Surgery 3

Common medications prescribed for VTE prophylaxis in gynecological oncology patients include:

Low-molecular-weight heparin (LMWH) 

Low-molecular-weight heparin is a class of anticoagulant medication injected under the skin used to prevent blood clots and treat thrombosis-related diseases.LMWH works by activating antithrombin, which inhibits coagulation and can lead to thrombosis.LMWHs are often preferred over unfractionated heparin because they are just as effective but have a lower risk of heparin-induced thrombocytopenia.

•  Enoxaparin/Lovenox is the most commonly utilized LMWH in the US.

Fondaparinux 

Fondaparinux (trade name Arixtra) is an anticoagulant medication chemically related to low molecular weight heparins. Fondaparinux/Arixtra is also administered by injection under the skin used to prevent blood clots and treat thrombosis-related diseases. 

Oral anticoagulants 

Oral medications such as Aspirin and Warfarin/Coumadin

Direct oral anticoagulants (DOACs) 

Direct oral anticoagulants (DOACs) are blood thinners that prevent blood clots by inhibiting thrombin or factor Xa. These medications work differently than warfarin while still achieving similar anticoagulation effects. Some examples of DOACs are: Apixaban/Eliquis; Rivaroxaban/Xarelto; Dabigatran/Pradaxa; Edoxaban/Savaysa; Betrixaban/Bevyxx

• If a patient is unable to receive VTE prophylaxis after surgery due to a documented contraindication, indicate “Contraindicated, specify reason”.
• • Some examples of contraindications you may find documented: active bleeding; known hypersensitivity/allergy to an anticoagulation medication; patient history of heparin induced thrombocytopenia.

• • If you are unable to find the term “contraindicated” documented in the provider notes, mark “No”

• • If you are unable to find the reason VTE Prophylaxis is contraindicated, leave the (specify Reason) free text field blank. 

**Do not spend more than 5 minutes searching for the reason for contraindication

• In addition to “full anticoagulation” being noted specifically in the discharge note, these drugs/doses are also considered full anticoagulation:  
• • Warfarin/Coumadin (any dose)
  • Apixaban 5mg or 10mg 2x daily
  • Rivaroxaban/Xarelto 20 mg 1x daily
  • Enoxaparin/Lovenox syringe higher than 40mg 1x or 2x daily

If you encounter HRD result reported as “equivocal”-abstract as HRD negative

Search the EMR for genetic testing results from labs such as Caris, Foundation One, Tempus, Myriad, and SOPHiA Genetics as well as provider notes for documentation of HRD status. 

• Additional HRD testing is not needed in patients with a positive BRCA mutation since all BRCA+ are HRD+ as well. If a patient has had a positive BRCA test, even for a prior cancer (such as breast cancer), you may select “yes-positive” for HRD status (post op or biopsy) question
• A negative BRCA test would require additional HRD testing for other biomarkers because HRD positivity can be BRCA positive or BRCA negative.  If a patient is BRCA negative, continue to search the EMR for additional testing to have been completed.

You may also find Next Generation Sequencing(NGS)/Whole Genome testing with a positive BRCA mutation or Loss of Heterozygosity (LOH) which is also considered HRD positive.

EXAMPLE OF CARIS/MYRIAD HRD RESULTS

EXAMPLE OF INVITAE HRD RESULTS #2

EXAMPLE OF OTHER LABORATORY HRD RESULTS #3 

If a patient receives anticoagulation therapy while admitted to the hospital post-operatively and then is discharged on a different anticoagulation medication for use at home, count both the length and type of inpatient anticoagulation and anticoagulation medication prescribed at discharge. Count from the day of surgery which is considered “day 1”.

Example #1

A patient is admitted to the hospital 11/15/24 after a Total Abdominal Hysterectomy and is started on Lovenox on 11/15/24.  The patient was then discharged on 11/18/24 and prescribed Apixaban 2.5mg BID (twice a day) with a quantity of 52 tablets. You would add the length of days the patient was anticoagulated after surgery with both the Lovenox (3 days) and Apixaban (26 days) and indicate “Yes” for this question as the duration of anticoagulation is 28 days or greater (29 days total)  

Example #2

The patient was prescribed Apixaban 2.5mg tablets to be taken two times daily upon discharge from surgery.  The quantity ordered is 60 tablets. The quantity dispensed would be for a duration greater than 28 days following surgery (two tablets a day for 28 days would equal 56 tablets), therefore you would indicate “Yes” for this question

Example #3

The patient was prescribed Apixaban 2.5mg tablets to be taken two times daily for 10 days upon discharge from surgery.  The quantity ordered is 20 tablets. Although the patient was prescribed anticoagulation at discharge, the quantity prescribed would be for a duration less than 28 days, therefore you would indicate “No” for this question

If opioids were NOT prescribed at discharge, abstractors will still need to “Add New Entry” and choose “None” from the dropdown list.  Abstractors will then enter “0” for the number of pills prescribed and pill strength.