Today, I lead a journal club discussion on the use of dabigatran vs warfarin in afib patients at risk of experiencing a stroke. My journal CONSORT assessment is available at my e-portfolio for viewing. There was a good discussion that happened after the paper presented. Some interesting questions were brought up that lead to interesting ideas.
Below is the CONSORT assessment on the trial assessed:
Dabigatran versus Warfarin in Patients with Atrial Fibrillation
Didactics on DVT/PE:
- DVT- virchow’s triad : (1) abnormalities of blood flow ( afib, obestity, bed rest, tumor), (2) abnormalities of clotting ( estrogen, preg, malignancy, thrombocytosis- platelet only, myloproliferative disorder – increased WBC and others) (3) abnormaliities of surfaces in contact with blood ( vasuclar injury, trauma)
- for temporary DVT risk that can be resolved: bridging warfarin therapy can last 3 to 6 months
- heparin tx for DVT: (1) 1 mg/kg BID enoxaparin or 1.5 mg /kg daily enoxaparin (2) 175 units/kg daily for tinazparin (3) dalteparin : mostly for prophlaxis and surgery
- (1) enoxaparin: more cardiac (2) tinzaparin : least renaly affected (3) dalteparin: mostly prophylaxis & surgery
- LMWH: antiXa: antiIIa (2:1- 4:1); no aPTT monitoring, sc only; longer action–> pk stable- less binding; reversible
- UFH: iv or sc ; irreversible; half life: 30 min to 2 1/2 hour ( short)
- aPTT monitoring : q6 h, then daily when PTT stable
- LMWH monitoring: anti-Xa
- UFH switch to LMWH–> wait 12 hour ( based on half life)
- no IM heparin–> cause hemotoma ( bruising)
- heparin: ( large dose) affect Xa & IIa directly; ( small dose) affect Xa, indirectly inhibit IIa
- DVT Prevention: (1) enoxaparin 30 mg BID or 40 mg daily (2) dalteparin 2500-5000 daily for surgery (3) 15 units/ g tinzaparin
- venography: use contrast dye–> anaphylactic rx sometimes
- HIT type 1: happens in 1st several days; moniroting –> don’t D/C heparin
- HIT type 2: happens between day 5 to 14–> d/c heparin ; don’t switch to LMWH
- PE: Dx by VQ scan–> breath in –> check where blood perfuses to –> X ray to see if blood stops somewhere–? ventolation perfusion
- PE: tx in hospital, not for outpatient therapy
- vit K: take orally, given quickly–> anaphylactic rxn ( SOB, flushing)
- INR more than 5, no bleed: skip dose
- INR 5-9 , no bleed: vit K 0.5- 2.5 mg orally
- INR more than 9, no bleed: vit K 5-10 mg orally
- DIC (Disseminated Intravascular Coagulopathy)–> clot & bleed at the same time; trigger: infection/malignancy; increase INR; increase aPTT; decrease pH; Clot in microvascular area ( brain, kidney, etc); don’t tx with anticoagulant; tx cause, fluid replacement, sx management; controversy on the use of heparin and fibrinolytic for management
FMI:
- topiramate = aka the stupid drug
- potassium: KCl elixir and Slow K ( 8mmol KCl) are available at the hospital
- K-Dur ( 20 mmol KCl) is not available at the hospital
CSHP Clinical Symposium
It has been a few years since my last CSHP clinical symposium. From what I remember from my last encounter, the material flew right over my head. It was very different this time. I felt that I understood the material and was eager to implement it in real practice.
- ALLHAT: 1/3 black patients; 7 years old trial
- BB: usually not 1st line in HTN management, no mortality benefit
- ACCOMPLISH- 11,000 pt at high risk for HTN; CCB outperformed thiazides ( more peripheral edema in CCB; more hypotension in thiazide group; no difference in adverse events); 18% pt had less than 60ml/min GFR~ impaired diuretic efficacy; HCT inferior in bp effect in 24 hr post therapy; chlorthalidone ( half life : 12 hours) –> longer half life than HCTZ; chlorthalidone is twice as potent as HCTZ and they are non-interchangeable
- risk factors for thiazide induced hyponatremia: lean women, elderly
- controlled hypokalemia doesn’t correlate with controlled hyponatremia
- low salt diet may be more effective than initiating therapy? sustained difference?
- Aliskiren- direct renin inhibitor
- Olmesartan–> most potent ARB
- Predialysis solution may interfere with home glucose monitoring–> give false high reading
- intermetant IP–> concentration dependent antibiotic curve
- continuous IP–> time dependent antbiotics
- COPD: nicotine replacement has best cessation rate for COPD smokers
- inhaled anticholingerics doesn’t increase all cause morality ( meta-analysis: JAMA 2008)
No comments:
Post a Comment