1. Treatment of deep venous thrombosis and pulmonary embolism Anders Waage Avdeling for blodsykdommer

2. Arterial thrombosis: anti platelet agents Venous thrombosis: agents affecting the coagulation system

3. Anticoagulation/Trombolytic treatment Heparin Marevan (warfarin) Local vs systemic thrombolysis Trombin/aFX inhibitors Stockings Other

4. Deep venous thrombosis, LE Treament of acute DVT Duration of treatment Prophylactic treatment

5. What is the purpose of the treatment ?

6. Treatment schedule Heparin Marevan INR 2-3 6 months

7. Start concomitant with heparin and warfarin. Heparin has effect after 30 min, warfarin after 5 days Stop heparin when INR >2, but not before 5 days

8. Therapeutical range of INR INR = 2-3: DVT, LE, atrial fibrillation, other conditions INR 2,5-3,5: mechanical heart valve

9. Genetic variation in degradation of warfarin (CYP 2C9) Dose of Marevan ½-7 tablets/day

10. Nye godkjente antikoagulasjonsmidler ved DVT, LE

11. Antitrombin hemmer,tabletter –Dabigatran (Pradaxa) –Behandling og profylakse DVT og LE –150 mg x 2

12. Anti faktor Xa hemmere, tabletter Rivoksaban (Xarelto) –Behandling og profylakse DVT og LE –15 mg x 2 i 3uker, deretter 20 mg x 1 Apixaban (Eliquis) –Behandling og profylakse DVT og LE –10 mg x 2 i 7 dager, deretter 5 mg x 2

13. Hva skal jeg velge? NOAC trenger ikke monitorering Fast dose Virker med en gang, ikke innledning med heparin Marevan er særdeles velprøvd Pasienter som er godt innstilt på Marevan kan fortsette

14. Duration of treatment

15. Thrombolytic treatment DVT with great risk of serious post thrombotic syndrome DVT v. femoralis, iliaca, cava Serious LE

16. Thrombolytic therapy Delivered locally by a catheter Presumably less side effects by local therapy, but not well documented

18. Side effect thrombolytic treatment Serious bleeding: 0,5 % Serious bleeding lmw. heparin: 0,1 %

19. Choice of treatment LMWHMarevan«nye midler»Local trmblysis DVTYes No Serious DVTYesyesYes CancerYesNo/yes No pregnancyYesNeverNo Proph pregnancy Yesneverno Mechanic valves yes no

20. Prophylactic treatment Consider: Number of thrombosis Idiopatic, temporary, permanent cause What is the risk of new thrombosis What is the consequence of new thrombosis What is the risk of bleeding on anticoagulation

21. Prophylactic situations Relapsing DVT, LE Surgery Atrial fibrillation Mechanical heart valve Other situations

22. Risk factors Genetic: Deficiency of protein s, protein c, antithrombin III, Factor V Leiden (APC resistance) Aquired: Age, surgery, immobilisation, oestrogen ++

23. Prophylaxis Orthopedic surgery (hip, knee) Abdominal, gynecological surgery Moderate risk: 30-120 min duration High risk: >2 hours Age, weight, malignancy, oestrogen, p-pill, history of thrombosis

24. Moderat risk: Fragmin/Klexane 2500 U/ 20 mg High risk: Fragmin/Klexane 5000U/40 mg Start6 hours after surgery Stopwhen mobilised

25. DVT and pregnancy Risk 0,5-3/1000 pregnancies (x6 compared to normal) Use lmw heparin, never Marevan (Teratogenecity) After delivery: Marevan, continue for 6 weeks

26. Heparin do not pass placenta Marevan and breast-feeding

27. Prophylaxis in pregnancy DVT in previous pregnancy: 10 % risk for new DVT Prophylaxis with lmw heparin

28. Stockings after DVT Reduces risk of post-thrombotic syndrome Use for 6 months Compression stocking up to the knee