Fondaparinux For Venous Thromboembolism Prophylaxis Research Articles

Preventing venous thromboembolism in hospitalized patients with cancer: Improving compliance with clinical practice guidelines

The use of anticoagulants for the prevention of venous thromboembolism (VTE) in hospitalized medical and surgical oncology patients is discussed. Hospitalized patients are often at risk for developing VTE, and risk is increased in patients who have cancer. Moreover, the incidence of VTE appears to be rising in hospitalized cancer patients, who have a 2.2-fold increased risk of mortality with a VTE compared with similar patients without VTE. The literature indicates that these patients are often inadequately anticoagulated, despite strong recommendations for prophylaxis. Although there are few studies that specifically address VTE prophylaxis in cancer patients, there are several large trials that have examined data in cancer subgroups. The trials have directly compared low-molecular-weight heparin (LMWH) with placebo, unfractionated heparin with LMWH, factor Xa inhibitor (fondaparinux) with placebo, and fondaparinux with LMWH. Three important guidelines provide current recommendations for VTE prophylaxis; the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the American College of Chest Physicians (ACCP) recommend unfractionated heparin, LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications. Pharmacists can play an essential role in ensuring that VTE prophylaxis is appropriate for individual patients. Interventions to improve compliance with guidelines are particularly important now due to financial incentives from quality-focused organizations whose mandate is to decrease preventable mortality events in hospitals. Hospitalized patients with cancer often do not receive appropriate thromboprophylaxis. Guidelines from ASCO, ACCP, and NCCN recommend unfractionated heparin, an LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications to such therapy.

Spontaneous acute subdural hematoma due to fondaparinux: Report of two cases.

Background:Spontaneous acute subdural hematomas (SDHs) are rare. Risk factors for development of these hematomas include conditions such as hypertension, vascular abnormalities such as aneurysm or arteriovenous malformation, or consumption of anticoagulants.Case Description:Here, the authors report two patients who suffered from spontaneous acute SDH while taking fondaparinux for venous thromboembolism prophylaxis. One patient suffered from a remote episode of traumatic brain injury and underwent a decompressive craniectomy 3 weeks prior to presentation, whereas the other patient had been self-medicating with aspirin.Conclusion:To our knowledge, these two patients illustrate the first cases of spontaneous acute SDH formation most likely attributed to consumption of fondaparinux.

Venous Thromboembolism Prophylaxis following Acute Ischemic Stroke: A Retrospective Comparison of Unfractionated Heparin, Enoxaparin, and Fondaparinux

Purpose The objective of this study was to retrospectively review the efficacy and safety of unfractionated heparin (UFH), enoxaparin, and fondaparinux for venous thromboembolism (VTE) prevention following acute ischemic stroke. Methods A retrospective chart review was conducted of VTE and major bleeding event rates in patients receiving UFH, enoxaparin, or fondaparinux for VTE prophylaxis following ischemic stroke. This review included charts from an 18-month period at all facilities in the Lehigh Valley Health Network. A total of 889 patients were evaluated. Results There was no significant difference between the 3 anticoagulants for the primary outcome of VTE with an incidence of 2.5% (n=9) for UFH, 1.2% (n=3) for enoxaparin, and 0.4% (n=1) for fondaparinux ( P = .065). However, the incidence of major bleeding events was significantly different with an occurrence of 6.2% (n=22) for UFH, 3.2% (n=8) for enoxaparin, and 0.7% (n=2) for fondaparinux ( P = .001). A comparison of the individual agents showed that UFH had a significantly higher rate of major bleeding events when compared to fondaparinux ( P = .003). Conclusions In this study population, UFH was observed to increase the risk of major bleeding events in ischemic stroke patients receiving subsequent VTE prophylaxis. Additionally, the possibility of using fondaparinux for VTE prophylaxis in ischemic stroke patients appears to provide at least comparable safety and efficacy compared to UFH and enoxaparin. However, more studies are needed to determine the ideal anticoagulant and timing of prophylaxis in patients following ischemic stroke.

The new oral anticoagulants, do they change the benefit vs. risk for thromboprophylaxis in association to ambulatory surgery?

Several randomized controlled trials have shown that pharmacological thromboprophylaxis with low-dose unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux reduces venous thromboembolism (VTE) after general surgery. No high-quality evidence supports the use of pharmacological thromboprohylaxis with traditional antithrombotic drugs in patients undergoing ambulatory surgery without additional VTE risk factors, stratified at low risk of VTE by the American College of Chest Physicians guidelines. Two new drug classes, the direct thrombin and factor Xa (FXa) inhibitors, have been developed with a potentially better risk-benefit profile. Oral administration, predictable anticoagulant responses, low potential for drug-drug interactions render direct thrombin and factor Xa inhibitors good candidates to replace UFH, LMWH and fondaparinux for VTE prophylaxis. Most of all, the positive results of the first published clinical trials in orthopedic thromboprophylaxis allowed dabigatran etexilate and rivaroxaban to be licensed in Canada and in European Union for the prevention of VTE in patients undergoing hip-replacement and knee-replacement surgery. No randomized trials with the new anticoagulants are ongoing in ambulatory surgery. However, currently available drugs--that is UFH, LMWH or fondaparinux--are administered subcutaneously and the new anticoagulants would offer the clear advantage of an oral administration, without request for blood testing to monitor potential adverse effects such as heparin-induced thrombocytopenia, thus potentially simplifying the treatment out of the hospital.

Is There a Role for Aspirin in Venous Thromboembolism Prophylaxis After Total Knee Replacement?

American College of Chest Physicians (ACCP) guidelines for venous thromboembolism prophylaxis (VTEP) after total knee arthroplasty (TKA) favor LMWH, pentasaccharides (Fondaparinux), and warfarin over aspirin. However, recent data suggest that ACCP recommended therapies may increase bleeding complications after TKA. To determine the risks and benefits of various VTEP strategies, we compared rates of DVT, PE, surgical site bleeding, and mortality in a large national population of patients who received aspirin, warfarin, LMWH, or Fondaparinux for VTEP after TKA.

Choosing the Appropriate Antithrombotic Agent for the Prevention and Treatment of VTE: A Case-Based Approach

To review the risk of venous thromboembolism (VTE) in various patient populations and evaluate the agents available for the prevention and treatment of VTE using a case-based approach. A MEDLINE search (1995-July 2006) was conducted to identify relevant literature. Additional references were reviewed from selected articles. Articles related to the prevention of VTE in orthopedic surgery, general surgery, and medically ill patients, as well as the treatment of VTE, were reviewed. Pharmacologic options for the prevention and treatment of VTE include warfarin, unfractionated heparin (UFH), low-molecular-weight heparins (LMWH), and fondaparinux. Current guidelines support the use of warfarin, LMWH, or fondaparinux for VTE prophylaxis following lower limb major orthopedic surgery. For VTE prophylaxis in hospitalized medical patients or patients undergoing general surgery, use of UFH and LMWH is supported; however, recent data on fondaparinux suggest that it is also effective in these patient populations. The use of UFH or LMWH (both in conjunction with warfarin) for treatment of acute deep venous thrombosis or nonmassive pulmonary embolism is recommended. Recent data suggest that fondaparinux (in conjunction with warfarin) is also effective for the treatment of VTE. A variety of pharmacokinetic, pharmacodynamic, and pharmacoeconomic factors differentiate each agent for the various indications. Currently, a "one-size-fits-all" anticoagulant is not available for treatment of VTE. A variety of patient factors, including type of surgery, medical indication, thrombotic risk factors, bleeding risk, history of heparin-induced thrombocytopenia, and a variety of comorbid conditions can affect the safety, efficacy, and selection of appropriate VTE therapy.