Pulmonary Thromboembolism Drug Summary

• Hematologic effects (anemia, hemorrhage, hematoma, contusion, epistaxis, hematuria); GI effect (nausea)

• Contraindicated in patients with clinically significant active bleeding, hepatic disease with coagulopathy and clinically relevant bleeding risk
• Use with caution in hip fracture surgery, galactose intolerance, glucose-galactose malabsorption, severe renal and hepatic impairment
• Discontinue use in severe hemorrhage
• Monitor for signs of neurological impairment

Adverse Reactions

• Hematologic effects (anemia, hemorrhage); GI effect (nausea); Other effects (abnormal LFT, increased blood bilirubin and gammaglutamyltransferase, rash, pruritus)

Special Instructions

• Contraindicated in patients with clinically significant active bleeding or conditions at risk for major bleeding, hepatic disease with coagulopathy and clinically relevant bleeding risk, uncontrolled severe hypertension, concomitant treatment with any other anticoagulants except when switching oral anticoagulant therapy or when UFH is given at doses necessary to maintain an open central venous or arterial catheter
• Use with caution in patients with an increased risk of bleeding, moderate or severe renal impairment, mild or moderate hepatic impairment, concomitant use of medicines affecting hemostasis
• Perform LFT prior to treatment and CrCl at the start of therapy and thereafter

Adverse Reactions

• Hematologic effects (hemorrhage, thrombocytopenia, anemia, purpura); Hepatic effect (abnormal LFT); Other effects (edema, fever)

Special Instructions

• Concomitant treatment with vitamin K antagonists should be initiatied within 72 hours
• Avoid in patients with clinically significant bleeding, severe renal impairment or in those with confirmed Heparin-induced thrombocytopenia (HIT)
• Use with caution in patients with increased risk of hemorrhage, acute GI ulcer, recent intracranial hemorrhage, or shortly after brain, spinal or ophthalmic surgery, patients <50 kg, those with moderate renal impairment, severe hepatic impairment, history of HIT, elderly >75 years old
• Consider risk versus benefit before neuraxial intervention is employed in patients anticoagulated or to be anticoagulated for thromboprophylaxis
• Monitoring of platelets is recommended at baseline and at the end of treatment

Adverse Reactions

• Hematologic effects (hemorrhage, anemia, decreased hemoglobin); Hepatic effect (increased LFT); CNS effects (dizziness, headache, syncope), CV effects (tachycardia, hypotension) GI effect (nausea); Dermatologic effects (pruritus, rashes); Other effects (fever, peripheral edema, postprocedural hemorrhage)

Special Instructions

• Contraindicated in patients with clinically significant active bleeding, pregnant, lactating and hepatic disease associated with coagulopathy that can lead to relevant risk of bleeding
• Use with caution in patients with hemorrhagic risk, lactose or galactose intolerance, and those with moderate to severe renal impairment

Adverse Reactions

• Hematologic effects (hemorrhage, anemia, hematoma, thrombocytopenia); Renal effect (hematuria); GI effects (dyspepsia, nausea/vomiting, GI hemorrhage, abdominal pain, diarrhea, gastroesophagitis, abnormal hepatic function); Other effects (wound secretion, post-procedural discharge)

Special Instructions

• Contraindicated in patients with severe renal impairment, hemorrhagic manifestations, bleeding diathesis, patients with spontaneous or pharmacological hemostatic impairment, organ lesions at risk of clinically significant bleeding (including hemorrhagic stroke within the last 6 months, patients on concomitant therapy with systemic Ketoconazole, prosthetic heart valve replacement)
• Use with caution in hepatic impairment, renal insufficiency, increased hemorrhagic risk, spinal/epidural anesthesia, lumbar puncture
• Discontinue use in patients who develop acute renal failure

Adverse Reactions

• Hematologic effects (hemorrhage especially from puncture sites, severe internal bleeding, intracranial hemorrhage has occurred); GI effects (nausea/vomiting, abdominal pain); Other effect (fever)
• Infusion may be associated with hypotension (both direct and as a result of reperfusion), bradycardia and arrhythmias may occur because of reperfusion
• Break-up of clots may occasionally cause emboli elsewhere hence the need for Heparin prophylaxis

Special Instructions

• Absolutely contraindicated in patients with hemorrhagic stroke or stroke of unknown origin within the last 3 months, ischemic stroke within the last 3 months, presence of benign/malignant tumor or damage within the CNS, major surgery, trauma, or injury within the past 3 months, GI bleeding within the last 30 days, known bleeding risk or current active bleeding, allergy to compounds, bleeding diathesis
• Relatively contraindicated in patients with transient ischemic attack within the past 6 months, on oral anticoagulants, uncontrolled severe hypertension (SBP >180 mmHg, diastolic BP >100 mmHg), pregnancy or within 1 week postpartum, recent traumatic cardiopulmonary resuscitation, infective endocarditis, advanced liver disease, active peptic ulcer, puncture of a non-compressible vessel, older age (>75 years old)

• Hematologic effects (hemorrhage especially from puncture sites, severe internal bleeding, intracranial hemorrhage has occurred); Allergic reactions (rashes, flushing, urticaria); GI effects (nausea/vomiting); Other effects (fever, chills with back and abdominal pain, Guillain-Barré syndrome)
• Infusion may be associated with hypotension (both direct and as a result of reperfusion), bradycardia and arrhythmias may occur because of reperfusion
• Break-up of clots may occasionally cause emboli elsewhere
• Serious allergic reactions may be less likely to occur with Urokinase than with Streptokinase

• Absolutely contraindicated in patients with hemorrhagic stroke or stroke of unknown origin within the last 3 months, ischemic stroke within the last 3 months, presence of benign/malignant tumor or damage within the CNS, major surgery, trauma, or injury within the past 3 months, GI bleeding within the last 30 days, known bleeding risk or current active bleeding, allergy to compounds, bleeding diathesis
• Relatively contraindicated in patients with transient ischemic attack within the past 6 months, on oral anticoagulants, uncontrolled severe hypertension (SBP >180 mmHg, diastolic BP >100 mmHg), pregnancy or within 1 week postpartum, recent traumatic cardiopulmonary resuscitation, infective endocarditis, advanced liver disease, active peptic ulcer, puncture of a non-compressible vessel, older age (>75 years old)
• Anti-streptokinase antibodies are formed after about 5 days after Streptokinase use
  • These antibodies may cause resistance or hypersensitivity to subsequent doses of Streptokinase
  • Recommend not to administer Streptokinase 5 days-12 months after the first administration (alternative thrombolytic not including Anistreplase may be used)

Adverse Reactions

• Hematologic effects (hemorrhage, thrombocytopenia); Rare hypersensitivity reactions (anaphylaxis); Effects that may occur with long-term use (osteoporosis, alopecia); Other effects (increased LFT, injection site reaction)

Special Instructions

• Avoid in patients with active major bleeding, patients with positive in vitro test for antiplatelet Ab to the specific heparin
• Use with caution in patients with hemophilia or other hemorrhagic disorders (including history of Heparin-induced thrombocytopenia), peptic ulcer, recent cerebral hemorrhage, severe hypertension, severe liver disease, post-major trauma or recent surgery to brain, spinal or ophthalmic surgery, hypersensitivity to Heparin
• Consider risk versus benefit before neuraxial intervention is employed in patients anticoagulated or to be anticoagulated for thromboprophylaxis
• Monitoring of platelets at baseline and periodically during treatment is recommended

• Hematologic effects (hemorrhage, thrombocytopenia); Rare hypersensitivity reaction (anaphylaxis); Effects that may occur with long-term use (osteoporosis, alopecia)
• Sulodexide
  • Cap: nausea/vomiting, diarrhea, epigastralgias
  • Injection: Pain, burning sensation and hematoma at injection site

• Avoid in patients with active major bleeding, patients with positive in vitro test for antiplatelet Ab to the specific heparin
• Use with caution in patients with hemophilia or other hemorrhagic disorders (including history of Heparin-induced thrombocytopenia), peptic ulcer, recent cerebral hemorrhage, severe hypertension, severe liver disease, post-major trauma or recent surgery to brain, spinal or ophthalmic surgery, hypersensitivity to Heparin
• Consider risk versus benefit before neuraxial intervention is employed in patients anticoagulated or to be anticoagulated for thromboprophylaxis
• Monitoring of platelets at baseline and periodically during treatment is recommended
• Heparin: (Please see UFH infusion rate adjusted according to body weight and aPTT)

• Hemorrhage can occur even within therapeutic INR levels
• Less common effects: Cholesterol embolization (skin necrosis and purple discoloration of the toes); GI effects (nausea/vomiting, diarrhea); Other effects (alopecia, skin reactions, hepatic dysfunction, pancreatitis)

• Dosage must be adjusted based on regular monitoring of INR
• Patients should be counseled on the risks of therapy along with drug and food interactions
• Avoid in patients with active or at risk of hemorrhage, peptic ulcer disease, severe wounds, cerebrovascular disorders and bacterial endocarditis
• Use with extreme caution or not at all in patients with severe renal or hepatic impairment
• INR monitoring is usually performed daily until the therapeutic range (2.0-3.0) is achieved
  • INR monitoring is reduced to 2-3x/week for the next 2 weeks, then done weekly or less depending on INR

• aPTT <35 seconds (<1.2 x mean normal)

• aPTT 35-45 seconds (1.2-1.5 x mean normal)

• aPTT 46-70 seconds (1.5-2.3 x mean normal)

• aPTT 71-90 seconds (2.3-3 x mean normal)

• aPTT >90 seconds (>3 x mean normal)