Drug Topics - March 10, 2008 - (Page HSE5) www.drugtopics.com MARCH 10, 2008 DRUG TOPICS HSE 5 Addressing CVA prophylaxis 60-year-old, female, bilateral leg amputee has diagnoses including PVD, diabetes, COPD, and history of CVA. She is residing in a nursing home with 100% G-tube feeding and is dependent on a tracheostomy artificial respirator. In a recent hospital visit for a CVA she was given heparin IV and was discharged with SC Heparin 5000 units three times daily. The only other significant medications included insulin, metoprolol 25mg bid, and Com- A bivent inhaler tid. The nursing home continued the heparin for more than three months and no bleeding complications were observed. No laboratory data were available for a baseline PTT from the hospital. No signs of other complications or thrombocytopenia were evident. How long can heparin be given at this SC dose without any coagulation monitoring and, if she is not a candidate for warfarin, what are the other alternatives? I n this case, the patient has the continuing DVT risk factors of immobility and respiratory disease that warrant prophylaxis. The heparin 5000 units SC TID dose is appropriate and can be given long term if the DVT risk continues, which it will in this case. Of additional concern is a recent CVA. If this was of cardioembolic origin, then warfarin would be preferred, although there would be issues with control and monitoring in this patient’s case. If the patient is non-cardioembolic, then aspirin 81 mg daily would be recommended for CVA prophylaxis. LDUH is not sufficient for CVA stroke prophylaxis, and not recommended by the ACCP Consensus Guidelines. In this patient, the combination of LDUH and daily ASA is warranted. Due to the addition of the daily ASA, we recommend getting a baseline CBC (including PLT count) so that monitoring can be performed to track changes in PLT and H/H. There is still a small risk of HIT with the long term use of LDUH, so routine PLT monitoring (i.e., CBC) at least every three to six months would be warranted. Nancy L. Shapiro, Pharm.D., BCPS Aimee Chevalier, Pharm.D. Clinical Pharmacists, Antithrombosis Clinic Clinical Assistant Professor, Dept. of Pharmacy Practice University of Illinois at Chicago College of Pharmacy Key: PVD = peripheral vascular disease COPD = chronic obstructive pulmonary disease CVA = cerebrovascular accident IV = intravenous SC = subcutaneous PTT = partial thromboplastin time DVT = deep vein thrombosis LDUH = low-dose unfractionated heparin ASA = aspirin ACCP = American College of Clinical Pharmacy CBC = complete blood count PLT = platelet H/H = hemoglobin and hematocrit HIT = heparin-induced thrombocytopenia clinical adverse events,” said Craig Paterson, M.D., a retired surgeon now in charge of medical affairs and medical development for King Pharmaceuticals. Reports of adverse events with bovine thrombin have been few, said Paterson, and, because they have been anecdotal reports or case studies, there is no real clinical evidence indicating bovine thrombin was directly responsible for them. Antibodies to recombinant thrombin have been observed during clinical trials, but in much smaller numbers than with bovine thrombin. “There is no adverse reaction deemed related to Recothrom,” said Douglas E. Williams, president and chief scientific of- ficer for Zymogenetics. Both the newer thrombins have exhibited efficacy comparable to bovine thrombin in Phase III studies. “Without evidence of increased efficacy or decreased adverse effects, I think [human thrombin’s] role may be as a fill-in when there are shortages of the bovine product,” said Chernin. Bruce L. A. Carter, Ph.D., CEO for ZymoGenetics, acknowledged it would not be easy to gain market share. “We know that it will be hard work, but we do expect that the advantages of recombinant manufacturing technology will win out over the competition,” he said. THE AUTHOR is a writer based in the Seattle area. http://www.drugtopics.com
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.