Management Of Thromboembolism Research Articles

Are direct oral anticoagulants an economically attractive alternative to low molecular weight heparins in lung cancer associated venous thromboembolism management?

Venous thromboembolism is highly prevalent in lung cancer patients. Low molecular weight heparins are recommended for long term treatment of cancer associated venous thromboembolism. Direct oral anticoagulants are however an interesting alternative as they are administered orally and don't require monitoring. There are currently studies comparing both their efficacy and tolerance for cancer patients and more and more guidelines suggest considering direct oral anticoagulants for cancer associated venous thromboembolism treatment. The objective of this study was to evaluate the budgetary impact that direct oral anticoagulants use would have for lung cancer associated venous thromboembolism treatment and prevention in France. An economic model was made to evaluate the cost of venous thromboembolism treatment and prevention among patients with primary lung cancer in France by two strategies: current guidelines versus direct oral anticoagulants use. The model was fed with clinical and economic data extracted from the French national health information system. The analysis was conducted from the national mandatory Health insurance point of view. The time horizon of the study was the evaluation of the annual management cost. Lung cancer associated venous thromboembolism management's mean cost was estimated of 836€ per patient, that is a total cost of about 40 million euros per year at a national level. A 76% decrease of this cost can be expected with direct oral anticoagulants use. However, despite their benefits, these treatments raise new issues (medication interactions, bleeding management), and would likely not be recommended for all patients.

Catheter Related Thrombosis (CRT) in Hematologic Malignancy: A Retrospective Study of Venous Thromboembolism Management

Introduction: Central Venous Catheters (CVC) improve quality of life for patients with hematologic malignancy but long-term presence may result in CRT. Optimal treatment of CRT is uncertain. Here, we focus on a retrospective study of CRT in patients with hematologic malignancy to identify clinical features associated with increased risk for recurrent thrombosis. Methods: Demographic and management information of patients with CRT and hematologic malignancy was extracted from the medical record of a single academic medical center. Data was described using summary statistics. Nonparametric Cox proportional hazard models were utilized for thrombosis recurrence and bleeding occurrence. Unadjusted models were utilized for CRT treatment, type of anticoagulation, platelet count, and other factors. Results: 85 patients were included for analysis. Summary statistics are noted in Table 1. Median platelet count differed across initial treatment approach [Anticoagulation (AC): 177 (106.5- 662), Anticoagulation and Catheter Removal (AC+): 112 (61.75-304), Catheter Removal only 24 (20.25-35.5), No treatment 30.5 (16.75-10.8), p<0.0001]. For CRT treatment, patients with AC+ have more than a 660 % chance of thrombosis recurrence compared to AC as reference group. This significant difference is also seen in the Kaplan Meir curves for CRT treat (log-rank p=0.0484), Figure 1. Of note, 15 patients treated with AC+ developed recurrent thrombosis, the majority of which (53%, 8/15) occurred within 100 days. Of these patients, 62% (5/8 patients) had at least 2 days delay in starting anticoagulation while no delays in starting anticoagulation were noted in patients who were primarily treated with AC. Of the 8 patients who received no therapy for CRT, 7/8 patients (87%) had noted brachial (peripheral deep). Discussion: Significant variability in management of CRT in patients with hematologic malignancy is noted. Platelet count at time of thrombosis may influence treatment decision. Our data indicate that treatment with anticoagulation is superior to treatment without anticoagulation. The difference in thrombosis recurrence seen in patients who received AC v. AC+ could potentially be explained by delays in starting AC in the latter group. Interestingly, patients who did not receive any therapy for CRT had no recurrence, which may be explained by the fact that the majority had peripheral deep thrombosis, which are less likely to have deep recurrences. In addition, type of anticoagulation used for treatment was notHowever, our data is limited by its population of single institutional patients and retrospective nature. Prospective, studies are needed to better delineate differences in outcomes. Disclosures Jaglal: NOVARTIS: Consultancy.

578 Resuming Anticoagulation Following Hospitalization for Gastrointestinal Bleeding Is Associated With Reduced Thromboembolic Events and Improved Mortality: Results From a Systematic Review and Meta-Analysis

INTRODUCTION: Systemic anticoagulants are widely prescribed for prevention and treatment of thromboembolism, but are commonly complicated by gastrointestinal bleeding (GIB). There is limited data on the management of anticoagulation after hospitalization for GIB and the subsequent risks of recurrent GIB, thromboembolism, and mortality. METHODS: We performed a systematic review and meta-analysis to determine the risk of recurrent GIB, thromboembolism and mortality after resuming anticoagulation following GIB. PubMed, Embase and Scopus were searched for randomized controlled trials and cohort studies in patients with atrial fibrillation, venous thromboembolism or valvular heart disease who received long-term warfarin or direct oral anticoagulants before experiencing GIB. Studies were included if data were available on anticoagulation management and outcomes of recurrent GIB, thromboembolism and mortality following initial hospitalization for GIB. RESULTS: A total of 5,354 studies were reviewed of which 10 were included in the meta-analysis (Figure 1). There were 2,080 patients who resumed anticoagulation and 2,296 patients who stopped their anticoagulation post index GIB (Table 1). Resumption of anticoagulation was associated with a significant increase in recurrent GIB (OR 1.646, 95% CI 1.035-2.617, P = 0.035, I2 = 55.5%) though recurrent GIB leading to death was rare (Figure 2). There was a significant decrease in thromboembolic events in patients who resumed anticoagulation compared to those who did not (OR 0.340, 95% CI 0.178-0.652, P = 0.001, I2 = 62.7%) and a significant reduction in all-cause mortality (OR 0.499, 95% CI 0.419-0.595, P = 0.000, I2 = 14.2%) (Figure 2). Optimal timing of re-initiation of anticoagulation varied, but as early as 2 weeks from index GIB or hospital discharge may be ideal. CONCLUSION: While resumption of anticoagulation following index GIB was associated with a significant increase in recurrent GIB, it was also associated with a significant decrease in thromboembolic events and all-cause mortality. Re-initiation of anticoagulation as early as 2 weeks post-GIB may be optimal.

Pregnancy and labor management: women with venous thromboembolism or associated significant risk factors

This paper describes diagnosis, treatment, and control of acute venous thromboembolism (VTE) and antithrombotic prophylactic management during pregnancy and puerperium, especially in women with inherited thrombophilia. VTE is currently one of the three main causes of maternal morbidity in Japan. With approximately 0.05%-0.08% incidence rate per total number of births, it is becoming increasingly comparable with other developed countries. Pregnancy is characterized by high blood clotting potential due to increased coagulation factors, decreased anticoagulant activity, and fibrinolysis. Additionally, unique obstetric risk factors exist, such as cesarean section, prolonged bed rest, obesity, preeclampsia, and dehydration due to hyperemesis. Moreover, notable risk factors for VTE in pregnancy and puerperium for patients with inherited thrombophilia (e.g., deficiencies in antithrombin, protein C, and protein S) and acquired thrombophilia (e.g., antiphospholipid antibodies, history of VTE) have been reported; this study describes inherited thrombophilia in details.

Direct-Thrombin Inhibitor Utilization in Patients With Heparin-Induced Thrombocytopenia and Undergoing Catheter-Directed Thrombolysis: A Summary of Published Case Reports.

Catheter-directed thrombolysis (CDT) is one of the emerging venous thromboembolism management modalities. There are fairly limited data regarding the use of direct-thrombin inhibitors (DTIs) in patients with heparin-induced thrombocytopenia and undergoing CDT. The aim of this study was to provide a summary of the available evidence supporting the use of DTIs in patients undergoing CDT. We included 6 case reports in our analysis after searching for peer-reviewed articles and case reports in multiple research engines. Four of the 6 cases used argatroban, and 2 cases used bivalirudin. Alteplase was used in all of the 6 cases. All cases used lower activated partial thromboplastin time target. The average initial dose of alteplase ranged from 0.5 to 3 mg/h. The average duration of CDT was 26 hours (SD, 13 hours). Five patients (83%) survived after the procedure, and no complications were reported. The use of DTIs might be safe and effective in selected patients with heparin-induced thrombocytopenia and undergoing CDT.

The Changing Face of Venous Thromboembolism Management in England

Aim: Venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, poses a global disease burden. Vitamin K antagonists have traditionally been the mainstay of treatment; however, the non-vitamin K oral anticoagulants (NOACs) are emerging as an alternative. The relative use of these treatment classes in the real world is unknown. Patients & methods: We performed a retrospective study using data from the UK Clinical Practice Research Datalink to understand VTE treatment patterns. Results: NOACs have unseated vitamin K antagonist as the main form of VTE patient treatment in England. Conclusion: The data highlight how comfortable physicians have become in using NOACs to treat VTE in England and it is likely that the increasing use of NOACs will continue.

Design of a liquid nano-sized drug delivery system with enhanced solubility of rivaroxaban for venous thromboembolism management in paediatric patients and emergency cases

The increasing incidence of venous thromboembolism (VTE) in paediatric population has stimulated the development of liquid anticoagulant formulations. Thus our goal is to formulate a liquid formulation of poorly-water soluble anticoagulant, rivaroxaban (RIVA), for paediatric use and to assess the possibility of its intravenous administration in emergencies. Self-nanoemulsifying drug delivery systems (SNEDDSs) were developed and characterized. SNEDDS constituents were estimated from the saturated solubility study followed by plotting the corresponding ternary phase diagrams to determine the best self-emulsified systems. Thermodynamic stability, emulsification, dispersibility, robustness to dilution tests, in vitro dissolution, particle size, and zeta potential were executed to optimize the formulations. The optimized formulation, that composed of Capryol 90:Tween 20:PEG 300 (5:45:50), increased RIVA solubility (285.7-fold than water), it formed nanoemulsion with a particle size of 16.15 nm, PDI of 0.25 and zeta potential of −21.8. It released 100.83 ± 2.78% of RIVA after 5 min. SNEDDS was robust to dilution with oral and parenteral fluids and showed safety to human RBCs. SNEDDS showed enhanced bioavailability after oral and intravenous administration than the oral drug suspension (by 1.25 and 1.26-fold, respectively). Moreover, it exhibited enhanced anticoagulant efficacy in the prevention and treatment of carrageenan-induced thrombosis rat model.

Aiming at Excellence in the Management of Pulmonary Thromboembolism

Aiming at Excellence in the Management of Pulmonary Thromboembolism

Construction and effects of orthopedic specialized nurse studio

Objective To explore the construction method and the effects of the orthopedic specialized nurse studio. Methods The orthopedic specialized nurse studio included 4 working groups, which were intravenous therapy group, wound care group, chronic diseases management group and perioperative venous thromboembolism (VTE) management group. Each group were assigned 1 team leader and 10 to 12 team members. Nursing training, management and research were carried out. The professional competency of orthopedic nursing staff and the nursing quality were compared before (January to December 2016) and after (January to December 2017) the construction of the studio. Results The scores of theoretical assessment, specialized nurses' performance and nursing quality in 2017 were (97.76±4.09) , (82.25±6.60) and (99.06±0.91) respectively, which were higher than those of the same period in 2016. The differences were statistically significant (t=2.169, 3.327, 2.129; P<0.05) . Conclusions The establish of the orthopedic specialized nurse studio can enhance the growth of specialized nursing team, improve the nursing quality and promote the development of multi-disciplinary integration. Key words: Hospital, orthopedics; Specialized nurse; Venous thromboembolism; Intravenous therapy; Wound care; Chronic disease management

Management of Thromboembolism (Pulmonary Embolism) in Coronary Cardiac Unit

Management of Thromboembolism (Pulmonary Embolism) in Coronary Cardiac Unit

Oral anticoagulants: Optimizing venous thromboembolism management

A decade ago, oral anticoagulants were limited to Vitamin K antagonists, i.e., warfarin. Since 2010, the US Food and Drug Administration has approved several non-Vitamin K oral anticoagulants: dabigatran is a direct thrombin inhibitor, while apixaban, edoxaban, and rivaroxaban are direct factor Xa inhibitors. Oral anticoagulants are used for the management of several venous thromboembolism (VTE) events, including the prevention of stroke in nonvalvular atrial fibrillation; acute coronary syndromes; treatment of VTE; and VTE prophylaxis after total hip or knee replacement. In this review article, we address the main indications, dosages, bleeding and reversal agents, pharmacokinetic and pharmacodynamic properties, and methods of switching between oral anticoagulants.

Assessment of Anticoagulation in Patients Receiving Ultrasound-Assisted Catheter-Directed Thrombolysis for Treatment of Pulmonary Embolism.

Ultrasound-assisted, catheter-directed thrombolysis (USAT) has emerged as a popular treatment option for submassive pulmonary embolism (PE). The optimal strategy for transitioning patients from full-intensity to reduced-intensity heparin during the procedure has yet to be established. The goal of this study was to evaluate the anticoagulation management in patients receiving catheter-directed thrombolysis with USAT. A retrospective chart review was conducted of patients who received USAT for the treatment of PE. Institutional review board approval was obtained. The primary objective was to determine the proportion of patients with a therapeutic activated partial thromboplastin time (aPTT) prior to and during tissue-plasminogen activator (tPA) infusion. Secondary outcomes included heparin requirements, the rate of bleeding complications, and the appropriateness of long-term venous thromboembolism management. A therapeutic aPTT value was achieved in 32 patients (54.2%) prior to USAT and 35 patients (59.3%) during tPA infusion. Heparin requirements were reduced from 15.1 ± 4.1 to 12.8 ± 4.2 U/kg/h for patients who achieved a therapeutic aPTT both prior to and during tPA infusion. Bleeding occurred in 34.4% of patients and tended to be minimal (20.3%) or minor (10.9%). The majority of patients were discharged on a direct oral anticoagulant (63%), followed by warfarin (32%) and enoxaparin (5%). Conclusion and Relevance: To our knowledge, this is the first study that has assessed heparin management in the setting of USAT. The results of these data may aid in empirically dose adjusting unfractionated heparin to ensure safe and effective anticoagulation for patients receiving USAT.

Direct oral anticoagulants: a review of common medication errors.

Stroke and venous thromboembolism continues to be a major cause of morbidity and mortality worldwide. The use of anticoagulation therapy has proven effective in the prevention of stroke and management of thromboembolism; however, initiating treatment may bear clinical burden given the capacity of these agents to cause bleeding. Originally, warfarin has been primarily used, but with the approval of direct oral anticoagulants, therapeutic recommendations have shifted to direct oral anticoagulants for first line therapy for venous thromboembolism for patients without cancer. As compared to warfarin, direct oral anticoagulants are associated with predictable pharmacokinetic profiles, lower bleeding risks, and minimal drug interactions. Complexities in the medication use process can however heighten the risks of causing adverse events. The purpose of this article is to describe common medication errors associated with direct oral anticoagulants, provide practical guidance on the management of direct oral anticoagulants, and suggest strategies to reduce errors. Efforts to minimize medication errors involve the participation of an interdisciplinary team that has standardized policies, risk reduction strategies, and guiding principles to achieve optimal therapeutic outcomes. Current primary literature is not robust in assessment of clinical impact of medication errors associated with DOACs but reports of adverse drug events have been noted. Future studies should be guided to assess clinical outcomes associated with medication errors and identify potential clinical interventions to optimize therapy.

ACOG Practice Bulletin No. 196 Summary: Thromboembolism in Pregnancy.

Women who are pregnant or in the postpartum period have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women (1, 2). Approximately 80% of thromboembolic events in pregnancy are venous (3), with a prevalence of 0.5-2.0 per 1,000 pregnant women (4-9). Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States, accounting for 9.3% of all maternal deaths (10).The prevalence and severity of this condition during pregnancy and the peripartum period warrant special consideration of management and therapy. Such therapy includes the treatment of acute thrombotic events and prophylaxis for those at increased risk of thrombotic events. The purpose of this document is to provide information regarding the risk factors, diagnosis, management, and prevention of thromboembolism, particularly VTE in pregnancy. This Practice Bulletin has been revised to reflect updated guidance regarding screening for thromboembolism risk and management of anticoagulation around the time of delivery.

ACOG Practice Bulletin No. 196: Thromboembolism in Pregnancy.

Women who are pregnant or in the postpartum period have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women (). Approximately 80% of thromboembolic events in pregnancy are venous (), with a prevalence of 0.5-2.0 per 1,000 pregnant women (). Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States, accounting for 9.3% of all maternal deaths ().The prevalence and severity of this condition during pregnancy and the peripartum period warrant special consideration of management and therapy. Such therapy includes the treatment of acute thrombotic events and prophylaxis for those at increased risk of thrombotic events. The purpose of this document is to provide information regarding the risk factors, diagnosis, management, and prevention of thromboembolism, particularly VTE in pregnancy. This Practice Bulletin has been revised to reflect updated guidance regarding screening for thromboembolism risk and management of anticoagulation around the time of delivery.

Prevention and Management of Thromboembolism in Pregnancy When Heparins Are Not an Option.

Heparins, unfractionated heparin, and low molecular weight heparin, are the preferred anticoagulants in pregnancy. There are circumstances, however, in which an alternative to heparin should be considered. These circumstances include, the presence of heparin resistance, a heparin allergy manifesting as heparin-induced skin reactions or heparin-induced thrombocytopenia, and the presence of a mechanical heart valve. From time to time, the obstetrician is called on to make recommendations about anticoagulants in pregnancy, including in circumstances in which an alternative to heparin has been suggested or is necessary. In this article, these circumstances are reviewed and alternative anticoagulants are discussed.

ClotAssist: A program to treat cancer-associated thrombosis in an outpatient pharmacy setting.

Stable cancer patients diagnosed with a pulmonary embolus or deep vein thrombosis are commonly referred to the emergency department for management. This practice strains an already overburdened emergency department and is associated with long wait times and poor disease/injection education for patients. This pilot study sought to determine if stable cancer patients with newly diagnosed cancer-associated thrombosis could be effectively managed by community-based pharmacists who followed an evidence-based protocol to prescribe and initiate low-molecular weight heparin therapy. We hypothesized that this novel care pathway could provide faster patient care with more comprehensive disease education, self-injection training, and follow-up. Fifty-five patients with various cancers, including gastroesophageal, urogenital, breast, brain, and lung were enrolled into this pilot study. We observed that this alternative first-dose treatment pathway provided safe and effective treatment of venous thromboembolism combined with excellent patient satisfaction. Following their interaction with the pharmacist, patients felt confident about their ability to self-inject and about their venous thromboembolism management overall. No occurrences of bleeding or other side-effects were observed. This pilot study demonstrates that community-based pharmacists are capable of delivering complex care services in the outpatient environment, particularly in the management of venous thromboembolism.

Thromboembolic and bleeding risk management in elderly patients: a case report

Thromboembolic and bleeding risk management in elderly patients: a case report

Non-Pharmacological Management of Pulmonary Thromboembolism

Non-Pharmacological Management of Pulmonary Thromboembolism

Venous thromboembolism management practices and knowledge of guidelines: a survey of Australian haematologists and respiratory physicians.

Current international clinical practice guidelines do not adequately address all clinical scenarios in the management of venous thromboembolism (VTE), and no comprehensive Australian guidelines exist. To identify areas of uncertainty in VTE management and whether self-reported practice is consistent with guidelines. We conducted an Australian cross-sectional online survey consisting of 53 questions to investigate doctors' VTE management practices. The survey was distributed to consultant and trainee/registrar haematologists and respiratory physicians with the aid of participating medical societies. A total of 71 haematologists and 110 respiratory physicians responded to the survey. The majority of survey respondents were 31-50-years old and worked in teaching hospitals and in the acute care setting. Under-treatment was reported for high-risk pulmonary embolism (PE) and duration of anticoagulation for first-episode unprovoked PE (32 and 83% respectively). Over-treatment was reported in areas of thrombolysis for intermediate-risk PE (16%) and duration of anticoagulation for first-episode provoked PE (41%). Uncertainty and variations in doctors' management approaches were also found. This survey demonstrated significant over-treatment, under-treatment and variability in the practice of VTE management. The findings highlight the need for the development and implementation of national guidelines for the management of VTE in Australia.