Anticoagulation Case Study: Riding The Struggle Bus PDF (Marian University)

Anticoagulation Case Study: Riding the Struggle Bus Brian Skinner, PharmD, BCPS Associate Professor of Internal Medicine Marian University – Wood College of Osteopathic Medicine BMS 551 Med Phys Pharm...

Anticoagulation Case Study: Riding the Struggle Bus Brian Skinner, PharmD, BCPS Associate Professor of Internal Medicine Marian University – Wood College of Osteopathic Medicine BMS 551 Med Phys Pharm Schedule Office Hours Fall 2024  Objectives Relate a patient’s medical history, diagnosis, and treatment to the medical physiology and pharmacology (MPP) course work Identify risk factors for thrombus development Identify contraceptive products that are contraindicated in patients with hypercoagulable disorders Identify the steps in the formation of a fibrin clot, including specific factors of the extrinsic, intrinsic, and common pathways Examine the affect of pregnancy on pharmacotherapeutic selections, and identify the most appropriate anticoagulant for a given patient  Agenda Clinical Case Patient presentation Pathophysiology of Disease Future Issues that Arose Treatment of Disease Conclusion Impact on me and my practice What can we learn? Clinical Case Riding the Struggle Bus  Patient: Sandie Lynn Kris, 18 yo female Social History: College freshman Flute player in the marching band Not sexually active Denies alcohol, tobacco, illicit drugs Past Medical History: Dysmenorrhea, Acne Medications: Yaz® (ethinyl estradiol & drospirenone) Travel History: Recent 5 hour bus trip to another college for football game with the marching band  Patient Case: Presentation Chief Complaint: Swelling and pain of left lower extremity Imaging: Ultrasound of the left leg reveals a thrombus in the great saphenous vein Genetic Testing: Prothrombin Gene Mutation: Negative Antithrombin III Deficiency: Negative Protein C Activity: Normal LLE swelling and erythema in a male patient Factor V Leiden: Positive (heterozygous)  What happened: Virchow’s Triad in Action Immobility Venous obstruction (obesity, Circulatory Stasis pregnancy, tumor) Varicose Veins Atrial fibrillation Surgery Malignancy Cellulitis Pregnancy THROMBUS Atherosclerosis Estrogen therapy FORMATION Venepuncture Inherited thrombophilia Trauma Hypercoagulability Endothelial Injury  Clotting Cascade: Simplified XII XI VII III Intrinsic Pathway IX Extrinsic Pathway (aPTT) (PT) VIII X V II Common Pathway (aPTT & PT) I Fibrin Clot Clotting Cascade: Full  Birth Control and Thrombus Formation Estrogen Containing Oral Contraceptives Affects gene transcription factors of various proteins including…. II, VII, X, XII, XIII, and Fibrinogen Progestins were added to decrease the amount of estrogen in OCP products Drospirenone and desogestrel are novel progestins that have antimineralocorticoid and antiandrogenic properties Found to increase blood clot risk by 1.5-fold compared with other progestins  What happened: Virchow’s Triad in Action Immobility Venous obstruction (obesity, Circulatory Stasis pregnancy, tumor) Varicose Veins Atrial fibrillation Surgery Malignancy Cellulitis Pregnancy THROMBUS Atherosclerosis Estrogen therapy FORMATION Venepuncture Inherited thrombophilia Trauma Hypercoagulability Endothelial Injury Venous System of the Legs Diagnosis: Superficial thrombophlebitis  Treatment Warm compress of the affected area NSAIDs as needed for pain Discontinue oral contraceptive – do not use estrogen-containing products ever Can use progestin-only pill, progestin IUD, progestin implant, or copper IUD Fast forward 10 years….  Patient: Sandie Lynn Kris, 28 yo female Social History: Elementary Music Teacher Past Medical History: Dysmenorrhea, Heterozygous Factor V Leiden, Unexplained Infertility, Varicose Veins Medications: Letrozole Reason for visit: Positive Pregnancy Test  What happened: Virchow’s Triad in Action Immobility Venous obstruction (obesity, Circulatory Stasis pregnancy, tumor) Varicose Veins Atrial fibrillation Surgery Malignancy Cellulitis Pregnancy THROMBUS Atherosclerosis Estrogen therapy FORMATION Venepuncture Inherited thrombophilia Trauma Hypercoagulability Endothelial Injury  Medications to Treat Thrombotic Disorders Injectable Formulations Oral Formulations* Direct Thrombin Vitamin K Heparin Products Factor Xa Inhibitors Inhibitors (Factor II) Antagonists Heparin Rivaroxaban Dabigatran Warfarin Low-molecular Apixaban Argatroban* weight heparins Betrixaban Bivalirudin* Enoxaparin Edoxaban Dalteparin Fondaparinux* *Only available as an injectable product  Thromboprophylaxis During Pregnancy Heparin Enoxaparin Route of Administration Subcutaneously Subcutaneously Dosing 10,000 units every 12 hours 40mg daily Factors Inhibited II and X X >>> II Onset 20-30 minutes 3-5 hours Half-life 1.5-2 hours 4.5-7 hours Epidural Placement 6-12 hours after last dose 12-24 hours after last dose Place in Therapy 3rd Trimester 1st and 2nd Trimester Thromboprophylaxis During Pregnancy  Treatment Plan Placed on enoxaparin until week 36 Switched to heparin until week 39 Induction planned for 39 + 1 Why a planned induction when full term can go to 42 weeks? Placed back on enoxaparin 24 hours after delivery x 6 weeks  Impact on Me and My Practice As a healthcare provider, it is incredibly difficult to be a patient or a patient’s family member Implementation of care is much more difficult than simply prescribing care  What Can We Learn? Chronic medical conditions – even if they don’t require treatment – are still chronic medical conditions! Underlying pathophysiology of disease is incredibly important to understanding at-risk populations Management of conditions during pregnancy has the added complication of ensuring safe and effective therapy for both mom and the developing fetus  MPP Patient Podcast Project For another patient perspective, check out this podcast by former BMS student Tanner Maxfield! https://open.spotify.com/episode/5ts53Va7nQOBuUJplFVedm?si=KZVf9AWETg23rXd7 nldHVQ  Anticoagulation Case Study: Riding the Struggle Bus Brian Skinner, PharmD, BCPS Associate Professor of Internal Medicine Marian University – Wood College of Osteopathic Medicine BMS 551 Med Phys Pharm Schedule Office Hours Fall 2024