outpatient dvt

[saintsfan180]

I know you can do it... At my training program we never did because follow up sucked. I had a guy today with a proximal dvt that I started on lovenox and admitted. The hospitalist didn't put up much of a fight, but asked why I didn't treat him outpatient. I just haven't before and wasn't too sure on the dosing, so he put him in. Are you guys doing this routinely in stable patients? I know it's done but it still feels weird to me to send someone out with lovenox shots to bridge themselves, I dunno.

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[BoardingDoc]

Why do they need to bridge themselves? You can just start them directly on apixaban as an outpatient if they are ok with a non-reversible anticoagulant. If you're worried, they can certainly go the lovenox --> coumadin route at home as well provided that they're otherwise healthy and responsible.

Now to actually answer your question.... no this isn't routinely done at my program. A large percentage of these patients are still being admitted. That said, I'd guess maybe 20-30% go home with an Rx for lovenox and PCP followup within 24 hrs.

 

[pianoman511]

Depends on how proximal, if its pretty much the entire leg it would be hard to justify outpatient although lovenox would be an option. Theoretically there's no reason you couldn't send someone home though, in fact I sent someone home with lovenox with a proximal DVT a few months ago. Just a long discussion with patient and family so they can understand the situation. I agree about discharging both PE and DVTs which are stable (there are decision rules for PE).

 

[USCDiver]

Depends on how proximal, if its pretty much the entire leg it would be hard to justify outpatient although lovenox would be an option.

Why would it be hard to justify? Maybe it's my ignorance of what happens in the inpatient realm on these folks, but aren't they just getting an anticoagulant and going home? Are they getting embolectomy? Is there some significantly increased risk of fatal PE in these patients over the first 24-48hrs after diagnosis of the DVT?

My understanding is that patients on medications like Xarelto are considered to be fully anticoagulated after one dose. There isn't a bridging period or anything as far as I know. I don't see much benefit of inpatient Xarelto administration unless there is a question of cost or followup.

 

[pianoman511]

NOACs and coumadin were never studied for treatment of extensive or very proximal DVT although lovenox and heparin would be acceptable treatment. There are some proof of concept and early clinical trials for xarelto but none have completed yet. I think that vascular surgery gets consulted on those types of patients before discharge depending on risk factors (although I too am not 100% of the course of the treatment).

 

[dotcb]

It requires institutional buy-in from your hospital. It's best done as a project coordinated between ED, pharmacy, hospitalist, and outpatient medicine. We DC DVT's from the ED, but only during hours when pharmacy is able to do lovenox teaching and we can ensure close follow up for transition to warfarin. We aren't beginning NOACs, and we still admit PE's.

At my hospital, for large thrombus DVT's (up to femoral head), our IR guys like to do catheter directed lysis/thrombectomy, so we admit those.

 

[Janders]

I just sent a DVT home a couple hours ago... I send 80% home. Still admit the great great majority of PEs.

Nurse taught her to do lovenox.
Lovenox and Coumadin 5 day Rx written
PCP aware, will see patient in 2-3 days for INR check, etc.
Easy peasy.
Sometimes I'll use xarelto depending on $$$ factors.
Agree that huge/proximal ones sometimes need admission for vascular input.

 

[Groove]

Almost all of my DVTs go home on anticoagulation. The exception are the massive proximal ileofemoral DVTs. They get put on heparin and admitted. That's an indication for CV eval for thrombectomy and/or greenfield filter placement. I just admitted one last week and he got IVC filter/angiojet thrombectomy.

 

[gman33]

So in some cases above you are sending home someone of an oral agent which is not approved for DVT tx.
What if the person develops a massive PE or some other bad outcome?

If your institution has a written protocol, maybe this is defendable.
I'm all for keeping people out of the hospital, but I want to protect both the patient and myself.

I had a patient the other day. DVT on output u/s.
Now hypoxic with massive PE. Note from PMD that CTA not needed because it wouldn't change management.
Not really true.
Also, this person developed HITT.
That probably would have never been picked up if the person was just given Lovenox and PMD f/u.

 

[turkeyjerky]

So in some cases above you are sending home someone of an oral agent which is not approved for DVT tx.
What if the person develops a massive PE or some other bad outcome?

If your institution has a written protocol, maybe this is defendable.
I'm all for keeping people out of the hospital, but I want to protect both the patient and myself.

I had a patient the other day. DVT on output u/s.
Now hypoxic with massive PE. Note from PMD that CTA not needed because it wouldn't change management.
Not really true.
Also, this person developed HITT.
That probably would have never been picked up if the person was just given Lovenox and PMD f/u.

The NOACs are actually FDA approved for the acute mgmt of VTE, and the studies look good, so I'm very comfortable using them. I have doubts that many of my patients will be able to comply with a lovenox to warfarin bridge, so I don't use this approach myself (plus lovenox is super expensive). I do not, however, use dabigatran, as this agent was studied after a lovenox bridge itself.

As to the post above, US does not have a 100% sensitivity for calf thromboses. Indeed, I had a patient the other day w/ multiple bilateral PEs; she had had intermittent leg swelling over the past several weeks but had a negative ultrasound a month prior to her ER visit. Do you admit everyone with a negative duplex ultrasound for monitoring until they get a repeat?

And maybe your patient wouldn't have developed HITT if you hadn't treated her with heparin.

Personally, I'm all for cautious and safe practice, but I'm also for progress.

 

[gman33]

The NOACs are actually FDA approved for the acute mgmt of VTE, and the studies look good, so I'm very comfortable using them. I have doubts that many of my patients will be able to comply with a lovenox to warfarin bridge, so I don't use this approach myself (plus lovenox is super expensive). I do not, however, use dabigatran, as this agent was studied after a lovenox bridge itself.

As to the post above, US does not have a 100% sensitivity for calf thromboses. Indeed, I had a patient the other day w/ multiple bilateral PEs; she had had intermittent leg swelling over the past several weeks but had a negative ultrasound a month prior to her ER visit. Do you admit everyone with a negative duplex ultrasound for monitoring until they get a repeat?

And maybe your patient wouldn't have developed HITT if you hadn't treated her with heparin.

Personally, I'm all for cautious and safe practice, but I'm also for progress.

I did not realize all the oral agents were now approved.

If I get a negative u/s, I go back to why I ordered the test in the first place.
Lower risk and normal person, they may get d/c with repeat u/s (or just monitoring and pmd f/u).
There may be something else like a cellulitis.
Or I may be really concerned and they need some other form of emergent imaging.

The way this is handled is system dependent as well as patient dependent.
If all the proper management can be done as an outpatient, I'm all for that.
But you have to be sure that it is ALL going to get done.
For a lot of people a 24 hour OBS is the easiest way for this to happen.

 

[Greenbbs]

I'll d/c stable patients in which I can get good follow-up with the PCP set before discharge. Most of our PCP's are fine with xarelto unless they have some element of financial issues or the patient us a hx of significant bleeding, then it's Coumadin and bridging.

I sent a guy home the other day on Xarelto. Why would I doom a guy with an isolated, provoked DVT to blood draws and bridging when they can be on xarelto for their 9 months if they're lower risk?

 

[Groove]

I d/c 90% of mine on Xarelto (minus the large proximal DVTs). Lovenox is too expensive for most pt's and few are compliant with bridge therapy as instructed. Xarelto is just so much easier to dose. I auto populate a blurb about consent to treatment and bleeding risks, etc.. in my MDM. You can get your local Xarelto rep to stock you with tons of those starter packs. It's therapeutic at ~2hrs.

 

[Janders]

Oh thats what I need, starter packs! I haven't seen a drug rep in... hrm... 8 years...

 

[xaelia]

Jeff Kline has published his own experience of a year+ of sending home low-severity VTE:
http://www.ncbi.nlm.nih.gov/pubmed/26113241

Covered by SGEM:
http://thesgem.com/2015/07/sgem126-take-me-to-the-rivaroxaban-outpatient-treatment-of-vte/

and REBEL EM:
http://rebelem.com/september-2015-rebelcast/

Helps to have follow-up and $$$. Obviously, my Kaiser experience is maximal outpatient VTE management.

 

[njac]

Jeff Kline has published his own experience of a year+ of sending home low-severity VTE:
http://www.ncbi.nlm.nih.gov/pubmed/26113241

Covered by SGEM:
http://thesgem.com/2015/07/sgem126-take-me-to-the-rivaroxaban-outpatient-treatment-of-vte/

and REBEL EM:
http://rebelem.com/september-2015-rebelcast/

Helps to have follow-up and $$$. Obviously, my Kaiser experience is maximal outpatient VTE management.

I've been waiting for a chance to hit up a computer and throw the same links up.

Sounds like they've been able to to pull it off successfully with minimal follow up as well. My current shop is a free standing community hospital without great mechanisms for follow up. So we've been hesitant to do this much unless they're kaiser or other hmo.

 

[d2305]

Lovenox isn't cheap either. Most of my patients get rat poison.

 

[gutonc]

This is one of those cases where I relish the call (as your friendly neighborhood on call hematologist) to save the patient the pain and frustration of lovenox bridging to coumadin, which they'll finally be stable and therapeutic on just about the time I recommend that they stop it.

If they're insured, give them a whack of lovenox (1.5mg/kg), send them with the 3w 15mg BID script for Xarelto (or a starter pack if you have it) and I'll see them sometime in that next 3 weeks to give them the rest of their Rx.

Obviously, there are exceptions to this rule as outlined above. But if you can (clinically or socially), send them home with a plan that doesn't suck for them.

I also recognize that not all of your consultants are likely as awesome as I am...that sucks for you.

 

[thorg12]

I send nearly all dvt's home with lovenox/Coumadin or Xarelto if case Managment around.
Just my friendly reminder to always know the evidence behind anticoagulation for VTE in general, very shaky.
Now there is this whole world for the treatment of VTE, never pitted against plain old NSAID's.
Not saying anticoagulation doesn't work but not really proven by prospective placebo controlled trials.
Even cochrane can't recommend anticoagulation for VTE, stating there is not enough evidence
http://www.cochrane.org/CD003746/PV...r-treating-people-who-have-venous-blood-clots

 

[Old_Mil]

I know you can do it... At my training program we never did because follow up sucked. I had a guy today with a proximal dvt that I started on lovenox and admitted. The hospitalist didn't put up much of a fight, but asked why I didn't treat him outpatient. I just haven't before and wasn't too sure on the dosing, so he put him in. Are you guys doing this routinely in stable patients? I know it's done but it still feels weird to me to send someone out with lovenox shots to bridge themselves, I dunno.

You can do it in Texas but not Pennsylvania, Illinois, Kentucky, Washington, or Oregon.

 

[winkleweizen]

You can do it in Texas but not Pennsylvania, Illinois, Kentucky, Washington, or Oregon.

Why's that.

 

[TheBlueBlazer]

I think that we're starting to get enough experience to be comfortable with one of the NOACs in this case, and it seems to be relatively economically feasible in many cases. Plus, the Janssen rep is really pretty and takes me to steak dinners at Ruth's Chris (j/k. But a guy can wish...)

 

[gutonc]

I think that we're starting to get enough experience to be comfortable with one of the NOACs in this case, and it seems to be relatively economically feasible in many cases. Plus, the Janssen rep is really pretty and takes me to steak dinners at Ruth's Chris (j/k. But a guy can wish...)

Xarelto was priced to be essentially identical to 2 weeks of lovenox followed by coumadin with weekly INR monitoring for 3 months. They knew what they were doing.

I also wonder if the lower rate of brain bleeds compared to coumadin correlates to decreased overall healthcare costs (but I doubt it) and Mrs. Jones' HMO doesn't give a s*** about that anyway.

 

[Apollyon]

Why's that.

Good (TX) malpractice environment vs ****ty (all the others). I'm guessing, at least.