We are using it for DVT treatment instead of the LMWH plus warfarin in the confirmed DVT group(provided patients happy to foot the bill).
I haven't needed to use it yet in the context of scan awaited however our physicians have indicated that they would like this policy considered.
It has FDA approval for DVT:
http://pulmccm.org/2012/policy-ethics-education-review/xarelto-rivaroxaban-new-fda-indication-for-dvt-and-pe/
Might be worth discussing costs with hospital pharmacy if you are going to stock it in the ED as it is a BD dose during the initial 3/52 period. Also important to check renal function.
Stuart
----- Original Message -----
From: "Jason Horan" <[log in to unmask]>
To: [log in to unmask]
Sent: Thursday, 4 April, 2013 4:13:18 PM
Subject: Rivaroxaban for suspected DVTs
Folks,
I'm looking for the collective advice from the list. I'm looking at potential mechanism to decrease costs in our ED.
Currently suspected DVTs have access to venous doppler ultrasound during office hours only. There can be some difficulty accessing time-slots and the lag time from first presentation to scan can be 4-5 days, particularly over the weekend. This week with the bank holiday we've had someone wait 6 days. We are working with hospital management with a view to improving the process in radiology but that's a long-game.
At the moment, patients return daily for their s/c LMWH. Again, for some bizarre reason this hospital uses enoxaparin (the only hospital that I'm aware of). We usually do 1.5mg/kg OD but the hospital formulary recommends 1mg/kg BD if your BMI is >27..... Normally this is only implemented above 100kg, and there is no mention of this in the SPC.
So there are some poor unfortunates that may have to re-present 8 times or more while waiting for the doppler. Public health (District) nursing resources are limited, particularly when trying to refer a the weekend.
One suggestion was to consider oral rivaroxaban pre-imaging. It is licensed for the treatment of VTE, similar to enoxaparin/tinzaparin. Obviously it's use in suspected VTE (prior to diagnosis) is not mentioned in the license, but neither is it mentioned for the LMWHs. For confirmed VTE there is no need for concomitant LMWH whilst initiating treatment (as is the case with warfarin). The pharmacokinetic profile would support this.
Searching, I could find no research on the subject of pre-diagnosis DVT. The recent American College of Chest Physicians guideline (Feb 2012) says they're waiting for research on it's use in diagnosed VTE. It is listed as been an acceptable option for suspected by the Worchestershire Area Prescribing Committee ( https://www.google.ie/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&ved=0CEsQFjAE&url=http%3A%2F%2Fwww.worcestershire.nhs.uk%2FEasySiteWeb%2FGatewayLink.aspx%3FalId%3D20059&ei=-pZdUfGQMPOS7Aa0hYDgDQ&usg=AFQjCNG3eGWC3rSmaHeSP04pvC-jUpVgHA )
I was wondering if anyone has any experience using rivaroxaban locally for suspected DVTs. What I imagine will happen is that people will get a 5-day pack of rivaroxaban, which will save against the cost of a return to the ED for s/c enoxaparin. Note we are not about replacing warfarin.
Any advice would be appreciated.
Regards,
Jason
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