then a decision about continuing for secondary prevention. The unprovoked nature of his VTE, taken with his gender (& CKD) would put him at his risk of recurrence were he to stop anticoagulation.
— @CKD_ce (@ckd_ce) July 1, 2022
🔓https://t.co/D58DyNGSNL pic.twitter.com/uWKGlDdYKC
40) 🚨CHECK YOUR DOSE: RIVAROXABAN & APIXABAN prescribing guidelines are DIFFERENT for VTE & AF. Take CARE not to underdose, esp for patients with renal impairment: e.g. AF rivaroxaban dose⬇️to 15mg OD if CrCl <50ml/min but standard VTE maintenance dose is 20mg OD.
— @CKD_ce (@ckd_ce) July 1, 2022
42) All of the DOAC phase 3 studies calculated creatinine clearance using Cockcroft-Gault & dosing algorithms are based on these thresholds. So, although Cockcroft Gault has its flaws it is the method of choice for DOACs. https://t.co/xVphL4b4e4, so for our pt, CrCl = 41 ml/min
— @CKD_ce (@ckd_ce) July 1, 2022
44) From phase 3 data are DOACs or warfarin more effective in moderate renal impairment? Meta analysis (A) says: non-inferior. In patients with moderate renal impairment is a DOAC safer than warfarin? Meta analysis (B) says: yes – less major bleeding 🔓https://t.co/Z89b4ezLxf pic.twitter.com/Z6ki656RdG
— @CKD_ce (@ckd_ce) July 1, 2022
46) I wouldn’t choose dabigatran in view of high proportion renal clearance. All the Xa inhibitors would be reasonable options for our patient. If adherence is an issue some might prefer once daily dosing but then OD vs BD and implications for adherence is another debate!
— @CKD_ce (@ckd_ce) July 1, 2022
48) Assessment of renal function must be made at initiation and as part of ongoing review. Frequency of monitoring depends on #CrCl, for our patient every 6 months! pic.twitter.com/muVNIquvmD
— @CKD_ce (@ckd_ce) July 1, 2022
49) So that brings us to the end of this tweetorial on treating VTE at extremes of body weight & renal function. I hope you have found it interesting & useful! I am @AryaRoopen. Go grab your CE/#CME credit right now at https://t.co/zasnZ9RmTL.
— @CKD_ce (@ckd_ce) July 1, 2022
FOLLOW US for more programs!