Traditionally, treatment of acute PE involved IV heparin with coumadin bridging, and d/c after therapeutic INR. Does anyone treat inpatients on day 1 with low molecular weight (weight-based) and then discharge them right away with f/u in coumadin clinic?
I realize the studies supporting this relate more to DVT's, but isn't the extrapolation to PE's a valid one?
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I start Pts on LMWH from day 1 for PE all the time. It is more reliable and predictable then UFH. The catch on sending them home is more of a legal one than a medical one. There are many trials from Europe and Canada on the success of LMWH for DVT/PE as outPt or inPt. However. The trials in the US for DVT with PE were for inPt treatment, so the FDA application and the "official" treatment indications for LMWH include only outPt Tx of DVT without PE or inPt Tx of DVT/PE. Unfortunately that means that if you were to send somebody home with a PE on Lovenox you would be medically correct but if anything happens, you have sent them home on an "off-label use" of the drug...
(you can see the PI for Lovenox on http://lovenox.com/professional/homeAction.do)
The ACCP guidelines actually even favor LMWH over UFH for PE but again for inPt Tx.
I think that the standard of care here has been to use LMWH from the onset, and d/c home with that as a bridge to coumadin based on clinical parameters. As said, the European studies showed equivalence in outcomes between unfractionated heparin and LMWH for patients with PE. I don't think a US study has looked at that specific question prospectively.
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