November’s Hemorrhage CE at Citrus Bar and Grill, Manhattan, NY

The first November continuing education event was held on the upper west side of Manhattan at Citrus Bar and Grill. The exhibit prior to the presentation was sponsored by Octa Pharma, who provided information about immunoglobulin therapy. Dr. Amisha Arya, President, opened the evening by thanking the table sponsors, Octa Pharma.

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President Arya then introduced the evening’s first presenter, Christopher Mendoza, student pharmacist from Touro College of Pharmacy. The title of his clinical pearl presentation was “COPD Management in The Elderly Population.” Christopher first discussed the prevalence of COPD and the signs and symptoms of the disease. He emphasized the importance of non pharmacotherapeutic lifestyle changes and the pharmacotherapy to prevent acute exacerbations and disease progression.

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The 2014 GOLD guidelines outline seven chapters: Definition and Overview, Diagnosis and Assessment, Therapeutic Options, Management of Stable COPD, Management of Exacerbations, COPD and Comorbidities, and Asthma and COPD Overlap Syndrome (ACOS). Three key components in COPD treatment and management for the elderly are smoking cessation, individualized pharmacotherapy and vaccinations, and family support to help with adherence to therapy. The presentation concluded with a question and answer session.

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President Arya proceeded with the evening by introducing Karen Berger, PharmD, BCPS. Dr. Berger is the Clinical Pharmacy Manager of Weill Cornell Medical Center’s Neurosciences Intensive Care Unit. The title of the evening’s CE presentation was “The Blood Truth: Pharmacologic Reversal of Life Threatening Hemorrhage.” Dr. Berger began by describing the different types of bleeds along with their origins of cause, including those due to pharmacotherapy.

DSC01890Next, was the pharmacology of hemostasis, explaining the body’s natural coagulation cascade pathway. A limiting factor of the coagulation cascade pathway is that it takes time. Pharmacotherapy and their reversal strategies work in different locations along the pathway to shift the balance of coagulation and thrombosis to aid with the body’s ability to form a clot. A limitation to the reversal strategy agents is their pharmacokinetics, mainly their route of elimination and protein binding (older agents such as dabigatran are less protein bound and can be reversed by dialysis).

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The discussion proceeded by describing the recommended pharmacotherapeutic agents based on the 2012 Chest Guidelines. Dr. Berger further described the agents’ mechanisms of action and clinical pearls about each agent, such as their reversal agents and how to monitor its efficacy vs. toxicity. Heparin and Low molecular weight heparins (LMWH) may be reversed with protamine. Warfarin may be reversed with vitamin K. Heparin and LMWH is monitored using aPTT, while warfarin is monitored by the patient’s baseline INR. Newer agents such as dabigatran, rivaroxaban, and apixaban are convenient, because they are available orally and ‘do not require monitoring,’ but they do not have definitive reversal agents or monitoring parameters.

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Blood products were briefly mentioned, but a limitation is that they require to be administered in large volumes, which may delay the onset of action. Concentrated factors such as 3 factor-PCC and 4 factor-PCC are also another reversal strategy and are available in much smaller volumes. The principles behind selecting an agent consist of the time of onset, severity of the bleed, indication, the hospital’s formulary, and the institution’s guidelines. Reversal should be individualized and depends on the severity of the bleed. The evening’s wonderful and informative presentation concluded with a question and answering session.

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Written by Jamie Chin

Photos by Jamie Chin

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