Pulmonary thrombosis treatment

SuccessM treatment of PEA and asystole depends almost entirely on diagnosis of the underlying cause. Potentially reversible causes include (1) hypovolemia, (2) hypoxia, (3) preexisting acidosis, (4) hyperkalemia, (5) hypothermia, (6) hypoglycemia, (7) drug overdose, (8) cardiac tamponade, (9) tension pneumothorax, (10) coronary thrombosis, (11) pulmonary thrombosis, and (12) trauma. 

It is indicated in the prophylaxis and treatment of deep vein thrombosis in major surgery and pulmonary embolism, treatment of atrial fibrillation with embolisation, prophylaxis and treatment of peripheral arterial embolism. 

Indications for treatment with streptokinase include acute occlusion of arteries, deep vein thrombosis, and pulmonary embolism. Streptokinase therapy in coronary thrombosis, which is the usual cause of myocardial infarction (54,71,72), has proved to be valuable. In this frequently fatal condition, the enzyme is adrninistered intravenously at a dose of 1.5 million units over 60 min, or given by intracoronary infusion at a 20,000- to 50,000-unit bolus dose followed by 2000 to 4000 units/min for 60 min therapy must be instituted as soon as practicable after the diagnosis of heart attack is made. For deep vein thrombosis, pulmonary embolism, or arterial occlusion, streptokinase is infused at a loading dose of 250,000 units given over 30 min, followed by a maintenance dose of 100,000 units over a 60-min period. 

Heparin and warfarin are widely used in the treatment of thrombotic and thromboembolic conditions, such as deep vein thrombosis and pulmonary embolus. Heparin is administered first, because of its prompt onset of action, whereas warfarin takes several days to reach full effect. Their effects are closely monitored by use of appropriate tests of coagulation (see below) because of the risk of producing hemorrhage. 

Streptokinase is administered by intravenous or intra-arterial infusion in the treatment of thrombo-embolic disorders, e g. pulmonary embolism, deep-vein thrombosis and arterial occlusiorrs. It is also used in acute myocardial irtfarclioa... 

Lenalidomide was approved recently for the indication of myelodysplastic syndrome where the 5q deletion is present. Since lenalidomide is an analog of thalidomide, all the same precautions must be taken to prevent phocomelia. The time to maximum lenalidomide concentrations occurs 0.5 to 4 hours after the dose. The terminal half-life ranges from 3 to 9 hours. Approximately 65% of lenalidomide is eliminated unchanged in the urine, with clearance exceeding the glomerular filtration rate. To date, no pharmacokinetic studies have been done in patients with renal dysfunction. Lenalidomide is used in the treatment of myelodysplastic syndrome and multiple myeloma. Other side effects are neutropenia, thrombocytopenia, deep vein thrombosis, and pulmonary embolus. 

Tamoxifen users present also a doubling incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) (118 vs. 62 cases). This increase is similar to that seen with HRT. There are some aspects of this side effect that should be commented on to improve the management of women eligible for tamoxifen treatment and at risk for DVT (Goldhaber 2005). In the subanalysis of the Italian study (Decensi et al. 2005), the venous thromboembolism definition included DVT, PE, and superficial phlebitis. Most of the VTE that the authors reported were, in fact, cases of superficial phlebitis, whereas the admitted definition of venous thromboembolism excludes this entity. Such conceptual differences, together with differences in age and background characteristics between the four studies, can explain the diversity in the incidences observed. 

Prophylaxis and treatment Prophylaxis and treatment of venous thrombosis and its extension pulmonary embolism peripheral arterial embolism atrial fibrillation with embolization. 

Fondaparinux is a synthetic pentasaccharide. It is used for the prevention of deep vein thrombosis in patients who have had orthopedic surgery as well as for the treatment of deep vein thrombosis and pulmonary embolism. 

Plasminogen, an inactive precursor, is activated to plasmin which as a protease is able to break down fibrin clots. The thrombolytic agents in use promote the conversion of plasminogen to plasmin at the site of a thrombus. Indications include post-myocardial infarction treatment. The thrombolytic must be administered within 6 hours for an optimal effect. Other indications are treatment of acute pulmonary thromboembolism, deep-vein thrombosis, acute arterial thrombosis and thromboembolism, as well as in the clearance of arteriovenous catheters and can-nulae. Agents are streptokinase, anistreplase, urokinase, alteplase, reteplase and tenecteplase. 

Lenalidomide, a derivative of thalidomide, was introduced in 2004. Patients with multiple myeloma stage II/III, who have undergone at least one previous treatment can be treated with bortezomib or with lenalidomide in combination with dexamethasone. There is good oral absorptin with peak plasma levels at 0.5-4 hours. Lenalidomide is maily eliminated by the kidneys with a half-life of circa 3-9 hours. Teratogenicity cannot be excluded. Side effects include thrombosis, pulmonary embolus, and hepato-toxicity, as well as bone marrow toxicity resulting in neutropenia and thrombocytopenia. 

I Unlabeled Uses Prevention of deep venous thrombosis, prevention and treatment of orthostatic hypotension, pulmonary thromboembolism... 

Treatment of venous thrombosis, pulmonary embolism, peripheral arterial embolism, atrial fibrillation with embolism Intermittently Initially, 10,000 units, then 50-70 units/kg (5000-10,000 units) q4 6h. IV Infusion Loading dose 80 units/kg, then 18 units/kg/hr, with adjustments based on aPTT. Range 10-30 units/kg/hr. 

Contraindications Concomitant coumarin-type therapy when used in the treatment of breast cancer in high-risk women, history of deep vein thrombosis or pulmonary embolism in high-risk women... 

Another example of a serious adverse effect that can surface through close systematic monitoring is the association of clozapine treatment with venous thromboembolytic complications (514, 515). Six cases of pulmonary embolism and six cases of venous thrombosis were reported to the Swedish Adverse-Reaction... 

Vorinostat (Zolinza) is a histone deacetylase inhibitor that is approved for the treatment of cutaneous T-cell lymphoma in patients with progressive, persistent, or recurrent disease on or after two systemic therapies. The recommended dosing is 400 mg orally once daily. Adverse effects include pulmonary embolus, deep vein thrombosis, thrombocytopenia, anemia, and gastrointestinal disturbances. 

Estrogens with or without progestins should not be used for the prevention of cardiovascular disease. The Women s Health Initiative (WHI) study reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis in postmenopausal women (50 to 19 years of age) during 5 years of treatment with oral conjugated estrogens (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg) relative to placebo.62... 

The use of iloprost has been proposed in patients with systemic sclerosis, a disease that is often characterized by pulmonary hypertension and Raynaud s phenomenon. Three patients with systemic sclerosis who were treated with iloprost developed acute thrombotic events (3). In one case, intestinal infarction occurred 1 day after infusion of iloprost. In another patient the left kidney was not perfused 22 days after the last infusion of iloprost because of thrombosis of the left renal artery. The last patient, 9 months after the start of treatment with iloprost, and 5 days after the last infusion, had an anterolateral myocardial infarction. The authors commented that their observations did not allow them to conclude that there is a direct relation between infusion of iloprost and thrombotic events. However, they said that this possibility should be considered, and they suggested that risk factors for thromboembolism should be carefully evaluated in each patient with systemic sclerosis who is receiving iloprost. 

The goal in the treatment of deep venous thrombosis and pulmonary embolism is the prevention of recurrent, fatal embolism. 

Fondaparinux is a chemically synthesized pentasaccharide that mimics the antithrombin-binding site of heparin and LMWH. Its molecular size (1728Da) is too small to bind to thrombin molecules while it is bound to antithrombin, Therefore, it is a pure anti-Xa inhibitor. It binds very little to platelets, proteins, or endothelium and is excreted in the urine, It does not form a complex with PF4 or other positively charged molecules. It is not neutralizable by protamine sulfate, Recent clinical trials have resulted in FDA approval for prophylaxis of deep vein thrombosis in orthopedic surgery, It has been shown to be effective and safe for the treatment of pulmonary embolism (20,21) and ACS (non-ST-elevation Ml) (OASIS 5—Michelangelo Trial) (17). 

Urokinase is intended for intravenous use only and indicated for the treatment of pulmonary embolism, coronary artery thrombosis, and intravenous catheter clearance. Typical dosages in peripheral arterial disease consist of an infusion at a rate ranging from 60,000 lU/hr to 240,000 lU/hr infused directly into the thrombus. 

Therapeutic uses Originally used for the treatment of deep-vein thrombosis and serious pulmonary embolism, thrombolytic drugs are now being used with increasing frequency to treat acute myocardial infarction and peripheral arterial thrombosis and emboli, and for unclotting catheters and shunts. 

Thrombosis (blood clot) - may occur up to six weeks after surgery. Rarely, a blood clot can pass to the lungs causing a pulmonary embolism and a medical emergency. Treatment may necessitate anticoagulants. 

When these patients are discharged from hospital, prophylactic treatment with an oral anticoagulant is recommended to prevent recurrence of the thrombosis. Warfarin sodium, which antagonizes the effects of vitamin K, is used in prophylaxis and treatment of DVT and pulmonary embolism. It is usual to start with an induction dose of 10 mg daily for two days the dose can then be reduced. Patients need to be monitored as there is a risk of haemorrhage with oral anticoagulant drugs. 

---