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Listen "The Hospitalist's Guide to Inpatient Anticoagulation: Choose Fast, Dose Smart, Avoid Disaster"
Episode Synopsis
In this episode of Hospital Medicine Unplugged, we run the inpatient anticoagulation playbook—pick the right drug, dose it safely, and dodge both clots and bleeds.
We start with why we anticoagulate in hospital: VTE treatment and prophylaxis, AF stroke prevention, ACS, and valve/bridging scenarios—always walking the tightrope between thrombosis and bleeding. Then we map the four main drug classes:
• DOACs as default for most nonvalvular AF and VTE—rapid onset, predictable PK, no routine monitoring, but no go in mechanical valves, APS, pregnancy, or severe CKD.
• LMWH as the inpatient workhorse—VTE treatment and prophylaxis, cancer, pregnancy, lower HIT and osteoporosis risk, but renally cleared and only partially reversible.
• UFH as the rescue drug—severe renal failure, high bleeding risk, need for rapid on/off, thrombolysis, or upcoming procedures.
• Warfarin for the “can’t DOAC” crowd—mechanical valves, rheumatic MS, triple-positive APS, advanced CKD/liver disease—with INR targets, monitoring, and all the interaction baggage.
From there we build a clinical decision framework:
• Renal and hepatic function drive DOAC vs LMWH vs UFH vs warfarin.
• Bleeding risk (HAS-BLED, IMPROVE) and prior GI bleed shape how hard you push.
• Drug–drug interactions (CYP3A4/P-gp, polypharmacy, antiplatelets/NSAIDs) push you toward or away from certain DOACs or warfarin.
• Extremes of body weight, procedures on the horizon, and the need for a reversal plan all feed into the choice.
For VTE treatment, we compare:
• Stable DVT/PE with good kidneys → DOAC first (EINSTEIN, AMPLIFY, Hokusai).
• Cancer-associated VTE → DOACs vs LMWH: DOACs now common, but LMWH still preferred for GI/GU tumors or very high bleeding risk.
• Severe CKD or tenuous bleeder → UFH infusion with aPTT-guided titration and protamine in your back pocket.
• Mechanical valves or APS → warfarin with bridging.
For VTE prophylaxis, we keep it practical:
• LMWH (enoxaparin/dalteparin) as first-line in most medical/surgical inpatients.
• UFH for CrCl <30 or when you need a super short half-life.
• DOACs (rivaroxaban, betrixaban) as select tools for extended prophylaxis, not routine inpatient starters.
• Warfarin stays out of acute prophylaxis.
We also tackle cardiology use cases:
• UFH (or bivalirudin) for ACS/PCI.
• Enoxaparin as an alternative in NSTE-ACS/unstable angina when managed medically.
• DOACs and warfarin move to the long-game: AF, LV thrombus, and post-ACS patients who need both antiplatelets and anticoagulation.
Finally, we walk through special populations:
• Severe CKD → UFH first; dose-reduced LMWH or off-label apixaban only with eyes wide open.
• Morbid obesity or very low weight → how we think about fixed-dose DOACs, weight-based LMWH, and when to consider anti-Xa levels.
• Pregnancy → LMWH only, no DOACs or warfarin.
• Cancer → choosing between DOACs and LMWH based on tumor site, bleeding risk, kidneys, and patient preferences.
We close with a bedside checklist: define the indication, check kidney/liver function, estimate bleeding risk, scan the med list for interactions, ask “how fast do I need on/off?”, then lock in an agent, dose, monitoring plan, and a clear reversal strategy. Right drug, right patient, right moment—while keeping both clots and bleeds off your service list.
We start with why we anticoagulate in hospital: VTE treatment and prophylaxis, AF stroke prevention, ACS, and valve/bridging scenarios—always walking the tightrope between thrombosis and bleeding. Then we map the four main drug classes:
• DOACs as default for most nonvalvular AF and VTE—rapid onset, predictable PK, no routine monitoring, but no go in mechanical valves, APS, pregnancy, or severe CKD.
• LMWH as the inpatient workhorse—VTE treatment and prophylaxis, cancer, pregnancy, lower HIT and osteoporosis risk, but renally cleared and only partially reversible.
• UFH as the rescue drug—severe renal failure, high bleeding risk, need for rapid on/off, thrombolysis, or upcoming procedures.
• Warfarin for the “can’t DOAC” crowd—mechanical valves, rheumatic MS, triple-positive APS, advanced CKD/liver disease—with INR targets, monitoring, and all the interaction baggage.
From there we build a clinical decision framework:
• Renal and hepatic function drive DOAC vs LMWH vs UFH vs warfarin.
• Bleeding risk (HAS-BLED, IMPROVE) and prior GI bleed shape how hard you push.
• Drug–drug interactions (CYP3A4/P-gp, polypharmacy, antiplatelets/NSAIDs) push you toward or away from certain DOACs or warfarin.
• Extremes of body weight, procedures on the horizon, and the need for a reversal plan all feed into the choice.
For VTE treatment, we compare:
• Stable DVT/PE with good kidneys → DOAC first (EINSTEIN, AMPLIFY, Hokusai).
• Cancer-associated VTE → DOACs vs LMWH: DOACs now common, but LMWH still preferred for GI/GU tumors or very high bleeding risk.
• Severe CKD or tenuous bleeder → UFH infusion with aPTT-guided titration and protamine in your back pocket.
• Mechanical valves or APS → warfarin with bridging.
For VTE prophylaxis, we keep it practical:
• LMWH (enoxaparin/dalteparin) as first-line in most medical/surgical inpatients.
• UFH for CrCl <30 or when you need a super short half-life.
• DOACs (rivaroxaban, betrixaban) as select tools for extended prophylaxis, not routine inpatient starters.
• Warfarin stays out of acute prophylaxis.
We also tackle cardiology use cases:
• UFH (or bivalirudin) for ACS/PCI.
• Enoxaparin as an alternative in NSTE-ACS/unstable angina when managed medically.
• DOACs and warfarin move to the long-game: AF, LV thrombus, and post-ACS patients who need both antiplatelets and anticoagulation.
Finally, we walk through special populations:
• Severe CKD → UFH first; dose-reduced LMWH or off-label apixaban only with eyes wide open.
• Morbid obesity or very low weight → how we think about fixed-dose DOACs, weight-based LMWH, and when to consider anti-Xa levels.
• Pregnancy → LMWH only, no DOACs or warfarin.
• Cancer → choosing between DOACs and LMWH based on tumor site, bleeding risk, kidneys, and patient preferences.
We close with a bedside checklist: define the indication, check kidney/liver function, estimate bleeding risk, scan the med list for interactions, ask “how fast do I need on/off?”, then lock in an agent, dose, monitoring plan, and a clear reversal strategy. Right drug, right patient, right moment—while keeping both clots and bleeds off your service list.
In God we trust