Thromboembolism Medication

  • Author: Vera A De Palo, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Jan 24, 2012
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

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Anticoagulants

Class Summary

Anticoagulant medications prevent further clot deposition. They allow the natural fibrinolytic mechanisms to lyse the existing clot.

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Heparin

 

Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse but is able to inhibit further thrombogenesis. Heparin prevents re-accumulation of clot after spontaneous fibrinolysis.

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Warfarin (Coumadin)

 

Interferes with hepatic synthesis of vitamin K–dependent coagulation factors. Used for prophylaxis and treatment of venous thrombosis, PE, and thromboembolic disorders. Tailor dose to maintain an INR in the range of 2-3.

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Enoxaparin (Lovenox)

 

Prevents DVT, which may lead to PE in patients undergoing surgery who are at risk for thromboembolic complications. Average duration of treatment is 7-14 d. Enhances inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, preferentially increases inhibition of factor Xa. Enoxaparin also has been approved for the treatment of DVT and PE.

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Dalteparin (Fragmin)

 

Indicated for the prevention of DVT, which may lead to PE. Enhances inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, preferentially increases inhibition of factor Xa. Average duration of treatment is 7-14 d.

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Ardeparin (Normiflo)

 

Indicated for the prevention of DVT, which may lead to PE following knee replacement surgery. Enhances inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, preferentially increases inhibition of factor Xa. Average duration of treatment is 7-14 d.

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Thrombolytic agents

Class Summary

As advanced by the American College of Chest Physicians in their fourth consensus conference on antithrombotic therapy, thrombolytic treatment is indicated for acute, massive pulmonary embolism with hemodynamic instability in patients who do not seem prone to bleeding. These agents dissolve recent clots promptly by activating a plasma proenzyme, plasminogen, to its active form, plasmin. Plasmin degrades fibrin to soluble peptides. Thrombolytic therapy speeds pulmonary tissue reperfusion and rapidly reverses the right heart failure. It improves pulmonary capillary blood flow and more rapidly improves hemodynamic parameters.

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Streptokinase (Kabikinase, Streptase)

 

Acts with plasminogen to convert plasminogen to plasmin. Plasmin degrades fibrin clots as well as fibrinogen and other plasma proteins. Increase in fibrinolytic activity that degrades fibrinogen levels for 24-36 h takes place with intravenous infusion of streptokinase.

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Reteplase; tPA (Retavase)

 

Used in the management of PE in hemodynamically unstable patients. Safety and efficacy with concomitant administration of heparin or aspirin during first 24 h after symptom onset have not been investigated.

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Urokinase (Abbokinase)

 

Direct plasminogen activator that acts on endogenous fibrinolytic system and converts plasminogen to enzyme plasmin, which in turn degrades fibrin clots, fibrinogen, and other plasma proteins. Most often used for local fibrinolysis of thrombosed catheters and superficial vessels. Advantage is that agent is nonantigenic. However, more expensive than streptokinase and thus limits use. When used for local fibrinolysis, urokinase is given as local infusion directly into area of thrombus and with no bolus given. Dose of medication should be adjusted to achieve clot lysis or patency of affected vessel.

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Contributor Information and Disclosures
Author

Vera A De Palo, MD  Assistant Professor, Department of Medicine, Brown University School of Medicine; Director, Intensive Care Unit, Associate Chief of Medicine, Memorial Hospital of Rhode Island

Vera A De Palo, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, Rhode Island Medical Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jegan Krishnan, MBBS, FRACS, PhD  Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Flinders Private Hospital

Jegan Krishnan, MBBS, FRACS, PhD, is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, and Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jerome D Wiedel, MD  Chair, Professor, Department of Orthopedics, University of Colorado Health Sciences Center

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor Dr Michael Belanger to the development and writing of this article.

References

  1. Merli GJ. Prevention of thrombosis with warfarin, aspirin, and mechanical methods. Clin Cornerstone. 2005;7(4):49-56. [Medline].

  2. Agnelli G, Sonaglia F, Becattini C. Direct thrombin inhibitors for the prevention of venous thromboembolism after major orthopaedic surgery. Curr Pharm Des. 2005;11(30):3885-91. [Medline].

  3. Agudelo JF, Morgan SJ, Smith WR. Venous thromboembolism in orthopedic trauma patients. Orthopedics. Oct 2005;28(10):1164-71; quiz 1172-3. [Medline].

  4. Mismetti P, Zufferey P, Pernod G, Baylot, Estebe JP, Barrelier MT, et al. [Thromboprohylaxis in orthopedic surgery and traumatology]. Ann Fr Anesth Reanim. Aug 2005;24(8):871-89. [Medline].

  5. Jaffer AK, Barsoum WK, Krebs V, Hurbanek JG, Morra N, Brotman DJ. Duration of anesthesia and venous thromboembolism after hip and knee arthroplasty. Mayo Clin Proc. Jun 2005;80(6):732-8. [Medline].

  6. Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American Association of Orthopedic Surgeons and American College of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients?. Chest. Feb 2009;135(2):513-20. [Medline].

  7. Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty. AAOS Clinical Practice Guideline Summary:. American Academy of Orthopaedic Surgeons. Available at http://www5.aaos.org/dvt/physician/ADU013/suppPDFs/OKO_ADU013_S10.pdf. Accessed December 9, 2009.

  8. Lachiewicz PF. Prevention of symptomatic pulmonary embolism in patients undergoing total hip and knee arthroplasty: clinical guideline of the American Academy of Orthopaedic Surgeons. Instr Course Lect. 2009;58:795-804. [Medline].

  9. Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, et al. Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Am Acad Orthop Surg. Mar 2009;17(3):183-96. [Medline].

  10. Markel DC, York S, Liston MJ Jr, Flynn JC, Barnes CL, Davis CM 3rd. Venous Thromboembolism Management by American Association of Hip and Knee Surgeons. J Arthroplasty. Oct 16 2009;[Medline].

  11. Merli G, Spyropoulos AC, Caprini JA. Use of emerging oral anticoagulants in clinical practice: translating results from clinical trials to orthopedic and general surgical patient populations. Ann Surg. Aug 2009;250(2):219-28. [Medline].

  12. Hippisley-Cox J, Coupland C. Development and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism: prospective cohort study. BMJ. Aug 16 2011;343:d4656. [Medline]. [Full Text].

  13. Qaseem A, Chou R, Humphrey LL, Starkey M, Shekelle P. Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. Nov 1 2011;155(9):625-632. [Medline].

  14. Woller SC, Stevens SM, Jones JP, et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. Oct 2011;124(10):947-954.e2. [Medline].

  15. Pabinger I, Ay C. Biomarkers and venous thromboembolism. Arterioscler Thromb Vasc Biol. Mar 2009;29(3):332-6. [Medline].

  16. Bauer KA. New anticoagulants. Curr Opin Hematol. Sep 2008;15(5):509-15. [Medline].

  17. Akl EA, Gunukula S, Barba M, et al. Parenteral anticoagulation in patients with cancer who have no therapeutic or prophylactic indication for anticoagulation. Cochrane Database Syst Rev. Apr 13 2011;4:CD006652. [Medline].

  18. Akl EA, Vasireddi SR, Gunukula S, et al. Oral anticoagulation in patients with cancer who have no therapeutic or prophylactic indication for anticoagulation. Cochrane Database Syst Rev. Jun 15 2011;6:CD006466. [Medline].

  19. Boutitie F, Pinede L, Schulman S, et al. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants' data from seven trials. BMJ. May 24 2011;342:d3036. [Medline]. [Full Text].

  20. Akl EA, Labedi N, Barba M, et al. Anticoagulation for the long-term treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev. Jun 15 2011;6:CD006650. [Medline].

  21. Goldhaber SZ, Haire WD, Feldstein ML, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet. Feb 27 1993;341(8844):507-11. [Medline].

  22. Hirsh J, Dalen J, Guyatt G. The sixth (2000) ACCP guidelines for antithrombotic therapy for prevention and treatment of thrombosis. American College of Chest Physicians. Chest. Jan 2001;119(1 Suppl):[Medline].

  23. The EINSTEIN Investigators. Oral Rivaroxaban for Symptomatic Venous Thromboembolism. N Engl J Med. Dec 3 2010;[Medline]. [Full Text].

  24. Aujesky D, Roy PM, Verschuren F, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. Jul 2 2011;378(9785):41-8. [Medline].

  25. Schulman S. Current strategies in prophylaxis and treatment of venous thromboembolism. Ann Med. 2008;40(5):352-9. [Medline].

  26. Prevention of venous thromboembolism in orthopedic surgery. Med Lett Drugs Ther. Nov 3 2008;50(1298):86-8. [Medline].

  27. Jaffer AK, Brotman DJ. Prevention of venous thromboembolism after surgery. Clin Geriatr Med. Nov 2008;24(4):625-39, viii. [Medline].

  28. Piazza G, Goldhaber SZ. Physician alerts to prevent venous thromboembolism. J Thromb Thrombolysis. Nov 4 2009;[Medline].

  29. Wittkowsky AK. New oral anticoagulants: a practical guide for clinicians. J Thromb Thrombolysis. Nov 4 2009;[Medline].

  30. Lu JP, Knudson MM, Bir N, Kallet R, Atkinson K. Fondaparinux for prevention of venous thromboembolism in high-risk trauma patients: a pilot study. J Am Coll Surg. Nov 2009;209(5):589-94. [Medline].

  31. Muntz J. Thromboprophylaxis in orthopedic surgery: how long is long enough?. Am J Orthop. Aug 2009;38(8):394-401. [Medline].

  32. Huo MH, Muntz J. Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: a review. Clin Ther. Jun 2009;31(6):1129-41. [Medline].

  33. Goldhaber SZ, Leizorovicz A, Kakkar AK, Haas SK, Merli G, Knabb RM, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med. Dec 8 2011;365(23):2167-77. [Medline].

  34. Merkow RP, Bilimoria KY, McCarter MD, et al. Post-Discharge Venous Thromboembolism After Cancer Surgery: Extending the Case for Extended Prophylaxis. Ann Surg. Jul 2011;254(1):131-137. [Medline].

  35. Kabrhel C, Varraso R, Goldhaber SZ, Rimm E, Camargo CA Jr. Physical inactivity and idiopathic pulmonary embolism in women: prospective study. BMJ. Jul 4 2011;343:d3867. [Medline].

  36. Enden T, Haig Y, Kløw NE, et al. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. Jan 7 2012;379(9810):31-8. [Medline].

 
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Pulmonary embolism within the pulmonary artery.
Ventilation-perfusion scan. Left image: Posterior view of normal findings on ventilation scan. Right image: Posterior view of a perfusion scan that reveals a perfusion defect in the left upper quadrant. The defect in the middle of the image is due to the position of the heart.
Helical CT scan of the pulmonary arteries. A filling defect in the right pulmonary artery is present, consistent with a pulmonary embolism.
 
 
 
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