Welcome to Department of Medicine Grand Rounds’ series: New Oral Anticoagulants: Are they better than what we have? This program includes a video, test and evaluation modules. After viewing the video, you will be asked to complete a five question test and a brief evaluation in order to be eligible for your CME credits. The estimated time to complete this entire activity is 1 hour and 15 minutes. This program requires: Windows Microsoft Windows 2008 (required Desktop experience), Windows 7, Windows Vista, Windows XP, Windows 2003 Microsoft Internet Explorer 7.0 or later, Firefox 3.6 or later or Google Chrome Windows Media Player 9.0 or later Media Silverlight 5.0 or later Broadband internet connection MAC MAC OS X 10.57 or later Safari 4.0 or later or Firefox 3.6 or later Microsoft Silverlight 5.0 or later (viewers are prompted to install this when attempting to view a presentation) Broadband internet connection (256 Kbps or more)
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New Oral Anticoagulants Are they better than what we have?
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Welcome to Department of Medicine Grand Rounds’ series:New Oral Anticoagulants: Are they better than what we have? This program includes a video, test and evaluation modules. After viewing the video, you will be asked to complete a five question test and a brief evaluation in order to be eligible for your CME credits. The estimated time to complete this entire activity is 1 hour and 15 minutes. This program requires: WindowsMicrosoft Windows 2008 (required Desktop experience), Windows 7, Windows Vista, Windows XP, Windows 2003Microsoft Internet Explorer 7.0 or later, Firefox 3.6 or later or Google ChromeWindows Media Player 9.0 or later Media Silverlight 5.0 or laterBroadband internet connection
MACMAC OS X 10.57 or laterSafari 4.0 or later or Firefox 3.6 or laterMicrosoft Silverlight 5.0 or later (viewers are prompted to install this when attempting to view a presentation)Broadband internet connection (256 Kbps or more)
Welcome to Department of Medicine Grand Rounds’ series:New Oral Anticoagulants: Are they better than what we have?
Geno J Merli, MD, MACP, FHM, FSVMProfessor of Medicine and SurgeryCo-Director Jefferson Vascular CenterJefferson Medical CollegeThomas Jefferson University Hospital
Recorded Wednesday, September 4, 2013.This program will be available for CMEs until September 4, 2015.
Objectives Following the completion of this program, participants should be able to:1. Compare and Contrast Treatment of DVT/PE with New Oral Anticoagulants2. Review Clinical Trials in Atrial Fibrillation3. Assess the Benefit of the New Oral Anticoagulants in the Hospitalized Medically ill patient 4. Review Data on the Management of Bleeding with the New Oral Anticoagulants
Disclosure: Dr. Merli has revealed he provides grant/research support for BMS, Johnson & Johnson, Sanofi-aventis; he is also a scientific consultant for BMS, Johnson & Johnson and Sanofi-aventis; none of the other planners have revealed any significant commercial interests.
Accreditation StatementThe Lancaster General Hospital is accredited by the Pennsylvania Medical Society to provide continuing medical education for physicians.Designation StatementThe Lancaster General Hospital designates this live activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with extent of their participation in the activity.Conflict of Interest StatementFaculty and all others who have the ability to control content of continuing medical education activities sponsored by Lancaster General Hospital are expected to disclose to the audience whether they do or do not have any real or apparent conflict(s) of interest or other relationships related to the content of their presentation(s).
New Oral AnticoagulantsAre they better than what we have?
Geno J Merli, MD, MACP, FHM, FSVMProfessor of Medicine and Surgery
Co-Director Jefferson Vascular CenterJefferson Medical College
A limitation of the study is that the first dose of dabigatran, was given only after initial parenteral anticoagulation therapy had been administered for median of 9 days
“There is no data to support the use of dabigatran monotherapy for acute venous thromboembolism”
Schulman S, et al NEJM 2009;361:2342-2352
Einstein Investigators NEJM 2010;363:2499-2510
Rivaroxaban 15 mg, PO, BID x 3 weeks then 20mg, QdayEnoxaparin 1mg/kg/Q12hrs bridge to Warfarin INR 2-3
Open Label, Non-Inferiority trial
Einstein DVT
DVT
Rivaroxaban15 mg, BID x 3 wks
20 mg, Qday
EnoxaparinWarfarin INR 2-3
Proximal DVT
2.1% 8.1%
3.0% 8.1%
VTE Major Bld
3, 6, 12 months
Einstein Investigators NEJM 2010;363:2499-2510
Warfarin TTR = 57.7%
Einstein Acute DVT StudyCauses of VTE
Riva Standard
Einstein Investigators NEJM 2010;363:2499-2510
Einstein Acute DVT StudySafety Outcomes
Einstein Investigators NEJM 2010;363:2499-2510
Riva Standard
Einstein Investigators NEJM 2012;366:1287-1297
Rivaroxaban 15 mg, PO, BID x 3 weeks then 20mg, QdayEnoxaparin 1mg/kg/Q12hrs bridge to Warfarin INR 2-3
Open Label, Non-Inferiority
Einstein PE
PE
Rivaroxaban15 mg, BID x 3 wks
20 mg, Qday
EnoxaparinWarfarin INR 2-3
2.1% 1.1%
1.8% 2.2%
VTE Major Bld
3, 6, 12 months
Einstein-PE Investigators NEJM 2012;366:1287-1297
Warfarin TTR = 62.7%
Non-Inferior
Einstein PECauses
Einstein Investigators NEJM 2012;366:1287-1297
Riva Standard
Einstein PEAnatomical Extent
Einstein Investigators NEJM 2012;366:1287-1297
Riva Standard
ED - OBS
History & PhysicalLaboratory Testing
Diagnosis DVTSelect Treatment
Hospital Admission OBS Discharge Plan
Secure Rx Communication Follow Up
Acquire Med
Pt Education
Contact PCP
D/C Summary
Phone call 24 hrs
Appointment 3-5 days
Discharge OBS
Your patient who has been on long term warfarin would like to convert to one of the new oral
anticoagulant.
Einstein Investigators NEJM 2010;363:2499-2510
Rivaroxaban 15 mg, PO, BID x 3 weeks then 20mg, QdayEnoxaparin 1mg/kg/Q12hrs bridge to Warfarin INR 2-3
Thank you for viewing the video. In order to receive your CME credit, please click the “links” icon
at the bottom right hand side of your computer screen to take a post test quiz and evaluation receive your CME credits. For technical questions about this program, please contact [email protected]
For questions about the content, please contact Dr. Merli at [email protected]