Acute & General Medicine Issue 18 by CloserStill Media

Prof agin E2 g hy of essor Mo pe do BarEn ts Hecrine Hyrris Browrtension art C perte n, Pr entre nsion ofes sor ,

UES D

AY 2 ST 1

end

NO THEA VEMBER

cros

s-sp

TRE Dr abet 3 EndoFrancescic emerge crino a Sw when Unive nc NeurManjit Ma to re rsity logy, Noords, C ies ologis thar for Ne Hosp rfolk onsu assu itals and ltant urolo t, The Nau, Con re, THEA Foun Norw in gy an tio sultant D ag Os TRE datio ich obsstDi d Ne nal Ho Dr Ma teopor n Tr ructnosis an uros spita Trust Dr DDa 4 iv urge l Rh rwan osis Resp vid Ew e sleedp treatm ry up ma Bu Leceu ira The art Si apno ent Hosp turer,tologistkhari, C date Mo ob 10 mc e op ese ital,tory Phys ea of on :20 Londo icianock, C TrustrecambeUniversand Honosultant Tr tio 11 , Roya Bay ity Ho rary ache ns? patient , St Baonsulta n :0 P Ps : NH sp 0 BR Se what l ologisl Batte rtholo nt ls nio meddi ychi are EAK LancasteSrFounita mew’ urolo t at Thrham, C datioof r Dr AAl cal waatric em Infi s on rd e ice Spon Liaiso rmar n Squagy an Natio sulta Ashb s ergenc is y sore ies on Lew ity C re, andd Neurosnal Hospnt wishn Psychiay, Con d sess olleg Senio urge ital am the trist, sultant e Lon r L ry, ion: Unive MDU don ecture rsity r Hosp ital d sess 11:40 Spon o Di

Head when ache to sc Dr an -

12:0 ion: Baye 0 BR r EA

sore d sess

Head when ac

ion: BMS/ Pfi

to sc he Dr NeurManjit an when to

Canta

onso red se es

sion

keyHepato mana logy Gene m nt2017 Dr ral Phgeme LecGideon yssiician for th

He turer Hirscch Bi patologand C field,

: BI

5:15 rminghamistNH, UUnoonivesultantSenior HSS Fo rsity BREA unda Hospita K tio ls

n TTrru OSA: st frequ entlycommon Dr undi , impo Ph David Stroysician Hargro agnose rtant bu Univeke Medand Cl ves, Con d t

PAGE 2

Irrelevant tests in AMU doing more harm than good

U SE NEWDISCO YOUSJ TO UNT C

Impenorary and Gell, Consu NHS rial CollClinical riatricia ltant Tr Trust ege Senio n an Healt r Lec d hcar ture r, e

Fe 11:0 r 0 Drtravelve ler in the re 11:4-0 turn DiseAnna Ch in as

ec to Mo turer, logist ari, Con te RoyarecambeUniversand Honosultant l Lanc Bay ity Ho rary S nio aste NHS Fospitals Se r Infi rmar undatiooff r y n TTrru M st, Prof anagin es g En so hype cr r Mo r Cendo tre ine Hyperris Browtension rtens n, Pr ion, Ba ofesso s r of r ts H ar He ParkInpatie t Dr Pa inson’nt mana Adde ul Wo s Dise geme nbro rth, C ase nt of oke’s onsu Hosp ltant ital Neuroolo gist,

g TTrropic es C eckley, al Di onsulta Infec seas nt, tious es, UC Hosp LH ital fo r

12:0 0 12:40

Spon so

red se ssioon : BM

pu Diagno 13:3 0 Dr Lulmonarysis and 14:0ma Resp ke Ho embolis 5 Ho li nageme wa ira sp tory rd, C m nt

14:15

linic

EATR Falls hypo 09:0 E1 an - 0 PhDr Colitensiodn postur 09:3 n Mi al 5 Ho ysician tche

Ga dosc ton, Londstroente opy an Clinica on NH rolog d Con l Lea S TTrru ist, Ba sultantd rts an st d the

PAGE 4-6

rsity icine inical L sulta Foun , East ead fo nt datio Ken r Th n TTrru t Hosp eleve definiti st itals ve Kevinant test s inguide Jo i

lty c

TIME

09:4 5 Dr GI emer 10:2Sean genc 0 for En Pres ies

zer

reas for Neologist,Mathharu 12:4 sure urolo Thhe Na, Con 0 - 13 , gy an ltant ch th a d tionasu O te Os :30 Neur l Hosp Dr op BREA nt e osur ital Rh Marwan orosis gery K on, C L euma Bukh upda Sp

, Gu G y’onsultant on Tr Trusts and St

ecia

MAIN

al tr

PRO

GRA M THEA ME • W TRE travFeveer in 2 elleer th

Dr e retu DiseAnnaa Ch rning TTrropicasess C eckley, all Di onsulta Infec seas nt, tious es, UC Hosp LH ital fo r

in prMediical Prof eggnnan prob Prof essoor cy lems

N C Guy’ essoor ofCatherin s & St S ThObstet e Nelso omas ric M n-Pi ’ Foun edicine ercy, for s datio , Dr n Tr Fallss Trust Ge Ju hypo 10:2 an NHSriatr 0 - 11 Dr C tennsiod post Fo oli ur Ph n Mi n al :00 BREA Ho ysician a tche Impenorary and Gell, Consu K NHS rial CollClinical riatricia ltant TTrruuss ege Senio n an t Healt r Lec d US hcar ture r, e C

S/ Pfi zer Sess ion de tails

11:40

comi

ng so

TO SO E

DISC £2 - 12:0 OU 0 BR EAK

GI Dr emer for Sean Pr genc Ga Endosc eston, ies

o su NH ital, Phys on of Lec S TTrrustImperia ician, ltant ki Manag Institturer, Na, and Hol CollegeHammer a 12:4 Londstroente opy an Clin ute, tiona nora Healt smith Dr dney di ement 0 - 13 Impe l He ry Se hc on NH rolog d Co Ph Markk sease of chro ar rial C art :30 S TTrru ist, Ba nic oll & L nior e Cli ysicia Thoma BRE r

View the full 14 stream programme .

PAGE 11

b How

Acute heart failure, a common problem presented to A&E

. . . . .

Issue 18 | www.agmconference.co.uk

Doctors need to improve communication skills with dying patients A PE R KE

> CONTINUED ON PAGE 7

or this reason physicians need to have a good understanding of the challenges of identifying those people at risk of deterioration and death and be able to support people and their families in developing appropriate and realistic individualised advanced care plans. Dr Polly Edmonds, Consultant in Palliative Medicine, King's College Hospital NHS Foundation Trust, London, who is speaking at the Acute & General Medicine,

1 20

Nearly half of all deaths occur in hospitals, many on acute and general medical wards.

says this topic is important as the NHS caters for an ageing population presenting with increasing frailty and multi-morbidity. ‘Hospitals have a very active curebased culture and so if you are elderly, frail and unwell you're very likely to get a trial of active treatment. While that may be the right course of action, it is also important to be able identify those people whose reversibility is very limited or who might not really want that that trial of treatment or who actually may want a different plan of care. ‘We often see family members saying in

Dr Polly Edmonds, Consultant in Palliative Medicine, King's College Hospital NHS Foundation Trust

Medics often lack confidence in managing dementia R KE EA

> CONTINUED ON PAGE 7

his is really core business for the NHS and for acute hospitals,’ says Rowan Harwood, consultant physician and professor of geriatric medicine at Nottingham University Hospital NHS Trust. He believes a lot of hospital staff lack confidence in dealing with dementia and the many other issues that go with it. ‘The

17 20

One in three emergency admissions is of a confused older person and 40 per cent of those over 70 admitted to hospital have dementia.

things people often have problems with are preventing and dealing with difficult behaviours, communication, keeping patients safe, stopping people from wandering or falling over and embracing family involvement or more complex relationships, for example with care homes,’ he says. So in a presentation at the Acute & General Medicine Show, Professor Harwood will explore how crises for patients with dementia have multiple dimensions, including acute medical, delirium or other mental health issues,

Rowan Harwood, Consultant Geriatrician, Nottingham University Hospitals

SS NCE PA E R E F N CO

ATR

Man

r spita ls

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:36 Page 1

FULL HANDS-ON TRAINING TIMETABLE AND PROGRAMME UPDATED INSIDE >>

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:36 Page 2

www.agmconference.co.uk

CONTENTS: New treatments for stroke patients . . . . . . . . . . . . . . . 3 Full programme . . . . . . . . .4-6 Difficult airway workshop training sessions . . . . . . . . 8 Acute & General Medicine host EMA annual conference . . . . . . 9 New device helps patients get to surgery faster . . . . . 10 Refresher on syncope . . . . 11 Acute heart failure . . . . . . .11

14 Exhibition House Addison Bridge Place Kensington W14 8XP

Exhibition enquiries: 0207 348 1855

Dr Kevin Jones, Consultant in Acute Medicine, Bolton Hospitals NHS Foundation Trust

DON’T MISS DR JONES’S PRESENTATION AT ACUTE & GENERAL MEDICINE 2017!

Delegate bookings: 0207 348 1851

Sarah Bray, Marketing Manager Stephen Jenkins, Delegate Relationship Manager Yemi Ibidunni, Show Manager

EA SP

Acute & General Medicine Team:

he test that Dr Jones, a consultant in acute medicine at Bolton Hospitals NHS Foundation Trust, most worries about most is the CTPA (computerised tomographic pulmonary angiography), often used to overinvestigate chest pain. This is because it delivers a significant amount of radiation. Other pet hates are unnecessary requests for troponin and d-dimer tests and CT brain scans for asymptomatic adults with syncope. He observes junior doctors x-raying the abdomen of people vomiting blood when the Royal College of radiologists have been saying for years that that is a complete waste of time. As for drunks – Dr Jones says the Royal College of Emergency Medicine’s number one unnecessary intervention is connecting an intoxicated patient up to a drip and giving them intravenous fluids – there is no evidence

the pressure on my colleagues in radiology and pathology,’ he says. giogram as well. Who are you going to have to persuade that you need these tests? ‘Coming to this talk will help you to advocate for your patient when they need some of the less mainstream tests. When you have to have a conversation with a busy radiologist or the lab to get the test that you want, you need to have the confidence to explain why this is necessary for your patient.

Francesca Robinson

Dr Kevin Jones is 62 and says he gets grumpier by the month because he is fed up with patients in the acute medical unit (AMU) undergoing swathes of unnecessary tests.

that this will help them to feel better, or speed up their discharge from hospital. These patients just need to be left to sober up. When junior doctors order futile tests it is usually because of a lack of training and supervision, claims Dr Jones. ‘The problem is if you if you do an unnecessary investigation and get an abnormal result which may have nothing whatsoever to do with the initial condition, you find yourself going down false alleys investigating things that don't really matter.’ Dr Jones is not a lone voice raising concern about irrelevant tests. He points to a new website www.choosingwisely.co.uk which has published the top five tests or interventions that each Royal College considers unnecessary but is still practised in their speciality. He will be setting out his definitive guide to all the irrelevant tests ordered in the AMU in a talk at the Acute & General Medicine Show and highlighting the evidence based guidelines for many common emergency medical presentations that medics need to be aware of. ‘Hopefully my presentation will save thousands of pounds for the NHS and relieve

Editorial Team:

IRRELEVANT TESTS IN THE ACUTE MEDICAL UNIT CAN DO MORE HARM THAN GOOD

ASS ENCE P R E F N CO

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

Organised by:

@AGMConfUK /AGMConference Acute & General Medicine

Sponsorship Statement AGM is for healthcare professionals only. The seminars at AGMhave been brought to you by Closer2Medical in association with our partners and sponsors. The views and opinions of the speakers are not necessarily those of Closer2Medical or of our partners and sponsors.AGM’s association partners have helped develop the programme. Sponsors have not had any input into the programme except where an individual session states it is sponsored. The session topic and speaker have been developed by each sponsoring company.

USE DISCOUNT CODE: NEWSP2 ONLINE: WWW.AGMCONFERENCE.CO.UK/NEWSP2 OR CALL: 0207 348 1851

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 3

www.agmconference.co.uk

NEW TREATMENT OPTIONS ARE IMPROVING OUTCOMES FOR STROKE PATIENTS Stroke is a leading cause of death, disability and dementia but the good news is that treatment has advanced rapidly over the last two decades considerably improving outcomes for patients.

A PE R KE

patient with stroke. Things are every different now from 20, 30 years ago when all that could be offered to a patient was rehabilitation and a wait and see approach.’ Delegates who come to this talk will gain an understanding of the pathophysiologic concepts of an acute ischaemic stroke, the indications and contraindications for thrombolysis and the indications for interventional treatment of acute stroke. This talk will be suitable for all grades of doctors. ‘All medical professionals working in acute care should know which patients will benefit from an escalation of treatment by the stroke team,’ says Dr Khadjooi. Dr Khadjooi will also be giving a talk on stroke prevention in atrial fibrillation.

an effective emergency treatment for severe ischaemic stroke, significantly improving patient outcomes. NICE approved the data and the treatment has been used in the NHS since 2015. Up to 15% of patients with ischaemic stroke are currently benefiting from these new treatments in the UK. They are particularly suitable for treating tricky patients who suffer strokes post operatively or during pregnancy or postpartum, who would previously have ended up severely disabled can be offered intra arterial treatment. Dr Khadjooi says: ‘As a stoke physician I am very passionate about educating colleagues about the treatments now available to prevent major disability in the

1 20

r Kayvan Khadjooi, Consultant in Stroke Medicine at Addenbrooke’s Hospital and Associate Lecturer in University of Cambridge School of Medicine, will be updating Acute & General medicine Show delegates in the latest treatment options for ischaemic stroke and the strong evidence that supports them. Intravenous thrombolysis has been the established treatment for ischaemic stroke since 1996. But in the last few years researchers have achieved a breakthrough in randomised controlled trials of new intra-arterial to treatments, including thrombectomy. The trials were stopped early because the results were so successful, demonstrating that these treatments were

Dr Kayvan Khadjooi, Consultant in Stroke Medicine, Cambridge University Hospitals

DON’T MISS DR KAYVAN KADJOOI’S PRESENTATION AT ACUTE & GENERAL MEDICINE 2017! REN CONFE

S CE PAS

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 4

www.agmconference.co.uk

4 S C R ED IT D P C 2 1 V ED B Y APPRO YAL TH E RO OF E C O LLEG T IS T S TH E A N A ES

TIME

EUROPE’S MUST ATTEND CROSS-SPECI

THEA ATRE TRE 1

MAIN PROGRAMME • TUESDA AY Y 21ST NOVEMBER THEA ATRE TRE 2 TH HEA ATRE TRE 3

THEA ATRE TRE 4

yp tension and treatment of When is a stroke, a stroke? Managing g g hyper Diabetic emergencies Diagnosis g investigations, treatment and cure Dr Francescaa Swords, Consultant in obstructive ti ti t t ti sleep l apnoea 09:00 Dr David Hargroves, Consultant Physician and Clinical Lead for Professor Morris Brown, Professor Endocrinology, gy, Norfolk and Norwich Dr David Ewart Simcock, Consultant 09:35 Stroke Medicine, East Kent Hospitals of Endocrine Hypertension, Barts University Hospitals ospitals Foundation Trust Trust Respiratory Physician, St University Foundation Trust Trust

Acute heart failure

09:45 10:20

Dr Unni Krishnan, Honorary Consultant Cardiologist, Cambridge University Hospitals NHS Trust r

and the London School of Medicine

Bartholomew’s Hospital, London

Headache - when to reassure, Osteopoorosis update when to scan Dr Marwan BBukhari, Consultant

Managing g g hyper yp tension tigations, treatment and cure investigations,

Dr Manjit Matharu, Consultant Neurologist, The National Hospital for Neurology and Neurosurgery

Rheumatologgist and Honorary Senior Professor Morris Brown, Professor of Lecturer, University Hospitals of Endocrine Hypertension, Barts and Morecambe BBay NHS Foundation the London School of Medicine TTrust, rust, Royal Lancaster Infirmary

10:20 - 11:00 BREAK Acute coronary syndrome

11:00 11:40

Dr Unni Krishnan, Honorary Consultant Cardiologist, Cambridge University Hospitals NHS Trust r

The obese patient: what are ti ? the options? Dr Rachel Batterham, Consultant Neurologist at The National Hospital for Neurology and Neurosurgery, Queen Square, and Senior Lecturer University College London

GMC: facingg investigation

Sponsored session: Diiachi Sankyo

11:40 - 12:00 BREAK

*Programme accurate at time of print

Sponsored session: BMS/ Pfizer Session details coming soon

GI emergencies Dr Sean Preston, Clinical ical Lead for Endoscopy and Consultant o Gastroenterologist, Baarts and the London NHS Trust Trust

12:00 112:40

Medical cal problems in pregnanccy Professorr Catherine Nelson-Piercy, Professorr of Obstetric Medicine, Guy’s & St Thomas’ Foundation TTrust rust

12:40 - 13:30 BREAK

13:30 14:05

14:15 14:50

Diagnosis and management of Management of chronic pulmonary embolism kidney disease

Dying in an acutee hospital one chance to get itt right

Vitamin D deficiency

Dr LLuke D k Howard, H d Consultant lt t Respiratory Physician, Hammersmith Hospital, Imperial College Healthcare NHS Trust Trust, and Honorary Senior Lecturer, National Heart & Lung Institute, Imperial College London

Dr Mark D M k Thomas, Th Consultant lt t Physician and Nephrologist, and Clinical Director for Professional Education, Heart of England NHS Foundation Trrust

Dr Polly D P ll Ed Edmonds, d Consultant in Palliative Medicine, King’s College Hospital NHS Foundation Trust r

How to approach the breathless patient

Managing the dementia patient in the acute hospital

Writing reports and appearing as Anticoaggulating the PE patient: a witness Where, when w and how?

Dr Kirsty Challen, Consultant in Emergency Medicine, Lancashire Teeaching Hospitals NHS Foundation Trrust

Professor Rowan H Harwood, Consultant Geriatrician, Nottingham University Hospitals

Dr Nicola Lennard, Medico-Legal Adviser, The Medical Defence Union (MDU)

Dr Teerry Aspray, Consultant in Metaboolic Bone Disease, The Newccastle Hospitals NHS Foundation on

Dr Luke Howard, H Consultant nt Respiratory Physician, Hammersmith Hospital

14:50 - 15:15 BREAK 15:10 15:45

15:55 16:30

Update on acute kidney injury

Dying in an acute hospital one chance to get it right

Dr Mark Thomas, Consultant Physician and Nephrologist, and Clinical Director for Professional Education, Heart of England NHS Foundation Trrust

Dr Polly Edmonds, Consultant in Palliative Medicine, King’s College Hospital NHS Foundation TTrust rust

Vitamin D deficiency

Emergency gency ultrasound interesting cases

Dr Terry Terry Aspray, Consultant Physician and Clinical Senior Lecturer, Freeman Hospital

Dr Nicholaas Smallwood, Consultant in Acute M Medicine, Surrey and Sussex Healthcare ealthcare NHS TTrust rust

Diagnosis and management of How to approach the pulmonary embolism breathless patient

Managing the dementia patient in the acute hospital

Dr Luke Howard, Consultant Respiratory Physician, Hammersmith Hospital, Imperial College Healthcare NHS Trust r , and Honorary Senior Lecturer, National Heart & Lung Institute, Imperial College London

Professor Rowan H Harwood, Consultant Geriatrician, Nottingham University Hospitals

Dr Kirsty Challen, Consultant in Emergency Medicine, Lancashire TTeaching eaching Hospitals NHS Foundation Trust r

The reealities of leadership Dr Carolinne Sayer, Chair, Camden CCG

Information was correct at time of press. CloserStill reserve the right to amend content without prior warning. The conference has been brought to you by CloserStill Medical al in association with our partners par and sponsors. The views and opinions of the speakers are not necessarily those of CloserStill Medical or of our partners and sponsors. Sponsors have not had any input intoo the programme except where an individual session states it’s sponsored. The session topic and speaker have been developed by each sponsoring company. Our audience is made up of medical professionals, fessionals, Doctors , Nurses.

BOOK BEFORE 29TH SEPTEMBER FOR £289+VA VA ATT BEFORE THE PRICE INCREASES TTO £349+V VA AT! A T!

USE CODE NEWSP2: WWW.AGMCONFERENCE.CO.UK/NEWSP2 OR CALL 02207 348 1851 GASTROENTEROLOGY

HAEMATO ATOLOGY

HOT TOPICS

NEPHROLOGY

NEUROLOGY

PALLIAT ATIVE CARE

RESPIRAT ATORY

RHEUMATO ATOLOGY

STROKE

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 6

www.agmconference.co.uk

N EW

PROGRAMME CONTINUED... THEATRE 5 TUESDAY 21ST NOVEMBER

THEATRE 6

Hosting the first ever European Medical Association’s Annual Conference

Cystic fibrosis - an update

09:45 10:20

10:30 10:50

Dr Nicholas Simmonds, Consultant Respiratory Physician, Royal Brompton & Harefield NHS Foundation Trust

The importance of measuring ionized magnesium in critically ill patients Germano Ferrari, European Director, Medical and Scientific Affairs, Nova Biomedical

Managing gout – crystallising the evidence

11:45 12:05

TUESDAY 21ST NOVEMBER European Medical Association Annual Conference opening and introduction 09:00 Dr Vincenzo Costigliola, EMA President, 09:30 European Medical Association (Brussels), Institute of Health Salzburg

Perspectives of adipose mesenchymal stem cells (AdMSCs) 09:30 -based therapy for osteoarthritis (OA) 10:00 Professor Dragan Primorac M.D., Ph.D., President of the Board of Trustees, St. Catherine Hospital, Croatia

Dr Muhammad Nisar, Consultant Rheumatologist & Physician, Luton & Dunstable University Hospital, NHS Foundation Trust

10:00 10:30 Sepsis - the latest

13:30 14:05

Dr Ron Daniels, Critical Care Consultant, Heart of England NHS Foundation Trust, and CEO, Sepsis Trust

Inotropes and vasopressors

16:00 16:40

Dr Shahana Uddin, Consultant – Critical Care Medicine & Honorary Senior Clinical Lecturer, King’s College Hospital NHS Foundation Trust

WEDNESDAY 22ND NOVEMBER Tracheostomy management

09:45 10:20

Dr Mary White, Consultant Intensivist, Royal Brompton & Harefield NHS Foundation Trust

ADVANCED SESSIONS IN CRITICAL CA RE AND RESPIRATORY MEDICINE

11:00 11:40 14:15 14:50 15:15 15:50 17:05 17:40

Predictive, preventive and pesonalised medicine - innovative European concepts in sciences and healthcare Dr Olga Golubnitschaja, President of the Board of Trustees, St. Catherine Hospital, Croatia

The gut microbiota and human health - a molecular cross-talk Kieran Tuohy, Head of Department of Food Quality and Nutrition, Fondazione Edmund Mach, Italy

The critically ill patient – who should be admitted to ICU? Dr Chris Bassford, Consultant in Critical Care Medicine at NHS, University Hospitals Coventry and Warwickshire NHS Trust

COPD - preventing admissions Dr Jonathan Fuld, Consultant Physician, Cambridge University Hospitals NHS Foundation Trust

Acute brain dysfunction in critical illness Professor Martin Smith, Consultant and Honorary Professor; Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals

WEDNESDAY 22ND NOVEMBER Emerging respiratory infections

11:00 11:40

Dr Victoria Johnston, Consultant in Infectious Diseases, University College London Hospitals NHS Foundation Trust

The importance of measuring ionized magnesium in critically ill patients

11:45 12:05

Neurology: moving into the therapeutic era 09:00 Massimo Pandolfo, Professor of Neurology, 09:30 Erasme Hospital Macrophage activation and predisposition for infectious and 09:30 malignant diseases, related to single nucleotide polymorphisms Marion Schneider, Immunology, Laboratory 10:00 at the Institute of Hematostasis and Transfusion Medicine

Germano Ferrari, European Director, Medical and Scientific Affairs, Nova Biomedical

10:00 10:30 Leadership in practice: the day-to-day challenge of being a medical leader and how to improve your skill-set

12:45 13:05

Dr Helen Hartley, BSc(Hons) MBChB(Hons) FRCA MBA LLM, Head of Underwriting Operations, MPS

Human factors in the management of the critically ill patient

13:30 14:05

STREAMS:

Dr Elizabeth Haxby, Consultant Anaesthetist and Lead Clinician in Clinical Risk, Royal Brompton Hospital

CRITICAL CARE RESPIRATORY HOT TOPICS CAREER DEVELOPMENT RHEUMATOLOGY

11:00 11:40

Clinical ultrasound in general and emergency medicine - a valuable medical breakthrough in limited resources subsets Francesca M. Trovato, MD, Emergency Department, University Hospital Policlinico-Vittorio Emanuele, Catania

Question time “meet the speakers” Early identification of the deteriorating patient

13:30 14:05

Dr Joel Meyer, Intensive Care Consultant, Guys and St Thomas NHS Foundation Trust

14:15 14:50

Dr Paul Pfeffer, Consultant Respiratory Physician with Specialist Interest in Asthma, Barts Health NHS Trust

15:55 16:30

Dr Susanna Price, Consultant Cardiologist & Intensivist, Royal Brompton Hospital

Acute severe asthma

Heart failure in ICU

BOOK BEFORE 29TH SEPTEMBER FOR £289+VAT BEFORE THE PRICE INCREASES TO £349+VAT!

USE CODE NEWSP2 WWW.AGMCONFERENCE.CO.UK/NEWSP2 OR CALL 0207 348 1851

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 7

www.agmconference.co.uk

HANDS-ON TRAINING ULLTRASOUND TRASOUND TRAINING - ZONE 1

ULLTRASOUND TRASOUND TRAINING G - ZONE 2

TUESDA AY Y 21ST NOVEMBER WEDNESDA AY Y 22ND NOVEMBER

TUESDA AY Y 21ST NO N VEMBER WEDNESDA AY Y 22NDD NOVEMBER

09:00 - 09:50, 10:00 - 10:50, 11:00 - 11:50, 12:00 - 12:50,, 13:00 - 13:50, 15:00 - 15:50, 16:00 - 16:50

09:00 - 09:50, 10:00 - 10:50, 11:00 :00 - 11:50, 12:00 - 12:50, 13:00 - 13:50, 15:00 - 15:50, 5:50, 16:00 - 16:50

Session description: • Basic skills • Advanced skills • RUSH scan (Rapid Ultrasound for Shock and Hyptension)

Session description: • Overview of key principles of ultrasound nd and basic controls • Hands on sessions composed of 3 stations, tions, 15 minutes each • Initial 5 minutes will be a demonstration, followed by 10 minutes of practice • Allow 3-4 candidates to be booked onto to every station; a maximum total of 12 candidates ates per session.

AIRWA AY Y TRAINING ZONE TRAINING INFORMA ATION TION Ambu are delighted to be demonstrating the innovative Ambu® aScope™ ope™ single-use, flexible videoscope that challenges conventions in flexible le optical intubation, offering immediate accessibility, a higher level of practicality and no risk of cross-contamination at Acute & General Medicine 2017. TTopics opics covered include: • Current Challenges in Airway Management • Overview of clinical evidence and current guidelines • Clinical use of single-use scopes • Hygiene, advantages and disadvantages of single-use scopes • Cost efficiency of single-use scopes • Practical demonstrations of Ambu aScope 3 system • An overview of where Ambu products fit in to difficult airways Get expert Difficult Airway training providing opportunities to learn more about the benefits of using advanced single-use visualization equipment ment for management of the difficult airway and to learn how the aScope™ ™ system is suitable for a wide range of endoscopic procedures in the OR, ER and ICU. Delivered by experienced Ambu Clinical Educators, you will learn how aScope™ can enhance patient safety, reduce infection risk at hospitals and help to control costs. Instantly improve your advanced airway skills through ugh hands on practical demonstrations, delivered in accordance with clinical consensus guidelines as stated by the National TTracheostomy racheostomy Safety Project oject and the Intensive Care Society, as recommended in the NCEPOD report. < CONTINUED FROM PAGE 1 complaints after people have had a trial of treatment then died in hospital, that if only they had understood how sick they were they would have wanted things to be done very differently. A lot of complaints around endof-life care relate to a lack of identification of dying and poor communication,’ she says. These conversations can be difficult and because hospitals are busy places it is important that inexperienced junior doctors are not left to face these crises with distressed families on their own late at night. ‘What is ideal is if senior clinicians can identify these very sick patients who may have limited reversibility early in the day. Then

they can start having the conversations about what is best for the patient and what their wishes might be. ‘The numbers of older people are rising and so increasingly this is something that all grades of doctor need to think about,’ says Dr Edmonds. Dr Edmond’s talk will cover: • The demographic changes in the UK and the impact on morbidity and mortality • How to identify the person at high risk of progressive deterioration and death • How to support patients and families in considering priorities and preferences towards the end of life • How to make individualised end of life care plans for dying patients

STTA ATIONS A TIONS NS Station 1

Aortic scan for identification and measurement of Abdominal Aortic Aneuurysms (AAA)

Station 2

Focused Assessment with Sonography in Trauma (FFAST AST scan) for the ide identification entification of free fluid in the peritoneal cavity

Station 3

Peripheral and Central IV access

NIV TRAINING ZONE NE LEARNING OUTTCOMES New guidelines from the British Thoracic Society ciety are about to be published so now is the time to refresh your NIV knowledge ge and skills. Delegates can expect 45 minute stimulatingg and interactive hands-on sessions including: • A shorrtt presentation ntation NIV introduction: benefit, indication and contraindications. ions. • What to consider der when selecting a NIV ventilator (leak adaptation and compensation). n). • Selecting the right patient interface NIV masks – types, pros and cons, correct fitting. g. • The opporrtunity tunity ity to see “live” changesof distribution of ventilation inside the patients lungss using Pulmovista our innovative EIT technology. Delegates can expect to increase their awareness of the setting up and trouble-shooting ng of NIV during these sessions and will have the opporrtunity tunity to discuss any other her ventilator questions with the Draeger team at the meeting.

< CONTINUED FROM PAGE 1 functional problems, and carer or care system problems. He will talk about the different models for managing patients appropriately, including comprehensive geriatric assessment, rehabilitation, person-centred and end of life care. But the main problem, he says, is that acute hospitals are not structured or have processes that are appropriate for this very complex and needy group of people. Adjustments to hospital processes are required to accommodate the needs of a person with dementia, despite an often adverse environment. Family involvement is

important and decisions must be made carefully, and discharges planned. But Professor Harwood says all is not doom and gloom: ‘There are increasingly beacons of extremely good practice for example with hospitals providing specialist medical, and mental health units or dementia wards. Older people’s liaison psychiatry services are also quite widespread now and are contributing to a better standard of care and a better experience for patients.’ Delegates who come to this talk will understand what dementia is and its importance amongst medical inpatients, why people with dementia are admitted to hospital and how care should be adjusted to take account of the needs of these patients.

DON’T MISS DR POLLY EDMONDS' OR MISS PROFESSOR HARWOOD’S PRESENTATIONS AT ACUTE & GENERAL MEDICINE 2017! CONFE

PASS RENCE

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 8

www.agmconference.co.uk

NEW FOR 2017: DIFFICULT AIRWAY WORKSHOP TRAINING SESSIONS

mbu bring efficient healthcare solutions to life within our fields of excellence: Anaesthesia, Patient Monitoring & Diagnostics and Emergency Care. Millions of patients and healthcare professionals worldwide depend on the functionality and performance of our products. The manifestations of our efforts range from early inventions like the Ambu bag to our latest landmark solutions such as the aScope™ – the world’s first singleuse videoscope. Our commitment to bringing new ideas and superior service to our customers has made Ambu one of the most recognised medico-technical companies in the world. Ambu are delighted to be demonstrating the innovative Ambu® aScope™ single-use, flexible videoscope

that challenges conventions in flexible optical intubation, offering immediate accessibility, a higher level of practicality and no risk of cross-contamination. The scopes are compatible with the highresolution monitor, Ambu® aView™, which enables easy navigation and fast identification of anatomical landmarks. Ambu are dedicated to improving patient safety and determined to advance single-use devices which is why we believe it is important to implement NAP4’s recommendations of regular multidisciplinary training for difficult airway management after purchasing suitable equipment to manage difficult airways. Our dedicated staff will be on-site to offer Difficult Airway Workshop training sessions which provide opportunities to

learn more about the benefits of using advanced single-use visualization equipment for management of the difficult airway and to learn how the aScope™ system is suitable for a wide range of endoscopic procedures in the OR, ER and ICU. Delivered by experienced Ambu Clinical Educators, you will learn how aScope™ can enhance patient safety, reduce infection risk at hospitals and help to control costs. Instantly improve your advanced airway skills through hands on practical demonstrations, delivered in accordance with clinical consensus guidelines as stated by the National Tracheostomy Safety Project and the Intensive Care Society, as recommended in the NCEPOD report.

Topics covered at Acute & General Medicine include: • Current Challenges in Airway Management • Overview of clinical evidence and current guidelines • Clinical use of single-use scopes • Hygiene, advantages and disadvantages of single-use scopes • Cost efficiency of single-use scopes • Practical demonstrations of Ambu aScope 3 system • An overview of where Ambu products fit in to difficult airways

DON’T MISS OUT ON DIFFICULT AIRWAY TRAINING AT ACUTE & GENERAL MEDICINE 2017! PASS RENCE CONFE

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 9

www.agmconference.co.uk

ACUTE & GENERAL MEDICINE TO HOST THE FIRST EVER EUROPEAN MEDICAL ASSOCIATION ANNUAL CONFERENCE R

EA SP

systems in Europe. So while you have the Beverage system in the UK, in a number of European countries we have the Bismarck system, in the European Eastern countries we have a mixture between social and state healthcare systems, and this means our members have a wide range of different experiences of providing healthcare. ‘But what for us is important, and equally for UK doctors, is that we all respond to the needs of our patients as best we can. Having a global approach to medicine enables us all to share good practice with colleagues from around the world. ‘Our members are very much looking forward to coming to London in November and meeting the Acute & General Medicine Show delegates,’ says Dr Costigliola.

ideas and it is more important than ever to collaborate and to find out how global referrals and international consultations are improving patient care worldwide,’ says Dr Costigliola. The EMA, based in Brussels, was established in 1990 by doctors from the then 12 European member states, as an ‘international foundation pursuing a scientific aim’. The association’s ethos is to create a European network of doctors, to actively influence the development of European health care and to add a European dimension to members’ professional and social life. ‘Our organisation incorporates 28 different cultural backgrounds, different languages and different traditions. Unlike the UK we have many different healthcare

ondon is an exciting venue for our conference and this will be a great opportunity for our members to meet other doctors from the UK, to network and to our share expertise, clinical excellence and training,’ says Dr Vincenzo Costigliola, EMA President, Institute of Health Salzburg. ‘This will also be chance to introduce the Acute & General Medicine event to our members. We will be bringing six speakers, each one a specialist in their field. Each will bring something new to share with delegates. ‘They will be discussing the latest advances in their specialties, new drugs, the current ethical medical dilemmas, what the future is likely to bring and how we can improve care of the patient. It’s important for doctors to share these

Dr Vincenzo Costigliola, EMA President, European Medical Association (Brussels), Institute of Health Salzburg

ATTEND THE FIRST EVER EMA CONFERENCE AT ACUTE & GENERAL MEDICINE 2017. REN CONFE

S CE PAS

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 10

www.agmconference.co.uk

MEDICAL DEVICE HELPS PATIENTS GET TO SURGERY FASTER NHS patients at Teesside are getting to surgery faster thanks to an innovative medical device used for oedema reduction.

very year up to 200 patients undergo ankle fracture surgery at the Middlesbrough hospital. For many this can mean spending up to a week in hospital waiting for swelling to reduce before a surgeon can operate. A new neuromuscular electrostimulation device, called the geko™, is now in routine use at the Middlesbrough Hospital to help reduce pre-operative oedema, and to accelerate the time to theatre1. The size of a wrist-watch, the selfadhesive geko™ device is fitted to a patients leg above their backslab plaster cast, causing the muscles to rhythmically contract

References 1. Data on file, Firstkind, June 2017

and relax, resulting in increased blood flow and the accelerated reduction of oedema. More commonly used for the prevention of DVT (deep vein thrombosis), the geko™ was evaluated in an initial study that recruited ankle fracture patients requiring surgical fixation. The study showed the geko™ was well tolerated by patients and saved pre-operative bed days. Orthopaedic surgeon, Paul Baker says: “This could be a game changer for the treatment of swelling for ankle fractures. As far as we are aware the geko™ device has never been used for ankle fractures before. It’s much better for patients, as sitting in a

hospital bed for a week can be very frustrating and can also cause people to lose muscle mass” The geko™ device is available through Firstkind Ltd, a wholly owned subsidiary of Sky Technology Ltd, a UK based medical devices that has developed a groundbreaking neuromuscular electrostimulation technology platform, OnPulse™. Firstkind will be attending the Acute & General Medicine Exhibition. Please visit their stand A60, located outside theatre 3. To find out more about the device and how it is helping patients in the NHS please visit: www.gekodevices.com.

20117 AGM Newspaper issue 18 Sep.qxp_Layout 1 25/09/2017 15:37 Page 11

www.agmconference.co.uk

A REFRESHER ON SYNCOPE IN THE ED Syncope is a common complaint in the emergency department, accounting for about 1 in 20 of all visits. those blood tests as a reference standard, but blood tests only mean something if they are done in the right clinical context. So for example if you stand outside the station and measure a heart enzyme in everyone that comes out, some of them would be elevated because that's just the way they are, but it would not actually have any meaning. It is not nice to be over investigated - that just produces anxiety in people.’ This talk is aimed at both junior and senior doctors working in acute care.

17 R

EA SP

‘This is not a well taught subject and it doesn't make it much into medical literature, so this talk will bring people up to speed. Delegates will learn how to risk assess syncope and which tests to do to pick up the people who are at risk. This is a clinical topic which is easy to get right and is important to get right because we admit a lot of these patients,’ he says. Professor Harris says many doctors tend to do the same tests on everybody regardless of risk. ‘Junior doctors tend to put a lot of faith in blood tests and they often use

hile the vast majority of people will have had a simple faint, a few will have worrying heart trouble. So doctors need the skills to be able to pick out those that have a heart problem while not exposing otherwise healthy people to a barrage of unnecessary tests. Professor Tim Harris, Professor of Emergency Medicine, QMUL, Barts Health Trust, will be giving Acute & General Medicine delegates a refresher in these skills in a talk on the evaluation and management of syncope.

EMERGENCY MEDICINE STREAM AT ACUTE & GENERAL MEDICINE View additional emergency medicine sessions at Acute & General Medicine, via www.agmconference.co.uk/emergencymed

Professor Tim Harris, Professor of Emergency Medicine, QMUL, Barts Health Trust

DON’T MISS PROFESSOR TIM HARRIS’S PRESENTATION AT ACUTE & GENERAL MEDICINE 2017! REN CONFE

S CE PAS

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

ACUTE HEART FAILURE - ONE OF THE MOST COMMON HEART PROBLEMS TO PRESENT TO A&E Acute heart failure is a very common and potentially fatal condition and is one of the most likely heart problems to result in admission to hospital on a non-elective basis.

he prevalence of heart failure is roughly one per cent of the entire population but all these patients will have at least one admission to hospital during their lives. Generalists working in acute care need to be confident in dealing with heart failure because these patients require very rapid assessment and decisive management within the first hour of presenting in an emergency, says Dr Krishnan Unni, Honorary Consultant Cardiologist, Cambridge University Hospitals

NHS Trust. The majority of the first contact care is most likely not going to be provided by specialist cardiologists but junior doctors in the middle of the night manning A&E or an acute medical admissions unit. Dr Unni will be giving Acute & General Medicine Show delegates a blueprint for how to treat this condition and a systematic way of working through the list of possible causes and pathophysiology that underlie the presentation.

‘There are very many things within the heart which might cause heart failure so the acute physician requires a strategy to rapidly explore and identify the most likely reason for that person coming at that time to hospital,’ he says. The learning outcomes of this talk will be to understand the mechanism of heart failure, how to derive a shortlist of the probable causes in every case, to gain confidence in the immediate management of these patients and to know when to call for specialist input

including escalation of care to intensive care and when to contact the tertiary centre for further advice. The delegates who will benefit from this talk are the junior doctor who sees the patient at 3am, the registrar who will be asked for an opinion in the middle of the night and the consultant who comes the next morning to do a ward round. Dr Unni will also be giving a talk on acute coronary syndrome.

DON’T MISS DR UNNI’S PRESENTATION AT ACUTE & GENERAL MEDICINE 2017! R CONFE

A ENCE P

Secure your discounted conference pass for just £289+VAT using discount code NEWSP2 before rates increase to £349+VAT after 29th September via www.agmconference.co.uk/newsp2 or call 0207 348 1851.

20117 AGM Newspape ssue 18 Sep qxp_Layou 1 25 09 2017 15 37 Page 12

www.agmconference.co.uk

SYMPPOSIA A SPONSORED D BY BA AYER YER

Acute and General M Medicine Conference, r ExCel, London

Control bey yond the clinic: l i : Treating pattientss with w h non-valvula ar AF an n DVT nd DVT in an acute setting ng 21st November 2017 Thea atre 2 12:00-12:40 4 40 Dr Raj Patel, Consultant H Haematologist, King’’s College Hospital Dr Craig Prescott, Consulttant Acute Physician, Poole Hospital

Anticoagula A ti lating ti th the PE patient: where, w when and h how? 22nd November 2017 The eatre 4 14:15-14:50 Dr Luke Howard, Consulta ant Respiratory Physician, Hammersm mith Hospital Xarelto® Ϯ͘ϱ͕͕ ϭϬ͕͕ ϭϱ ĂŶĚ ϮϬ Ϯ ŵŐŐ ĮůŵͲĐŽĂƚĞĚ ƚĂďůĞƚƐ ;ƌŝǀĂƌŽǆ ; ŽǆĂďĂŶͿͿ WƌĞƐƐĐƌŝďŝŶŐŐ ǁŝƚŚ ĐŽĂŐƵůŽƉĂƚŚǇ Θ ĐůŝŶŝĐĂůůǇ ƌĞĞůĞǀĂŶƚ ďůĞĞĚŝŶŐ ƌŝƐŬ ŝŶĐůƵĚŝŶŐ ĐŝƌƌŚŽƟĐ ďůĞĞĚŝŶŐ ƌŝƐŬ͘ ŽŶĐŽŵŝƚĂŶƚ ƵƐĞ ŽĨ ƐƚƌŽŶ ŶŐ zWϯ ϰ ŝŶĚƵĐĞƌƐ ƐŚŽƵůĚ ďĞ /ŶĨŽƌŵĂƟŽŶ ƉĂƟĞŶƚƐ ǁŝƚŚ ŚŝůĚ WƵŐŚ Θ WĂĞĚŝĂƚƌŝ W ƌŝĐƐ͗ EŽƚ ƌĞĐŽŵŵĞŶĚĞĚ͘ ŽŶƚƌĂͲ ĂǀŽŝĚĞĚ ƵŶůĞƐƐ ƉĂƟĞŶƚ ŝƐ ĐůŽƐĞůǇ ŽďƐĞƌǀǀĞĚ ĨŽƌ ƐŝŐŶƐ ĂŶĚ ƐǇŵƉƚŽŵƐ ŽĨ ŝŶĚŝĐĂƟŽŶƐ͗ ,ǇƉĞƌƐĞŶƐŝƟǀŝƚǇ ƚŽ ĂĐƟǀĞ ƐƵďƐƚĂŶĐĞ Žƌ ĂŶǇ ĞǆĐŝƉŝĞŶƚ͖ ĂĐƟǀĞ ƚŚƌŽŵďŽƐŝƐ͘ WƌĞŐŶĂŶĐǇ Θ ďƌĞĂƐƚ ĨĞ ĨĞĞĚŝŶ ŶŐ͗ ŽŶƚƌĂͲŝŶĚŝĐĂƚĞĚ͘ īĞ īĞĐƚƐ ŽŶ Ŷ ;ZĞĨĞƌ ƚŽ ĨƵůů ^ƵŵŵĂƌǇ ŽĨ WƌƌŽĚƵĐƚ ŚĂƌĂĐƚĞƌŝƐƟĐƐ ;^ŵW Ϳ ďĞĨŽƌĞ ƉƌĞƐĐƌŝďďŝŶŐͿ ĐůŝŶŝĐĂůůǇ ƐŝŐŶŝĮĐĂŶƚ ďůĞĞĚŝŶŐ͖ ůĞƐŝŝŽŶ Žƌ ĐŽŶĚŝƟŽŶ ĐŽŶƐŝĚĞƌĞĚ ƚŽ ĐŽŶĨĞƌ Ă ĂďŝůŝƚǇ ƚǇ ƚŽ ĚƌŝǀĞ ĂŶĚ ƵƐĞ ŵĂĐŚŝŶĞƐ͗ ƐǇŶ ŶĐŽƉĞ ;ƵŶĐŽŵŵŽŶͿ Θ ĚŝǌǌŝŶĞƐƐ WƌĞƐĞŶƚĂƟŽŶ͗ Ϯ͘ϱŵŐͬϭϬŵ ŵŐͬϭϱŵŐͬϮϬŵŐ ƌŝǀĂƌŽǆĂďĂŶ ƚĂďůĞƚ͘ /ŶĚŝĐĂƟ ƟŽŶ;ƐͿ͗ ƐŝŐŶŝĮĐĂŶƚ ƌŝƐŬ ĨŽƌ ŵĂũŽƌ ďůĞĞĚŝŶŐ ;ƌĞĨĞ ĨĞƌ ƚŽ ^ŵW Ϳ͖ ĐŽŶĐŽŵŝƚĂŶƚ ƚƌĞĂƚŵĞŶƚ ;ĐŽŵŵŽŶͿ ǁĞƌĞ ƌĞƉŽƌƚĞĚ͘ WĂƟĞŶƚƐ ĞǆƉĞƌƌŝĞŶĐŝŶŐ ƚŚĞƐĞ ĞīĞ īĞĐƚƐ ƐŚŽƵůĚ ŶŽƚ 2.5mg g yĂƌĞůƚŽ͕ ĐŽͲĂĚŵŝŶŝƐƚĞƌĞĚ ǁŝƚŚ ĂĐĞƚǇůƐĂůŝĐǇůŝĐ ĂĐŝĚ ; ^ Ϳ ĂůŽ ŽŶĞ Žƌ ǁŝƚŚ ĂŶǇ ŽƚŚĞƌ ĂŶƟĐŽĂŐƵůĂŶƚƐ ĞǆĐĞƉƚ Ğ īĞĐƚƚƐ͗ Common: ĂŶĂĞŵŝĂ͕ ĚŝǌǌŝŶĞƐƐ͕ ƵŶĚĞƌ ƐƉĞĐŝĮĐ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŽĨ ĚƌŝǀĞ Žƌ ƵƐĞ ŵĂĐŚŝŶĞƐ͘ hŶĚĞƐŝƌĂďůĞ ĞīĞ ǁŝƚŚ ^ ƉůƵƐ ĐůŽƉŝĚŽŐƌĞĞů Žƌ ƟĐůŽƉŝĚŝŶĞ͕ ƟĐůŽƉŝĚŝŶĞ ŝƐ ŝŶĚŝĐĂƚĞĚ ĨŽƌ ƚŚĞ ƉƌĞǀǀĞŶƟŽŶ ƐǁŝƚĐŚŝŶŐ ĂŶƟĐŽĂŐƵůĂŶƚ ƚŚĞƌĂƉǇǇ Žƌ ǁŚĞŶ ƵŶĨƌĂĐƟŽŶĂƚĞĚ ŚĞƉĂƌŝŶ ŝƐ ŚĞĂĚĂĐŚĞ͕ ŚĞĂĚĂĐŚĞ ĞǇĞ ŚĂĞŵŽƌƌŚĂŐĞ͕ ŚĂĞŵŽƌƌŚĂŐĞ ŚǇƉŽƚĞĞŶƐŝŽŶ͕ ĞŶƐŝŽŶ ŚĂĞŵĂƚŽŵĂ͕ ŚĂĞŵĂƚŽŵĂ ĞƉŝƐƚĂǆŝƐ͕ ĞƉŝƐƚĂǆŝƐ ŽĨ ĂƚŚĞƌŽƚŚƌŽŵďŽƟĐ ĞǀĞĞŶƚƐ ŝŶ ĂĚƵůƚ ƉĂƟĞŶƚƐ ĂŌĞƌ ĂŶ ĂĐƵƚĞ ĐŽ ŽƌŽŶĂƌǇ ŐŝǀĞŶ Ăƚ ĚŽƐĞƐ ŶĞĐĞƐƐĂƌǇ ƚŽ ŵĂŝŶ ŶƚĂŝŶ ĂŶ ŽƉĞŶ ĐĞŶƚƌĂů ǀĞŶŽƵƐ Žƌ ĂƌƚĞƌŝĂů ŚĂĞŵŽƉƚǇƐŝƐ͕ ŐŝŶŐŝǀĂů ďůĞĞĚŝŶŐ͕ '/ ƚƌĂĐƚ ŚĂĞŵŽƌƌŚĂŐĞ͕ '/ Θ ĂďĚŽŵŝŶĂů ƐǇŶĚƌŽŵĞ ; ^Ϳ ǁŝƚŚ ĞůĞĞǀĂƚĞĚ ĐĂƌĚŝĂĐ ďŝŽŵĂƌŬĞƌƐ͘ 10mg g WƌĞǀĞŶƟ ƟŽŶ ŽĨ ĐĂƚŚĞƚĞƌ͖ ŚĞƉĂƟĐ ĚŝƐĞĂƐĞ ĂƐƐŽĐĐŝĂƚĞĚ ǁŝƚŚ ĐŽĂŐƵůŽƉĂƚŚǇ Θ ĐůŝŶŝĐĂůůǇ ƉĂŝŶƐ͕ ĚǇƐƉĞƉƐŝĂ͕ ŶĂƵƐĞĂ͕ ĐŽŶƐƟƉĂƟŽŶ͕ ĚŝĂĂƌƌŚŽĞĂ͕ ǀŽŵŝƟŶŐ͕ ƉƌƵƌŝƚƵƐ͕ ƌĂƐŚ͕ ǀĞŶŽƵƐ ƚŚƌŽŵďŽĞŵďŽůŝƐŵ ŵ ;sd Ϳ ŝŶ ĂĚƵůƚ ƉĂƟĞŶƚƐ ƵŶĚĞƌŐŽŝŶŐ ĞůĞĐƟ ƟǀĞ ŚŝƉ ƌĞůĞǀĂŶƚ ďůĞĞĚŝŶŐ ƌŝƐŬ ŝŶĐůƵĚŝŶŐ ĐŝƌƌŚŽƟĐ ƉĂƟĞŶƚƐ ǁŝƚŚ ŚŝůĚ WƵŐŚ Θ ecchymosis, ĐƵƚĂŶĞŽƵƐ Θ ƐƵďĐƵƚĂŶĞŽƵƐ ŚĂĞŵŽƌƌŚĂŐĞ͕ ƉĂŝŶ ŝŶ ĞǆƚƌĞŵŝƚǇ͕ Ś Ǉ͕ Žƌ ŬŶĞĞ ƌĞƉůĂĐĞŵĞŶƚ ƐƵƌŐĞĞƌǇ͘ 15mg/20mg g/ g WƌĞǀĞŶƟŽŶ ŽĨ ƐƚƌŽŬĞ Θ ƐǇǇƐƚĞŵŝĐ ͖ ƉƌĞŐŶĂŶĐǇ Θ ďƌĞĂƐƚ ĨĞ ĨĞĞĚŝŶŐ͘ 2.5mg 2 g Ͳ ĐŽŶĐŽŵŝƚĂŶƚ ƚƌĞĂƚŵĞŶƚ ŽĨ ^ ƵƌŽŐĞŶŝƚĂů ƚƌĂĐƚ ŚĂĞŵŽƌƌŚĂŐĞ ;ŵĞŶŽƌƌŚĂŐŝĂ very common ŝŶ ǁŽŵĞŶ фϱϱ ĞŵďŽůŝƐŵ ŝŶ ĂĚƵůƚ ƉĂƟĞĞŶƚƐ ǁŝƚŚ ŶŽŶͲǀĂůǀƵůĂƌ ĂƚƌŝĂů ĮďƌŝůůĂƟŽŶ Ŷ ǁŝƚŚ ǁŝƚŚ ĂŶƟƉůĂƚĞůĞƚ ƚŚĞƌĂƉǇ ŝŶ ƉĂƟ ƟĞŶƚƐ ǁŝƚŚ Ă ƉƌŝŽƌ ƐƚƌŽŬĞ Žƌ ƚƌĂŶƐŝĞŶƚ ǇƌƐ ƚƌĞĂƚĞĚ ĨŽ ĨŽƌ sd͕ d͕ W Θ ƉƌĞǀĞŶƟŽŶ ŽĨ ƌĞĐƵƌƌĞŶĐĞͿ͕ ƌĞŶĂů ŝŵƉĂŝƌŵĞŶƚ͕ ŽŶĞ Žƌ ŵŽƌĞ ƌŝƐŬ ĨĂ ĨĂĐƚŽƌƐ ƐƵĐŚ ĂƐ ĐŽŶŐĞƐƟǀĞ ŚĞĂƌƚ ĨĂ ĨĂŝůƵƌĞ͕ ŚǇƉĞƌƚĞĞŶƐŝŽŶ͕ ŝƐĐŚĂĞŵŝĐ ĂƩĂĐŬ͘ tĂƌŶŝŶŐƐ Θ ƉƌĞĐĂƵƟŽŶƐ͗ Ɖ ůŝŶŝĐĂů ƐƵƌǀĞŝůůĂŶĐĞ ŝŶ ůŝŶĞ ĨĞǀĞƌ͕ƌ͕ ƉĞƌŝƉŚĞƌĂů ŽĞĚĞŵĂ͕ ĚĞĐƌĞĂƐĞĚ ŐĞŶ ŶĞƌĂů ƐƚƌĞŶŐƚŚ Θ ĞŶĞƌŐǇ͕ Ǉ͕ ŝŶĐƌĞĂƐĞ ĂŐĞ ш ϳϱ͕ ĚŝĂďĞƚĞƐ ŵĞůůŝƚƵƐ͕ ƉƌŝŽƌ ƐƚƌŽŬĞ Žƌ ƚƌĂŶƐŝĞŶƚ ŝƐĐŚĂĞŵŝĐ ĂƩĂĐŬ ǁŝƚŚ ĂŶƟĐŽĂŐƵůĂŶƚ ƉƌĂĐƟĐĞ ŝƐ ƌĞĐĐŽŵŵĞŶĚĞĚ ƚŚƌŽƵŐŚŽƵƚ ƚŚĞ ƚƌĞĂƚŵĞŶƚ ŝŶ ƚƌĂŶƐĂŵŝŶĂƐĞƐ͕ ƉŽƐƚͲƉƌŽĐĞĚƵƌĂů ŚĂĞĞŵŽƌƌŚĂŐĞ͕ ĐŽŶƚƵƐŝŽŶ͕ ǁŽƵŶĚ ;^W &Ϳ͘ dƌĞĂƚŵĞŶƚ ŽĨ ĚĞĞƉ Ě ǀĞŝŶ ƚŚƌŽŵďŽƐŝƐ ; sdͿ Θ ƉƵůŵ ŵŽŶĂƌǇ ƉĞƌŝŽĚ͘ ŝƐĐŽŶƟŶƵĞ ŝĨ ƐĞǀĞƌĞ ŚĂĞŵŽƌƌŚĂŐĞ ŽĐĐƵƌƐ͘ /ŶĐƌĞĂƐŝŶŐ ĂŐĞ ŵĂǇ ƐĞĐƌĞƟŽŶ͘ ^Ğƌŝ ƌŝŽƵƐ͗ ĐĨ ĐĨ͘ / /ͬtĂƌŶ ƌŶŝŶ ŝŶŐƐ ĂŶĚ WƌĞ ƌĞĐĂƵƟŽŶƐ ʹ ŝŶ ĂĚĚŝƟŽŶ͗ ĞŵďŽůŝƐŵ ;W Ϳ͕ Θ ƉƌĞǀĞŶƟŽŶ ŽĨ ƌĞĐƵƌƌĞŶƚ sd Θ W ŝŶ ĂĚƵůƚƐ ;ƐĞĞĞ tΘW ŝŶĐƌĞĂƐĞ ŚĂĞŵŽƌƌŚĂŐŝĐ ƌŝƐŬ͘ yĂƌĞĞůƚŽ ƐŚŽƵůĚ ďĞ ĚŝƐĐŽŶƟŶƵĞĚ Ăƚ ƚŚĞ ĮƌƐƚ ƚŚƌŽŵďŽĐǇƚŚĞŵŝĂ͕ ƚŚƌŽŵďŽĐǇƚŽƉĞŶŝĂ͕ ^ƚƚĞǀĞŶƐͲ:ŽŚŶƐŽŶ ƐǇŶĚƌŽŵĞͬd ͬdŽǆŝĐ ĨŽƌ ŚĂĞŵŽĚǇŶĂŵŝĐĂůůǇ ƵŶƐƚĂďůĞ W ƉĂƟĞŶƚƐͿ͘ WŽƐŽůŽŐǇ Θ ŵĞƚŚ ŚŽĚ ŽĨ ĂƉƉĞĂƌĂŶĐĞ ŽĨ Ă ƐĞǀĞƌĞ ƐŬŝŶ ƌĂƐŚ͕ Žƌ ĂŶǇ ŽƚŚĞƌ ƐŝŐŶ ŽĨ ŚǇƉĞƌƐĞŶƐŝƟǀŝƚǇ ŝŶ ƉŝĚĞƌŵĂů EĞĐƌŽůǇƐŝƐ͕ ĂŶŐŝŽĞĚĞŵĂ ĂŶĚ ĂůůĞƌŐŝĐ ŽĞĚĞŵĂ͕ ŽĐĐƵůƚ ďůĞĞĚŝŶŐͬ ĂĚŵŝŶŝƐƚƌĂƟŽŶ͗ 2.5mg g – Oral Or b.i.d. ĚŽƐĞ͖ ƉĂƟĞŶƚƐ ƐŚŽƵůĚ ĂůƐŽ ƚĂŬĞ Ă ĚĂŝůǇ ĐŽŶũƵŶĐƟŽŶ ǁŝƚŚ ŵƵĐŽƐĂů ůĞƐŝŽŶƐ͘ Not recommended: ŝŶ ƉĂƟĞŶƚƐ ǁŝƚŚ ĂŶ ŚĂĞŵŽƌƌŚĂŐĞ ĨƌŽŵ ĂŶǇ ƟƐƐƵĞ ;Ğ͘Ő͘ ĐĞƌĞďƌƌĂů Θ ŝŶƚƌĂĐƌĂŶŝĂů͕ ŚĂĞŵĂƌƚŚƌŽƐŝƐ͕ ĚŽƐĞ ŽĨ ϳϱ ʹ ϭϬϬ ŵŐ ^ Žƌ Ă ĚĂŝůǇ ĚŽƐĞ ŽĨ ϳϱ ʹ ϭϬϬ ŵŐ ^ ŝŶ ĂĚ ĚĚŝƟŽŶ ŝŶĐƌĞĂƐĞĚ ďůĞĞĚŝŶŐ ƌŝƐŬ ;ƌĞĨĞ ŝŶ ƉĂƟĞŶƚƐ ƌĞĐĞŝǀŝŶŐ ĐŽŶĐŽŵŝƚĂŶƚ ŵƵƐĐůĞͿ ǁŚŝĐŚ ŵĂǇ ůĞĂĚ ƚŽ ĐŽŵƉůŝĐĂƟŽŶƐ ;ŝŶĐů͘ ĐŽŵƉĂƌƚŵĞŶƚ ƐǇŶĚƌŽŵĞ͕ ĨĞƌ ƚŽ ^ŵW Ϳ͖ ^ ƚŽ ĞŝƚŚĞƌ Ă ĚĂŝůǇ ĚŽƐĞ ŽĨ ϳϱ ŵŐ ĐůŽƉŝĚŽŐƌĞů Žƌ Ă ƐƚĂŶĚĂƌĚ ĚĂŝůǇ ĚŽƐĞ Ě ŽĨ ƐǇƐƚĞŵŝĐ ƚƌĞĂƚŵĞŶƚ ǁŝƚŚ ƐƚƌŽŶŐ ĐŽŶĐƵƌƌĞŶƚ Đ ĨĂƚĂů ŽƵƚĐŽŵĞͿ͕ ƐǇŶĐŽƉĞ͕ ƚĂĐŚǇĐĂƌĚŝĂ͕ ĂďŶŽƌŵĂů ŚĞƉĂƟĐ zWϯ ϰͲ ĂŶĚ WͲŐƉͲŝŶŚŝďŝƚŽƌƐ͕ ƌĞŶĂů ĨĂŝůƵƌĞ͕ ĨĂ ƟĐůŽƉŝĚŝŶĞ͘ ^ƚĂƌƚ yĂƌĞůƚŽ ĂƐ Ă ƐŽŽŶ ĂƐ ƉŽƐƐŝďůĞ ĂŌĞƌ ƐƚĂďŝůŝƐĂƟŽŶ͕ ŝŶĐĐůƵĚŝŶŐ ŝ͘Ğ͘ ĂǌŽůĞͲĂŶƟŵǇĐŽƟĐƐ Žƌ ,/s ƉƌƌŽƚĞĂƐĞ ŝŶŚŝďŝƚŽƌƐ͖ 2.5mg g ƚƌĞĂƚŵĞŶƚ ŝŶ ĨƵŶĐƟŽŶ͕ ĐŚŽůĞƐƚĂƐŝƐ ĂŶĚ ŚĞƉĂƟƟƐ ;ŝŶĐů͘ ŚĞƉĂƚŽĐĞůůƵůĂƌ ŝŶũƵƌǇͿ͕ ƌĞǀĂƐĐƵůĂƌŝƐĂƟŽŶ ĨŽ ĨŽƌ ^͖ Ăƚ ƚŚĞ ĞĂƌůŝĞƐƚ Ϯϰ ŚŽƵƌƐ ĂŌĞƌ ĂĚŵŝƐƐŝŽŶ Θ Ăƚ ĐŽŵďŝŶĂƟŽŶ ǁŝƚŚ ĂŶƟƉůĂƚĞůĞƚ ĂŐĞŶƚƐ ŽƚŚĞƌ ƚŚĂŶ ^ Θ ĐůŽƉŝĚŽŐƌĞůͬ ŚǇƉĞƌďŝůŝƌƵďŝŶĂĞŵŝĂ͕ ũĂƵŶĚŝĐĞ͕ ǀĂƐĐƵůĂĂƌ ƉƐĞƵĚŽĂŶĞƵƌǇƐŵ ĨŽůůŽǁŝŶŐ Ă ĚŝƐĐŽŶƟŶƵĂƟŽŶ ŽĨ ƉĂƌĞŶƚƚĞƌĂů ĂŶƟĐŽĂŐƵůĂƟŽŶ͘ ĂŶƟĐŽĂŐƵůĂƟŽŶ /Ĩ ĚŽƐĞ ŝƐ ŵŝƐƐĞĚ ƚĂŬŬĞ ŶĞǆƚ ƟĐůŽƉŝĚŝŶĞ͖ 15mg/20mg g/ g ŝŶ ƉĂƟĞĞŶƚƐ ǁŝƚŚ ƉƌŽƐƚŚĞƟĐ ŚĞĂƌƚ ǀĂůǀĞƐ͖ ǁŝƚŚ ƉĞƌĐƵƚĂŶĞŽƵƐ ǀĂƐĐƵůĂƌ ŝŶƚĞƌǀĞŶƟŽŶ͘ ŝŶƚĞƌǀĞŶƟŽŶ WƌĞƐƐĐ ƐĐƌŝďĞƌƐ ďĞ Ɛ ƐŚŽƵ ƐŚŽƵůĚ Ě ĐŽŶƐƵ ĐŽŶƐƵůƚ ^ŵW ŝŶ Ŷ ĚŽƐĞ͕ ĚŽ ŶŽƚ ĚŽƵďůĞ ƚŚĞ ĚŽƐĞ͘ 10mg g – Oral o.d. ĚŽƐĞ͖ ŝŶŝƟĂů ĚŽƐĞĞ ƚĂŬĞŶ W ǁŚŽ ĂƌĞ ŚĂĞŵŽĚǇŶĂŵŝĐĂůůǇ ƵŶƐƚĂďůĞ Žƌ ŵĂǇ ƌĞĐĞŝǀĞ ƚŚƌŽŵďŽůǇƐŝƐ Žƌ ƌĞůĂƟŽŶ ƚŽ ĨƵůů ƐŝĚĞ ĞīĞĐƚ ŝŶĨŽ ĨŽƌŵĂƟŽŶ͘ KǀĞ K ĚŽƐĞ EŽ ƐƉĞĐ ĮĐ ĂŶƟĚŽ Ğ Ɛ ϲ ƚŽ ϭϬ ŚŽƵƌƐ ĂŌĞƌ ƐƵƌŐĞƌǇǇ ƉƌŽǀŝĚĞĚ ŚĂĞŵŽƐƚĂƐŝƐ ĞƐƚĂďůŝƐŚĞĚ͘ 15mg/20mg g//20mg / g ƉƵůŵŽŶĂƌǇ ĞŵďŽůĞĐƚŽŵǇ͘ Ǉ͘ hƐĞ ǁŝŝƚŚ ĐĂƵƟŽŶ͗ ŝŶ ƉĂƟĞŶƚƐ ǁŝƚŚ ƐĞǀĞƌĞ ƌĞŶĂů ĂǀĂŝůĂďůĞ͘ >ĞŐĂů ĂƚĞŐŽƌǇ ƌǇ͗ POM. WĂĐŬĂŐĞ YƵĂŶƟƟĞƐ ĂŶĚ ĂƐ Đ E,^ ŽƐƐ Ɛ ʹ dĂ dĂŬĞ ǁŝƚŚ ĨŽ ĨŽŽĚ SP PAF: ϮϬ Ϯ ŵŐ ŽƌĂůůǇ o.d. DVT & PE: ϭϱ ŵŐ b.i.d. d. for 3 ŝŵƉĂŝƌŵĞŶƚ Žƌ ǁŝƚŚ ƌĞŶĂů ŝŵƉĂĂŝƌŵĞŶƚ ĐŽŶĐŽŵŝƚĂŶƚůǇ ƌĞĐĞŝǀŝŶŐ ŽƚŚĞƌ 2.5mg g Ͳ ϱϲ ƚĂďůĞƚƐ͗ άϱϬ͘ϰϬ͘ 10mg g Ͳ ϭϬ ƚĂď ď Ğ Ɛ άϭϴ ϬϬ ϯϬ Ăď Ğ Ɛ άϱϰ ϬϬ ǁĞĞŬƐ ĨŽ ĨŽůůŽǁĞĚ ďǇ ϮϬ ŵŐŐ o.d. ĨŽƌ ĐŽŶƟŶƵĞĚ ƚƌĞĂƚŵĞŶƚ Θ ƉƌĞǀĞŶƟŽŶ ŽĨ ŵĞĚŝĐŝŶĂů ƉƌŽĚƵĐƚƐ ǁŚŝĐŚ ŝŶĐƌĞĂĂƐĞ ƌŝǀĂƌŽǆĂďĂŶ ƉůĂƐŵĂ ĐŽŶĐĞŶƚƌĂƟŽŶƐ͖ ĂŶĚ ϭϬϬ ƚĂďůĞƚƐ͗ άϭϴϬ͘ϬϬ͘ 15mg g ʹ ϭϰ ƚĂď ď Ğ Ɛ άϮϱ ϮϬ Ϯϴ Ăď Ğ Ɛ άϱϬ ϰϬ ƌĞĐƵƌƌĞŶƚ sd Θ W ͘ All strengths g Ͳ ZĞĨĞƌ ƚŽ ^ŵW ĨŽ ĨŽƌ ĨƵůů ŝŶĨŽƌŵĂƟ ƟŽŶ ŽŶ ƚƌĞĂƚĞĚ ĐŽŶĐŽŵŝƚĂŶƚůǇ ǁŝƚŚ ŵĞĞĚŝĐŝŶĞƐ ĂīĞ īĞĐƟŶŐ ŚĂĞŵŽƐƚĂƐŝƐ͖ ǁŚĞŶ ϰϮ ƚĂďůĞƚƐ͗ άϳϱ͘ϲϬ͕ ϭϬϬ ƚĂďůĞƚƐ͗ άϭϴϬ͘ϬϬ͖ 20mg g ʹ Ϯϴ Ăď Ğ Ɛ άϱϬ ϰϬ ϭϬϬ ĚƵƌĂƟŽŶ ŽĨ ƚŚĞƌĂƉǇ Θ ĐŽ ŽŶǀĞƌƟŶŐ ƚŽͬĨƌŽŵ sŝƚĂŵŝŶ < ĂŶƚĂŐŽŶŝƐƚƐƐ ;s< Ϳ ŶĞƵƌĂǆŝĂů ĂŶĂĞƐƚŚĞƐŝĂ Žƌ ƐƉŝŶĂůͬĞƉ ƉŝĚƵƌĂů ƉƵŶĐƚƵƌĞ ŝƐ ĞŵƉůŽǇĞĚ͖ ŝŶ ƉĂƟĞŶƚƐ ƚĂďůĞƚƐ άϭϴϬ͘ϬϬ D EƵŵďĞƌ;ƐͿ͗ 2.5mg g Ͳ hͬϭͬϬϴͬϰϳϮͬϬϮϱ Ϭϯϱ 10mg g Žƌ ƉĂƌĞŶƚĞƌĂů ĂŶƟĐŽĂŐƵůĂĂŶƚƐ͘ ^ƉĞĐŝĂů ƉŽƉ ŽƉƵůĂ ůĂƟŽŶƐ͗ WĂƟĞŶƚƐ ƵŶĚĞĞƌŐŽŝŶŐ Ăƚ ƌŝƐŬ ŽĨ ƵůĐĞƌĂƟǀĞ ŐĂƐƚƌŽŝŶƚĞƐƟŶ ŶĂů ĚŝƐĞĂƐĞ ;ƉƌŽƉŚǇůĂĐƟĐ ƚƌĞĂƚŵĞŶƚ ŵĂǇ hͬϭͬϬϴͬϰϳϮͬϬϬϭͲϭϬ͕ ͬ g/20mg Ͳ hͬϭͬϬϴͬϰϳϮͬϬϭϭ Ϯϭ ϬϮϯ ϬϮϰ ϬϮϮ 15mg/20mg ĐĂƌĚŝŽǀĞƌƐŝŽŶ͗ yĂƌĞůƚŽ ĐĂŶ Ŷ ďĞ ŝŶŝƟĂƚĞĚ Žƌ ĐŽŶƟŶƵĞĚ ŝŶ ƉĂƟĞŶƚƐ ǁŚ ŚŽ ŵĂǇ ďĞ ĐŽŶƐŝĚĞƌĞĚͿ͖ 2.5mg g ŝŶ ^ ƉĂƟ ƟĞŶƚƐ х ϳϱ ǇĞĂƌƐ ŽĨ ĂŐĞ Žƌ ǁŝƚŚ ůŽǁ ďŽĚǇ ϬϯϲͲϬϯϳ͕ ϬϰϬ &ƵƌƚŚĞƌ ŝŶĨŽ ĨŽƌŵĂƟŽŶ ĂǀĂŝůĂĂď Ğ Žŵ ĂǇĞ Ɖ Đ ϰϬϬ ^ŽƵ Ś ƌĞƋƵŝƌĞ ĐĂƌĚŝŽǀĞƌƐŝŽŶ͘ ZĞĞŶĂů ŝŵƉĂŝƌŵ ƌŵĞŶƚ͗ ŵŝůĚ ;ĐƌĞĂƟŶŝŶĞ ĐůĞĂƌĂŶ ŶĐĞ ϱϬͲ ǁĞŝŐŚƚ ;фϲϬŬŐͿ͘ WĂƟĞŶƚƐ ŽŶ ƚƌĞĂƚŵ ŵĞŶƚ ǁŝƚŚ yĂƌĞůƚŽ Θ ^ Žƌ yĂƌĞůƚŽ Θ ^ KĂŬ tĂǇ͕ Ǉ͕ 'ƌĞĞŶ WĂƌŬ͕ ZĞĂĚŝŶŐ͕ Z'Ϯ ϲ ͕ h < dĞ dĞ ĞƉŚŽŶĞ Ϭϭϭϴ ϮϬϲ ϯϬϬϬ ϴϬ ŵůͬŵŝŶͿ Ͳ ŶŽ ĚŽƐĞ ĂĚũũƵƐƚŵĞŶƚ͖ 2.5mg g ͬ10mg ͬ g - ŵŽĚĞƌĂƚĞ ;ĐƌĞĂĂƟŶŝŶĞ ƉůƵƐ ĐůŽƉŝĚŽŐƌĞůͬƟĐůŽƉŝĚŝŶĞ ƐŚŽƵůĚ ŽŶůǇ ƌĞĐĞŝǀĞ ĐŽŶĐŽŵŝƚĂŶƚ ƚƌĞĂƚŵĞŶƚ ĂƚĞ ŽĨ ƉƌĞƉĂƌĂƟŽŶ͗ :ƵůǇ ϮϬϭϳ͘ ĐůĞĂƌĂŶĐĞ ϯϬͲϰϵ ŵůͬŵŝŶ ŶͿ ʹ ŶŽ ĚŽƐĞ ĂĚũƵƐƚŵĞŶƚ͘ ^ĞǀĞƌĞ ;ĐƌĞĂĂƟŶŝŶĞ ǁŝƚŚ E^ / Ɛ ŝĨ ƚŚĞ ďĞŶĞĮƚ ŽƵƚǁĞŝŐŐŚƐ ƚŚĞ ďůĞĞĚŝŶŐ ƌŝƐŬ͘ All strengthsg dŚĞƌĞ ĐůĞĂƌĂŶĐĞ ϭϱͲϮϵŵůͬŵŝŶͿ Ͳ ůŝŵŝƚĞĚ ĚĂƚĂ ŝŶĚŝĐĂƚĞ ƌŝǀĂƌŽǆĂďĂŶ ĐŽŶĐĞŶƚƌĂƟŽŶƐ ŝƐ ŶŽ ŶĞĞĚ ĨŽƌ ŵŽŶŝƚŽƌŝŶŐ ŽĨ ĐŽĂĂŐƵůĂƟŽŶ ƉĂƌĂŵĞƚĞƌƐ ĚƵƌŝŶŐ ƚƌĞĂƚŵĞŶƚ ĚǀĞƌƐĞ ĞǀĞŶƚƐ ƐŚŽƵůĚ Ě ďĞ ƌĞƉŽƌƚĞĚ ĂƌĞ ƐŝŐŶŝĮĐĂŶƚůǇ ŝŶĐƌĞĂƐĞĚ Ě͕ ƵƐĞ ǁŝƚŚ ĐĂƵƟŽŶ͘ 15mg/20mg g/ g Ͳ ŵŽĚĞĞƌĂƚĞ Θ ǁŝƚŚ ƌŝǀĂƌŽǆĂďĂŶ ŝŶ ĐůŝŶŝĐĂů ƌŽƵƟŶĞĞ͕ ŝĨ ĐůŝŶŝĐĂůůǇ ŝŶĚŝĐĂƚĞĚ ƌŝǀĂƌŽǆĂďĂŶ ůĞǀĞůƐ ZĞƉŽƌƟŶŐ ĨŽƌŵƐ ĂŶĚ ŝŶĨŽƌŵĂĂƟŽŶ ĐĂŶ ďĞ ŽƵŶĚ Ăƚ ƐĞǀĞƌĞ ƌĞŶĂů ŝŵƉĂŝƌŵĞŶƚ Ͳ ůŝŵŝƚĞĚ ĚĂƚĂ ŝŶĚŝĐĂƚĞ ƉůĂƐŵĂ ĐŽŶĐĞŶƚƌĂƟŽŶƐ ĐĂŶ ďĞ ŵĞĂƐƵƌĞĚ ďǇ ĐĂůŝďƌĂƚĞĚ ƋƵĂŶƟƚĂƟǀĞ ĂŶƟͲ&ĂĐƚŽƌ yĂ ƚĞƐƚƐ͘ Xarelto Ƌ ǁǁǁ͘ŵŚƌĂ͘ŐŽǀ͘ƵŬͬǇĞůůŽǁĐĂƌĚ͘ ĚǀĞƌƐĞ ĞǀĞŶƚƐ ƐŚŽƵ Ě ĂƌĞ ƐŝŐŶŝĮĐĂŶƚůǇ ŝŶĐƌĞĂƐĞĚ Ě͕ ƵƐĞ ǁŝƚŚ ĐĂƵƟŽŶ ʹ SP PAF AF͗ ƌĞĚƵĐĞ ĚŽƐĞ ƚŽ Ž ϭϱŵŐ ĐŽŶƚĂŝŶƐ ůĂĐƚŽƐĞ͘ /ŶƚĞƌĂĐƟŽŶƐ͗ Ž ŽŶĐŽŵŝƚĂŶƚ ƵƐĞ ǁŝƚŚ ƐƚƌŽŶŐ ŝŶŚŝďŝƚŽƌƐ ŽĨ ĂůƐŽ ďĞ ƌĞƉŽƌƚĞĚ Ɖ Ž ĂǇĞƌ Ǉ Ɖ Đ ƚŽ o d DVT & PE PE: ϭϱ ŵŐ b i d ĨŽƌ ϯ ǁĞĞŬƐ ƚŚĞƌĞĂŌĞƌ ŚĞ ĞĂŌĞ ϮϬŵŐ o d Ž ŽŶƐŝĚĞƌ ŽŶƐ ĚĞ ďŽ ďŽƚŚ Ś zWϯ ϰ Θ W WͲŐƉ ŐƉ ŶŽ ŶŽƚ ƌĞĐŽŵŵ ĞĐŽŵŵ ŵĞŶĚĞĚ ĂƐ ĐĐůŝŶŝĐĂůůǇ Ŷ ĐĂ Ǉ ƌĞůĞǀĂŶƚ Ğ ĞǀĂŶ ŝŶĐƌĞĂƐĞĚ ŶĐ ĞĂƐĞĚ dĞ Ϭϭϭϴ ϮϬϲ ϯϱϬϬ &Ăǆ Ϭϭϭϴ ϮϬϲ ϯϳϬϯ ĞĚƵĐƟŽŶ Žŵ ϮϬŵŐ Ž ϭϱŵŐ o d ƉĂƟĞŶ Ɛ ď ĞĞĚ ŶŐ ƐŬ ŽƵ ǁĞ ǁ ŐŚƐ ǀĂ ŽǆĂďĂŶ Ɖ ĂƐŵĂ ĐŽŶĐĞŶ ĂƟŽŶ ŶƐ Ă Ğ ŽďƐĞ ǀĞĚ ǀŽ Ě ĐŽ ĂĚŵ Ŷ Ɛ ĂƟŽŶ ƐŬ Ž ĞĐƵ ĞŶ sd Θ W A s eng g hs ĞĂƟŶ ŶĞ Đ ĞĂ ĂŶĐĞ фϭϱ ŵ ͬ ǁ Ś Ě ŽŶĞĚĂ ŽŶĞ hƐĞ ǁ Ś ĐĂƵƟ ŵĂ ƉǀƵŬΛďĂĂǇĞƌƌ ĐŽŵ ƟŽŶ Ŷ ƉĂƟĞŶ Ɛ ĐŽŶĐŽŵ ĂŶ Ǉ ĞĐĞ ǀ ŶŐ ŵ Ŷ ŶŽ ĞĐŽŵŵĞŶĚĞĚ Ě ,ĞƉ ĞƉĂƟĐ ŵƉĂ ŵĞŶ Ž ŶŽ ƵƐĞ Ŷ ƉĂƟĞŶ Ɛ E^ Ɛ ^ Ž Ɖ Ă Ğ Ğ ĂŐŐ ĞŐŐĂƟŽŶ ŶŚ ď Ž Ɛ ĚƵĞ Ž ŚĞ ŶĐ ĞĂƐĞĚ

UKXAR04170188 81d Date of preparat o on August 2017