RCH Trust Thrombosis prevention and Anticoagulation Policy
Steering Group (TPAS)
Meeting held 5.15 pm on 1st August 2013
Minutes
1) Apologies: A Cornelius, S Adcock, R Kincaid, S Gupta, J Trugian, S Matthews,
NMarshall, S Harris,R Palmer J Trudgeon
Present: K Adie (KA), J Blundell (JB) J Glinn (JG) A Lee (AL) A McSorley (AM)
A Slade (AS) M D Creagh (DC) ?Eva Molnar
2) Minutes and actions from August 2012 were agreed wrt:
Thrombosis Practitioner (established within DVT Clinic July 2013)
Revision to Trust Clinical Guideline wrt to updated guidance and noval direct oral
anticoagulants, license and NICE approval and subsequently updated to the Trust
Document Library (with medical staff education) January 2013.
3) VTE CQUIN
The VTE CQUIN 2012-2013, based on 95% risk assessment (RA) was successful.
For 2013-2014 the RA target continues, together with a requirement for RCA of
hospital acquired VTE (“HAT”) RCA.
Current RA performance:
Monthly business unit UNIFY data collection July 97.0%
Monthly Pharmacy June audit for initial/admission RA of 92% with appropriate
prescribing 93%. There has been an issue, wrt to the NHSLA inspection, of lack of
signature and date for RA, though this was present to the prescription and so could
be considered as one process. Education of juniors and currently RA not signed/dated
for 8.6%. For the 24 hours RA re-assessment this is done in 46.1% (see below).
HAT RAC
Commended 22/7/13, utilising DATIX and reporting to respective Divisions for action.
4) NHSLA
As above, ahead of the assessment there was concern re the need for evidence of
RA process by signature and date, together with poor performance for 24 hr re-
assessment as proscribed by the Trust Policy (and NICE). A plan of action is place.
At the inspection there was a pass for the VTE criterion and the Trust attained Level
2. The plan is for on-going education and RA as part of module in EPMA update
December 2013, completion of which will be necessary for continuing
prescription/drug issue.
Patient information on admission/discharge – (Thrombosis Practitioner)
5) Clinical Governance
Continuing F1/2 education programme and consultant mandatory training
Thrombosis facilitator/practitioner established July 2013 (AM)
The use of rivaroxaban in PE NICE TA287 has been considered by CAPC for use,
with the recommendation for implementation through the DVT Clinic. A GASP audit is
in process.
Updated/new guidance
Trus
t Guidance on travel and venous thrombosis (update 2013)
http://intra.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Haematology/Gui
danceOnTravelAndVenousThrombosis.pdf
Clinical Guideline forthe Diagnosis Treatment and Ongoing Management Of VTE
in pregnancy, labour and post natal period (new July 2013)
http://intra.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/MidwiferyAndObst
etrics/CGDiagnosisTreatmentOngoingManagementOfVTE.pdf
Audit:
A pilot for Acute GP/primary care VTE screening using d-dimer has led to a
proposal for revision to primary care screening with e-access to Wells score
(KCC re-assessment of screening/diagnostic pathway)
6) Proposed update to the Trust Thrombosis Prevention and Anticoagulation CG
Corrections were accepted
Additions/revisions:
Fondarinux addition wrt to VTE and ACS licensed use (p7)
Referances to the (new) noval anticoagulants to include apixiban, as NICE’d for AF
and so may be in use in primary care, together with a list of drug interactions.
A: JG to review NOAC interactions (p10)
Monitoring of NOAC recommendations (for malabsorption and compliance)
(p11).
GPIIa/IIIb inhibitors (abciximab, eptifibatide and tirofiban) (p12):
A:JG has re-written
Obesity – thromboprophylaxis and therapeutic LMWH (p20):
This has arisen primarily from enquiries from the Bariatric Surgery Service. Advice
had been sought from Medicines Information, the manufacturers SPC, published
evidence and colleagues elsewhere. A review from the UK Clinical Pharmacy
Association 2010 for prophylaxis had been circulated and it was agreed to
incorporate this to the guidance
A: DC to propose change to Mr I Finley Lead Consultant for
the Bariatric Surgery Service (see addendum)
For VTE therapeutic heparin with dalteparin is dose limited for 100kg, other than for
pregnancy where pharmacokinetics differ. For enoxaparin “No dosage adjustments
are recommended in obesity or low body weight” and “once daily subcutaneous
doses of 1.5 mg/kg in healthy volunteers suggests that no dosage adjustment is
necessary in obese subjects (BMI 30-48 kg/m2) compared to non-obese subjects”,
however there are advocates for either limiting single injections to 150mg, use of bd
schedules and, or measurement of anti-Xa levels (as some do for dalteparin rg
200u/kg bd). A non weight restricted dose schedule might also result in a renal
impaired subject receveing a greater anti-Xa dose with enoxaparin than with
dalteperin. The Group were not aware of cases of VTE recurrence in obsese patients
with the use of dalteparin and it was suggested that an audit of practice and
outcomes for pt by weight and BMI should be undertaken to inform a further review of
this issue
No weight adjustment is recommended for the NOACs.
A: To continue with current maximum weight limited once daily
dalteparin schedule.
AM/DVT Clinic to lead on audit on weight BMI and outcomes
Update for use of NOAC’s in PE (rivaroxaban) and NICE implementation via DVT
Clinic (p29)
Review of (LMWH therapy) cancer VTE within 6 months (P30)
A: AM to liaise with site specific CNS to develop a
programme, based on disease response.
AS suggested revision re for Cardiac thrombolysis and the use of
tenecteplase “is uncommonly required, given standard practice of primary
angioplasty” so updated (p32)
NOACs surgery and invasive procedures (p65): The SPC licensed
recommendations were reviewed together with additional but similar
information from the manufacturers and reviews for endoscopy practice and
guidance such as that from the European Heart Rhythm Association Practical
Guide for non-valvular atrial fibrillation NOAC use
www.NOACforAF.eu. A derived schedule for pre-operative cessation of therapy was agreed
VTE thromboprophylaxis was agreed.
It was agreed that for patients at high risk of thromb-embolism, full dose
anticoagulation can be re-introduced from 48hrs (
rivaroxaban bd schedule) and
for low risk from from day 5, provided no significant bleeding.
Therapeutic dalteparin “bridging” for surgery and invasive procedures (p72): A cross
reference to the once daily 200u/kg pre-operative dosing was added together with a
Table: Post-procedure bridging with dalteparin (non-high bleeding risk procedures),
based on 100 units per kg twice daily.
7) Correspondance
Extended LMWH in hip fracture – ongoing concerns have been raised from CoE.
NICE recommendation is incorporated in the current Trust CG
A: It was suggested this might be taken on through the
governance processes. KA to liaise with colleagues
The TIA clinic have submitted to the CAPC for the use of NOAC in acute TIA and non
valvular AF. Dr Harrington had requested guidance on a subsequent switch to
warfarin. AS felt that this was inappropriate as “prior stroke or transient ischaemic
attack” was a NICE TAG qualifying recommendation for the NOAC’s and also wrt to
published guidance (2012 focused update of the ESC Guidelines for the management
of atrial fibrillation)
Dr Schuh from the Mermaid screening/diagnostic procedures has sought advice wrt
their warfarin practice of no interuption provided INR<4.0, MDC though a similar
practice was appropriate for NOACs and rather as per licensed recommendation for
epidural.
Drs Murray and Fortun have proposed a Trust Clinical Guideline For Managements
Of Patients Taking Anticoagulants In Endoscopy. This covers NOAC patients for
elective and emergency endoscopy ie with haemorrhage and broadly is line with the
proposed revised Trust Thrombosis Prevention and Anticoagulation CG. They have
been asked for their comment.
A: Dr Murray invited to join the group.
8) Date for next meeting January 2014 5.15pm
Addendum (October 2013)
Re 6) Obesity – thromboprophylaxis and therapeutic LMWH (p20)
Discussed within the Bariatric Team and with Mr Finlay as lead. No perceived VTE
problem, the patients commonly being mobilised and home on day1 with standard dose
prophylaxis. Collection of outcome data is in process, whilst the recently instituted
systematic RCA of each hospital aquired VTE (within 3 months of an admission) will
identify future cases.
A: No change to current practice
Membership:
Dr M D Creagh (DC)
Consultant, Clinical Lead for Thrombosis and Chairperson
Dr V Barnard
ST2 in Medicine and Junior Doctor Representative
Dr R Bland
Consultant in Elder Care
Dr J Blundell (JB)
Consultant Haematologist
Dr A Edwards
Consultant in Radiology
Mr J Glinn (JG)
Head of Pharmaceutical Clinical Services
Dr S Gupta (SG)
Consultant in MAU
Dr S Harris (SH)
Consultant in Paediatrics
Dr S Iles
Consultant in Respiratory Medicine
Dr N Marshall (NM) Consultant Anaesthetist
Mr R Kincaid (RK) Consultant in Orthopaedics
Mr A McSorley (AM) Nurse Practitioner DVT Clinic
Ms R Palmer (RP) Community Pharmacist Advisor
Ms C Richards (CR) Acting Clinical Nurse Manager for General Surgery
Dr A Slade
Consultant Cardiologist
Ms J Trudgeon
Tissue Viability Nurse Specialist
Dr Iain Murray
Consultant Gastro-enterologist
Recipient of minutes
Dr D Browne (DB) Medical Director (Governance)
I Nicholls
Medication Safety Lead Pharmacists
List of proposed corrections/addition/revisions/issues as circulated for the
1st August meeting.
Page
Addition/revision
Ref or action
5
EMC and SPC
glossary
6
Renal Appendix 1
correction
8
Licensed drug indications and local use
Update and NICE
Apixaban and rivaroxaban
approvals
10
Apixaban and drugs interactions
11
specific assessment of drug level of NOAC
in malabsorption, or questions of ompliance
16/17
Action for initial assessment on admission
Re-order of re-assessment recommendation
19
Extremes of weight:Obesity
?audit
Advice re “200u/kg and split the dose and give bd
And >150kg do a 4 hour peak anti-Xa and cap if very
high
27/31
*For patients with renal impairment
Issue remains re therapeutic in VTE/IHD
30
Need for/v of LMWH in cancer by 6/12
Who how? Care Pathway in development
DVT clinic/Oncology
44
Vit K 1-3 mg
correction
50
Consider Tranexamic Acid (1g i.v.) -
Reordered algorithim
62
provided renal function is adequate
(creatinine clearance < 30 ml/min in which
case substitute enoxaparin as per appendix
1,
64
NOAC and surgery
71
Peri-operative bridging with enoxaparin in
CRF
it may be reasonable to limit the total daily
dose to 150mg (as = standard dose for a
100kg and so otherwise end up with more
than would give with standard dose
dalteparin? Cf in STEMI enoxaparin dose is
1mg/kg bd max single dose 150mg but in
over 75 0.75mg/kg bd max single 75mg –
highest tabled weight is 150kg
Should we include a table for pre-filled
dalterparin syringe dose?
81
EHRA guidance ref
Document Outline