Sunday, June 29, 2014

4 Tips for new medical residents

Since July is here and the academic calendar is starting over, it is time for new medical residents to be arriving to the hospital floors.  With this in mind, here are a few tips to help in the transition from student to physician.

Sunday, June 15, 2014

Argatroban and warfarin dosing in heparin-induced thrombocytopenia

Let’s start with a patient case.  A 45 year old woman is referred to the hospital after seeing her primary care physician for unusual bruising.  She was discharged four days ago after a two day hospitalization for an asthma exacerbation.  Her PMH includes HTN and asthma.  Her CBC reveals platelets of 73 (baseline 190) and the comprehensive metabolic panel and CBC are otherwise within normal limits.  The diagnosis of heparin-induced thrombocytopenia (HIT) is suspected since she received heparin for DVT prophylaxis during her recent hospitalization.

To see another post on how to determine the probability of HIT by using the 4 T's score, click here.

If the diagnosis of HIT is confirmed, discontinuation of all forms of heparin is paramount.  This includes unfractionated heparin and low molecular weight heparins (including flushes and heparin-coated catheters).

After diagnosis, the decision needs to be made whether to institute a non-heparin anticoagulant, a vitamin K antagonist, and/or simply discontinue all heparins.

Sunday, June 1, 2014

Update to anticoagulation in atrial fibrillation

Let’s start with a patient case. A 72 year old female presents to the hospital with fatigue, palpitations, and shortness of breath that has occurred intermittently over the last two weeks.  Her PMH is significant for anxiety, seasonal allergies, and PAD which is rarely symptomatic and not lifestyle-limiting.  She is admitted to the hospital with the diagnosis new-onset atrial fibrillation.  What anticoagulation strategy is recommended for someone like this?

This pharmacy pearl highlights just a few of the key points regarding anticoagulation from the 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation which was just published in April of this year.1  There are several differences between this newest guideline and the most recent version of the Chest guidelines from 2012 (which only addressed warfarin and dabigatran since it was the only new oral anticoagulant approved at the time).  Note that this entire summary will be referring to nonvalvular atrial fibrillation.

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