A recording of this presentation is available HERE.
Anticoagulation (Nguyen, 12/10/2025)
A recording of this presentation is available HERE.
***
Thanks to Dr. Bao Chau Nguyen for a great review of Anticoagulation this week, with a quick review of warfarin, heparin/LMWH, and a particular focus on the Direct Oral Anticoagulants (DOACs), which have become the mainstay of anticoagulation.
Dr. Nguyen reminded us of the current 2025 indications for Vitamin K antagonist (warfarin), which have dwindled to three at this point
- mechanical heart valves
- atrial fibrillation with mod/severe mitral stenosis (esp rheumatic disease)
- antiphospholipid syndrome (APLS)
She also reminded us of the many challenges with Vit K antagonists, which include frequent monitoring, drug-food interactions, and drug-drug interactions.
Current indications for DOACs as first line:
- non-valvular Afib
- treatment of VTE (DVT/PE)
- prevention of VTE (extended)
- select stable PAD/CAD
Summary of indication and dosing of available DOACs:
Dabigatran
- AF: 150 mg BID, reduce to 110 mg BID (age >80, high bleed risk, interacting drugs), Avoid if CrCl <30 (varies by region)
- VTE: 5 days parenteral therapy, then 150 mg BID, 110 mg BID if elderly or high bleeding risk
Apixaban
- AF (stroke prevention): 5 mg BID, Reduce to 2.5 mg BID if ≥2 of the following: Age ≥ 80, Weight ≤ 60 kg, Creatinine ≥ 1.5 mg/dL (or CrCl <30–50 depending on guideline nuance)
- VTE: 10 mg BID x7 days, then 5 mg BID
- Extended therapy (>6-12 months): 2.5 mg BID
- AF: 20 mg once daily with food, reduce to 15 mg daily if CrCl 15–49 ml/min
- VTE: 15 mg BID x21 days, then 20 mg daily with food
- AF: 60 mg daily, reduce to 30 mg daily if CrCl 15–50, Weight ≤ 60 kg, certain P-gp inhibitors
- VTE: 5 days of initial parenteral anticoagulation, then 60 mg daily (or 30 mg if meeting criteria above)
Reversal agents for DOACs:
Factor Xa inhibitors (Apixaban, Rivaroxaban, Edoxaban): Andexanet alfa (preferred when available), 4-factor PCC 50 units/kg if andexanet unavailable
Dabigatran: Idarucizumab 5 g IVAdjuncts: tranexamic acid, local control, supportive care.
There are now practice guidelines for pausing and restarting DOAC in setting of non-urgent surgery
Finally, Dr. Nguyen presented three important 2025 updates on DOACs:
1) DOAC vs. warfarin in CKD patients (SCr<25), a metanalysis of >71K patients with Atrial fibrillation and CKD, which found that standard dose of DOAC compared to warfarin showed decrease risk of CVA, systemic embolism and ICH, with similar risk of bleeding. HOWEVER, inappropriate dose reduction of DOAC resulted in increased risk of CVA and death. Take home: DOACs are safe and effective in patients with AFib and decreased GFR but should be regular/full dose.
https://www.jabfm.org/content/early/2025/01/16/jabfm.2024.240155R0?utm_source=chatgpt.com
2) DOAC for patients with BMI >50: retrospective cohort study of 754 patients that compared DOAC to warfarin and found a non-statistically significant trend toward favoring DOAC (outcomes CVA, all cause mortality, major bleeding). Take home: DOACs are probably better than warfarin for morbidly obese patients with BMI>50.
https://www.sciencedirect.com/science/article/pii/S240584402417627X?utm_source=chatgpt.com
3) Reduced dosage of DOAC in extended treatment of VTE: systematic review and metanalysis of 5 RCTs looking at recurrent VTE, major bleeding. Found no significant increase in recurrent VTE between reduced vs. full dose, significantly lower bleeding risk in reduced dose group. Take home: It appears safe and effective to reduce DOAC to half dose after treating for acute VTE (usually 6 months).
Family Communication in Palliative Care (Wagner, 12/3/2025)
A recording of this presentation is available HERE.
***
Thanks to Dr. Andrew Wagner, who gave a really thoughtful and important Grand Rounds this week entitled, Palliative Care Pearls. He spent the bulk of the time showering us with pearls about how to connect and communicate with patients, particularly at the end of life. He touched on spirituality in medicine and lifted up the notion that good communication is good medicine. The sound quality on the recording isn't excellent, but still is worth watching so that you can experience directly his wisdom and experience.
I highlighted the key pearly questions in bold below.
He highlighted listening and relationship, generous listening, and presence/compassion/empathy. He talked about how death is a part of the life cycle (not a failure) and that healing is coming to peace with mind, body, and soul relationships with spirits on a higher power. If we reframe death as a life cycle event, we can help patients find peace.
One question: "What needs to happen so you can lay your head on your pillow, and say 'I am good'?"
Dr. Wagner talked extensively about centering the patient's identity, values and meaning, which lends itself toward shared decision making: align decisions with values and what matters most, explore "what are you hoping for and what are you most worried about"?, present options in terms of burdens and benefits, and ensure patient and family understand prognosis realistically.
We have the opportunity to offer "a sense of calm", which can be achieved by making eye contact, touch (if/when appropriate), reading the room, modulating voice, sitting down (and ensuring everyone has a chair), arranging the room.
Another possible question: "How are you doing? How is this going for you?"
Imagine if we regarded death as a final stage of growth. Could we then turn toward death as a master teacher and ask "How then shall I live?"
A third question: "What do you know about what the doctors have been telling you?"
Normalize things for patients, "most people in your situations are anxious/fearful-- how are you doing?", OR "Many people are afraid of dying, is that you?"
Palliative care is understanding people's values and goals and creating care plans that are consistent with those values and goals. Everyone gets tired and frustrated with serious illness, but if someone is feeling that way consistently, "it's important for you to tell us that because there are care plans for people who are tired of doing those things".
When dealing with surrogate decision makers, it is extremely important to help the surrogate bring the patient into the room: Tell us about [Joe]. Who was he? What did he love? What made him happy? What was important to him?
A fourth question: "Imagine [Joe] had a crystal ball and could hear all the things we have been talking about; what would [Joe] say?". And then a follow-up once you have elicited Joe's ideals, "I recommend, given what we know about what [Joe] cares about, I recommend . . ." (is this consistent/not consistent with Joe's values.
Dr. Wagner reminded us that physicians can and should be more directive when it comes to Code/CPR decisions.
And when it comes to families that do not want information disclosed to patients, try this fifth question: "I understand you don't want me to tell grandma, but is it okay if I ask grandma if she wants to know more about what is going on?"
Lean into the mystery. Nobody knows.
He also reminded us about self care-- I am enough (see below) and I am not alone (we have teammates, colleagues, chaplains, pastoral consultation), and we should be sharing stories as a means of self-healing.
For those of you interested in the resources he references, here are some:
- Rachel Naomi Remen, MD (Kitchen Table Wisdom and My Grandfather's Blessings) "Healing and the Inner Life: The role of clinician is witnessing>> connection>>healing
- "I am enough" (this he lifted up as important to physicians to remember and recite before stepping into challenging situations. We meet patients AS THEY ARE; our presence is enough"
- "All healing is mutual" (physicians are also healed by the encounter)
- Generous listening-- listening to understanding, NOT fixing, the quality of listening
- Blessing each other-- seeing wholeness beneath illness
- Ira Byock, MD "The Four Things:
- Please forgive me
- I forgive you
- Thank you
- I love you
- Balfour Mount, MD "Human Question": What would you want me to know that will allow me to give you excellent care?
- Harvey Chochinov, MD, "Dignity Therapy"
- continuity of self: "What do you most want remembered about you?"
- role preservation
- generativity
- hopefulness
Finally, some clinician take-aways: 1) holding safe space 2) healing at the end of life 3) honoring intuation and wisdom ("trust your gut, your intuition, your wisdom"). A final useful statement: "We are helping [Joe] to die".
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Great thanks to Dr. Jose Maldonado, a Stanford psychiatrist and neuropsychiatrist, who literally wrote the benzodiazepine-sparing alcohol wi... -
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