CVS - VTE prophylaxis and treatment

1. Rivaroxaban (Xarelto) - Direct Xa inhibitor - Peak 4 hours - Duration 8-12 hours 

- Use: prevent stroke in pt with AF, w/o heart valve disease, 1 stroke RF (age, HPT, DM, CCF, h/o CVA) - Use: prevent DVT in pt with THR/TKR - Use: treat DVT - Not for: prosthetic heart valve/ mitral stenosis - Dosage: Starting dose at 10 mg (6 - 10hours after surgery) followed by 10 mg daily - No dose adjustment in renal impairment with prophylactic dose 

2. Enoxaparin/LMWH (Clexane) - Potentiate antithrombin III  inhibit FXa and FIIa - Derive from pig intestine mucosa (Sanofi) - 

Use: prophylaxis and treat DVT +/- PE, with ACS - Use: treat UA, nonQ MI, THR, TKR, abd surgery - 40mg OD, half dose if renal impairment (GFR < 30ml/min) - Can give with aspirin 

3. Tinzaparin/LMWH (Innohep) - 3500U-4500U OD 

4. Fondaparinux (Arixtra) - synthetic pentasaccharide Factor Xa inhibitor - 2.5mg OD, CI in severe renal impairment 

5. Dabigatran etexilate (Pradaxa) - direct thrombin (factor IIa) inhibitor

 - Use: prevent stroke in pt with AF - 110mg, then 220mg OD - Elderly/mod AKI – 75mg, then 150mg OD - No need INR - Cannot reverse effect 

6. UFHeparin - Severe renal impairment (GFR < 15) - 5000U bd - Monitor platelet D4-14 (EOD basis)

 7. Consider extending anticoagulation beyond 3 months for patients with unprovoked proximal DVT/PE if their risk of VTE recurrence is high (e.g. male, family history) and there is no additional risk of major bleeding. 

 8. Offer LMWH to patients with active cancer and confirmed proximal DVT or PE, and continue the LMWH for 6 months. At 6 months, assess the risks and benefits of continuing anticoagulation