Patient Care Hematology & Oncology - October 2007 - (Page 7)

Strategies for bridge anticoagulation therapy The use of bridge therapy in patients on chronic oral anticoagulation who are undergoing surgery or other invasive procedures needs to be evaluated case by case. Though full-dose unfractionated heparin is the current standard, low-molecular-weight heparin appears to be as safe and effective—and much simpler and less expensive to use. Article at a glance I I I I I A clinical challenge arises when patients who are on chronic oral anticoagulation (OAC) require an interruption of their OAC for elective procedures, such as dental extractions, endoscopies, and elective surgeries. Procedures identified as requiring no interruption of OAC include most dental and ophthalmic procedures (excluding retinal surgery), joint and soft tissue injections, and upper endoscopy with or without biopsy. More invasive procedures requiring interruption of OAC include pacemaker insertion, major abdominal surgery, thoracic surgery, GU surgery, cancer surgery, and neurosurgery. Unfractionated heparin (UFH) has been the anticoagulant of choice in hospitalized patients for many years, and it has been used as the standard of care in patients requiring bridge therapy before and after a surgical procedure. Nonetheless, low-molecular-weight heparins offer several advantages over UFH for periprocedural bridge therapy, such as once- or twice-daily SC administration (instead of inpatient IV infusion) and, thus, lower costs. T he use of warfarin for the management of patients in need of chronic oral anticoagulation (OAC) due to their high risk for thromboembolism has been the standard of care in the United States for many years. Warfarin has been shown to be effective in the treatment and prevention of thromboembolism in patients with hypercoagulable states, prosthetic heart valves, and atrial fibrillation (AF), as well as for the primary and secondary prevention of venous thromboembolism (VTE), which comprises deep venous thrombosis (DVT) and pulmonary embolism (PE).1,2 With the lone exception of an isolated episode of VTE, these indications require lifelong OAC. A clinical challenge is posed when these patients require an interruption of their OAC for elective procedures, such as dental extractions, endoscopies, and elective surgeries. Maintaining OAC in the operative and immediate postoperative period places the patient at risk for bleeding diatheses, while withholding OAC increases the risk of thromboembolic complications. For years, clinicians have approached this dilemma with variations of a 6-stage bridging strategy, as follows: • Discontinue OAC several days preoperatively CONTRIBUTORS MIRZA E. PEREZ, PharmD, Assistant Professor, Department of Pharmacy Practice, School of Pharmacy, Temple University, Philadelphia, Pa. MARK G. GRAHAM, MD, Associate Professor of Medicine; Director, Jefferson Hospital Ambulatory Practice; and Associate Director, Internal Medicine Residency, Thomas Jefferson University Hospital, Philadelphia, Pa. OCTOBER 2007 PATIENT CARE HEMATOLOGY & ONCOLOGY 7

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Patient Care - Hematology & Oncology - October 2007 Research Digest Contents Information for Authors Medicine in the News Strategies for Bridge Anticoagulation Therapy How to Integrate the New Cervical Cancer Guidelines into Practice Dermatology Case Challenge Clinical Clips Classified Advertising

Patient Care Hematology & Oncology - October 2007

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