February 27, 2024

Selecting and Starting and Anticoagulant - Part 3 of 3

Dr. Kabrhel discusses the process of selecting and starting an anticoagulant.

Faculty: Dr. Christopher Kabrhel MD, MPH

Director, Center for Vascular Emergencies, Department of Emergency Medicine | Professor of Emergency Medicine, Harvard Medical School | MGH Endowed Chair in Emergency Medicine

Dr. Kabrhel has more than 15 years of experience performing research into the epidemiology, diagnosis, risk stratification and treatment of acute venous thromboembolism

Read the Full Transcript

- In other videos, we talked about how to discharge low risk patients with PE or DVT from the emergency department, but in order to do that, we need to select and start them on anticoagulation. For most patients, the best choice is one of the direct acting oral anti-coagulants or DOACs. These meds are highly effective, are associated with a low risk of bleeding, and don't require monitoring. Apixaban and rivaroxaban are two DOACs that we can use as initial therapy. Both are good choices. Other DOACs require parenteral anti-coagulation first, so we don't use them as much in the ED. DOACs have not been extensively studied in some groups, like pregnant women. They also may not be as safe or effective as other anti-coagulants for patients with severe renal or liver disease, antiphospholipid antibody syndrome, some cancers, gastric bypass, or other malabsorption syndromes. For patients in whom a DOAC isn't appropriate, we can still use our old standbys, low molecular rate heparin and warfarin. But low molecular weight heparin is contraindicated for patients with severe renal impairment, HIT, and extremes of body weight. Warfarin is contraindicated in patients in pregnancy and can interact with certain medications. If a patient, like someone with end stage renal disease, can't be treated with either a DOAC or low molecular weight heparin, they probably aren't a candidate for home treatment. But with the right anti-coagulant, studies show that more than 25% of ED patients with PE and most patients with DVT can safely be treated at home.

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