Outpatient PE management follow-up

PULMONARY EMBOLISM

Outpatient PE management follow-up

Who Should Receive Extended Duration Anticoagulation?

Indications for extended or indefinite anticoagulation include patients with an unprovoked proximal DVT or PE, a history of recurrent VTE events (more than 2), active cancer and select thrombophilia’s.  Additional indications to aid the clinician in considering extended therapy include: male sex, residual vein thrombosis, obesity, persistent immobilization, an elevated D-dimer off anticoagulation and a strong family history.  Prediction rules including the DASH score, Vienna Prediction Model and the Men Continue and HERDOO2 may also aid the physician in determining length of anticoagulation therapy. Patients who should not receive extended anticoagulation include those with a higher risk of bleeding, lower risk of recurrence and patient’s preference.

Outpatient Pulmonary Embolism Follow Up Protocol:

All Patients All Patients Warfarin Rivaroxaban Apixaban Edoxaban Dabigatran
Day 1-2: Nursing or Anticoagulation Clinic – phone call to patient Ensure patient has obtained prescription

Assess for bleeding complications, recurrent/progressive thrombotic symptoms

Ensure dosing is appropriate for renal function (checked at time of DVT diagnosis)

 Ensure patient is taking warfarin at dose prescribed Ensure patient is on 15 mg twice daily and taking with food Ensure patient is taking 10 mg twice daily
Day 5:

Nursing or Anticoagulation Clinic follow up

 Assess medication compliance, bleeding complications, recurrent/progressive  thrombotic symptoms, scheduled procedures, concomitant medications Check INR, when between 2 and 3 discontinue LMWH or fondaparinux Ensure dose change after day 7 from 10 mg twice daily to  5 mg twice daily Switch from LMWH to Edoxaban Switch from LMWH to Dabigatran
Day 21: Nursing or Anticoagulation Clinic- phone call to patient Assess medication compliance, bleeding complications, recurrent/progressive  thrombotic symptoms, scheduled procedures, concomitant medications Ensure dose change after day 21 from 15 mg twice daily to 20 mg/day
3 months

Clinic visit

 Assess medication compliance, bleeding complications, recurrent/progressive  thrombotic symptoms, scheduled procedures, concomitant medications

Reassess length of treatment (3 months vs. extended or indefinite)

Patients with Cockcroft-Gault (CrCl 30 -50 mL/min, repeat renal function testing
6 months:

Nursing or Anticoagulation Clinic follow up

 

Assess risk factors for the need to continue (extended duration or  (indefinite) anticoagulation

 Assess medication compliance, bleeding complications, recurrent/progressive  thrombotic symptoms, scheduled procedures, concomitant medications

Patients with Cockcroft-Gault (CrCl 30 -50 mL/min, repeat renal function testing

 Assess for extended duration dosage of 10 mg daily Assess for extended duration dosage of 2.5 mg twice daily Assess for extended duration dosage of 150 mg twice daily
9 months:

Nursing or Anticoagulation Clinic follow up

 Assess medication compliance, bleeding complications, recurrent/progressive  thrombotic symptoms, scheduled procedures, concomitant medications

Patients with Cockcroft-Gault (CrCl 30 -50 mL/min, repeat renal function testing
1 year: Clinic visit compliance, bleeding complications, recurrent/progressive  thrombotic symptoms, scheduled procedures, concomitant medications

Patients with Cockcroft-Gault (CrCl 30 -50 mL/min, repeat renal function testing
Patient Handout
References and Bibliography