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The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications, while minimizing bleed risks, was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient conference.
“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs Anticoagulation and Thrombosis Services at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and Dr. Minichiello said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.
“There is interest on both sides of that question,” Dr. Minichiello said, adding that the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion
of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.”
“We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.” —Tracy Minichiello, MD
Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk but comes with an increased risk for bleeding.
“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.
Literature increasingly recommends that hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, Dr. Minichiello noted. “[Hospitalists] must be mindful of the risks and benefits,” she said. Physicians should also think twice about concomitant antiplatelet therapy, like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”
Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Québec, attended Dr. Minichiello’s breakout session on challenging cases.
“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,”
Dr. Bouchard said. She also explained that a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries to offer the oral anticoagulants whenever possible.
Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around performing procedures, choosing anticoagulants, and determining when to restart treatments.
“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested that hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s Anticoagulation Services website, or the American Society of Health System Pharmacists’ Anticoagulation Resource Center.