5/5/2015 Where Do Our Heparin Doses Come From? Heparin nomogram assessment and revision based on anticoagulation indication CHEST 2012 AHA/ACC 2014 VTE: 80 units/kg bolus + 18 units/kg/hr infusion VTE: No comment ACS: 60-70 units/kg bolus + 12-15 units/kg/hr infusion ACS: 60 units/kg bolus + 12 units/kg/hr infusion AF: No comment AF: No comment Minu Jacob, PharmD PGY-2 Pharmacotherapy Resident Harper University Hospital, Detroit Medical Center The speaker has no actual or potential conflicts of interest in relation to this presentation. Why is Timing Important? VTE Mortality Data • Examine the relationship between achieving therapeutic anticoagulation and mortality in PE patients. Secondary Outcomes 3.0% 7.7% Mortality Based on Timing of Heparin Administration Heparin in ED Mortality Based on Timing of Therapeutic aPTT Heparin After Admission aPTT < 24 hours 20.00% aPTT > 24 hours 20.00% 15.30% 15.00% • In-hospital and 30-day all-cause mortality Mortality Primary Outcomes N = 400 30-day mortality • Retrospective study of 400 patients admitted to the Mayo Clinic with acute, symptomatic PE Methods Primary Outcome In-hospital mortality • Length of stay, hemorrhage events on heparin, recurrent VTE within 90 days 10.00% 4.40% 5.00% 4.70% 10.00% 5.60% 5.60% 5.00% 1.40% 1.50% 0.00% Smith SB, et al. CHEST 2010;137:1382-1390. 14.80% 15.00% Mortality Objective 0.00% Hospital Mortality (p=0.009) 30-Day Mortality (p < 0.01) Hospital Mortality (p=0.091) 30-Day Mortality (p=0.037) Smith SB, et al. CHEST 2010;137:1382-1390. Study Rationale Study Objectives • Recent quality assurance data has shown inconsistency in achieving target aPTT with 24 hours of heparin initiation. • Cardiology sub-committee identified a need to evaluate and improve the heparin dosing nomogram. Current Heparin Dosing Nomogram Indication Bolus Infusion Rate VTE 80 units/kg 18 units/kg/hr ACS AF PAD Valve 60 units/kg 12 units/kg/hr Optimize heparin dosing nomogram Patients on heparin IV who reach target aPTT within 24 hours Identify barriers to reaching target aPTT within 24 hours (protocol and practice) 1 5/5/2015 Outcomes Study Design • Number of patients who reach target aPTT within 24 hours preand post- nomogram revision implementation Primary Endpoint Secondary Endpoints • Rates of major and minor bleeding • New thrombosis • Time to target aPTT Study Methods • Site/system committee approval • Education • Data collection • New nomogram assessment Phase 1 Phase 3 Data Collection Inclusion Criteria • Age 18-89 years • Heparin pharmacy to dose consult for at least 36 hours Exclusion Criteria • Patients admitted to Children’s Hospital of Michigan • Heparin physician dosing • Off-protocol aPTT targets • Heparin monitored by thrombin times Phase I Results: Patients Heparin Dosing Demographics • Baseline labs • Co-morbidities Adverse Effects • Heparin dose changes • Corresponding aPTTs • Bleeding • New thrombosis Descriptive statistics used for Phase I statistical analysis Phase I Results: Demographics 151 admissions in July 2014 that met inclusion criteria 19 admissions excluded for improperly drawn aPTTs and inadequate documentation Phase 2 • Data collection • Pharmacists survey • Nomogram revision 131 unique patients included in analysis Baseline Characteristics N = 131 Age, mean ± SD 65 ± 14.5 years Male, n (%) 63 (48) ABW 30% > IBW, n (%) 73 (55.7) Heparin Indication, n (%) •ACS •VTE •AF •PAD •Valve 53 (40) 43 (33) 28 (21) 5 (4) 3 (2) 132 admissions included in analysis 2 5/5/2015 Patients Reaching Target aPTT within 24 Hours of Heparin Initiation Average Heparin Dose to Achieve Target aPTT 19 70.0% 18.3 62.8% Current nomogram initial heparin dosing 18 17.7 18 60.0% Heparin Dose (units/kg/hr) 46.4% 40.0% 40.0% 33.3% 30.0% 20.0% 17.1 16.2 16 16 15.5 15.5 15 15 14.8 14.7 Overall Non-obese Obese 14 13 10.0% 12 0.0% Overall (n=132) VTE (n=43) ACS (n=53) AF (n=28) Heparin Indication PAD (n=5) 11 Valve (n=3) VTE (n=41) Adverse Effects ACS (n=43) AF (n=28) Heparin Indication PAD (n=4) Valve (n=3) Survey Says… Phase I Results: Safety Incidence, No (%) Bleeding events* (n = 10) Major Minor 4 (40) 6 (60) Thrombosis 0 *Bleeding definitions based on ESSENCE trial Cohen M, et al. N Engl J Med 1997;337:447-52. > 10 Q2: When dosing heparin, what percent of the time do you deviate from the nomogram? (N = 64) 42% 6-10 14% 3-5 20% 0-2 24% 0% 5% 10% 15% 20% 25% Percent of Pharmacists 30% 35% 40% 45% Percent Deviation from Nomogram Q1: How many years of experience do you have dosing heparin? (N = 64) Years of Experience Percent of Patients 49.1% 17 16.9 17 50.0% 50.0% > 40 3% 21-40 22% 11-20 31% 0-10 44% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Percent of Pharmacists 3 5/5/2015 Association of Protocol Deviation and Achieving Target aPTT Study Results: Heparin Initiation Number of Patients With Deviations From Protocol (N = 75 out of 132 total admissions) Different bolus 7 3 No bolus 9 30 No bolus and different infusion rate Different bolus and different infusion rate 9 Different infusion rate 17 Wrong weight Percent of Patients in Target aPTT Range within 24 Hours 60.0% Upon heparin initiation , we deviate from protocol approximately 57% of the time! 35.0% 30.0% 25.0% With Deviation Increased risk of bleeding 95% 36% 68% Other responses: Elevated baseline coags •Thrombocytopenia •ESRD on hemodialysis Decreased Hgb/Hct •ABW > 180% IBW 42% 34% 24% ABW < IBW 19% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 10% 20% Q5: Patient characteristics that cause deviation on follow-up for bolus (N = 63) 89% Increased risk of bleeding 86% Decreased Hgb/Hct 54% Increased age 10% 20% 41% 34% 26% 23% 21% ABW < IBW 30% 40% 50% 60% 70% 80% 80% 57% Elevated baseline coagulation labs 17% 0% 70% 75% Increased risk of bleeding ABW > 130% IBW 19% ABW > 130% IBW 60% Proximity of aPTT to target Heparin indication with lower risk of thrombosis 21% ABW < IBW 50% Q6: Patient characteristics that cause deviation on follow-up for infusion rate (N = 61) Increased age 38% Elevated baseline coagulation labs 40% Decreased Hgb/Hct 44% Heparin indication with lower risk of thrombosis 30% Percent of Pharmacists Percent of Pharmacists Proximity of aPTT to target 59% 53% Increased age ABW > 130% IBW Heparin indication with lower risk of thrombosis 25% 23% 0% 40.0% Q4: Patient characteristics that cause deviation for initial infusion rate (N = 59) Patient Characteristic Patient Characteristic Increased risk of bleeding ABW < IBW 45.6% 45.0% No Deviation Other responses: •Oral anticoagulant prior to admission Elevated baseline coags 75% •Thrombocytopenia •ESRD on hemodialysis Decreased Hgb/Hct 56% •Recent administration of heparin SubQ (< 8 hours) •If INR is > 2 Increased age 52% •Patient continues on heparin after cardiac catheterization ABW > 130% IBW 50.0% 20.0% Q3: Patient Characteristics that cause deviation for initial bolus (N = 64) Heparin indication with lower risk of thrombosis 54.7% 55.0% 90% 100% 15% 0% 10% 20% 30% 40% 50% 60% 70% 80% 4 5/5/2015 Q7: If aPTT is ≤ 5 seconds below target range, for which indications would you most likely bolus per nomogram? (N = 64) Heparin Indication VTE Heparin Nomogram Changes 95% Valve 64% ACS 33% PAD 25% AF 23% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent of Pharmacists Heparin Nomogram Changes Study Design • Data collection • Pharmacists survey • Nomogram revision Phase 2 • Site/system committee approval • Education Phase 1 • Data collection • New nomogram assessment Phase 3 Study Limitations Future Directions • Retrospective study design • ESRD and liver disease patients not well represented • Small sample size • High variability in outcomes for obese patients • Documentation • Phase III post-implementation assessment – Evaluate rates of reaching target aPTT within 24 hours after nomogram revision – Assess the impact of pharmacy education on adherence to nomogram • Nursing and laboratory personnel education 5 5/5/2015 Conclusions • Therapeutic aPTT within 24 hours of heparin initiation improves outcomes in VTE patient population. • Results showed that current nomogram initiated heparin at lower bolus and infusion rates for ACS than required. • Pharmacist-perceived bleeding risk and elevated baseline coagulation labs were common reasons for deviation. • Nomogram revisions will need to be assessed at regular intervals for safety, efficacy, and adherence to protocol. Learning Question #1 • For which of the following indications has achieving a target aPTT within 24 hours shown to decrease mortality? A. B. C. D. Acute coronary syndromes Pulmonary embolus Peripheral arterial disease Mitral valve replacement Learning Question #2 Acknowledgments • What is the heparin dosing recommendation for NSTE-ACS according to the CHEST 2012 guidelines? • Elizabeth Petrovitch, Pharm.D., BCPS • Lynette Moser, Pharm.D. • Joanne MacDonald, Pharm.D. A. 70 units/kg bolus and 15 units/kg/hr infusion B. Target 1.8 to 2.3 times the baseline aPTT C. Target 1.5 to 2.5 times the baseline aPTT D. Fondaparinux is recommended over unfractionated heparin 6
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