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Sharp CR, Blais MC, Boyd CJ, Brainard BM, Chan DL, de Laforcade A, Goggs R, Guillaumin J, Lynch A, Mays E, McBride D, Rosati T, Rozanski EA. 2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 6: Defining rational use of thrombolytics. J Vet Emerg Crit Care (San Antonio) 2022; 32:446-470. [PMID: 35881647 PMCID: PMC9544803 DOI: 10.1111/vec.13227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To systematically review available evidence and establish guidelines related to the use of thrombolytics for the management of small animals with suspected or confirmed thrombosis. DESIGN PICO (Population, Intervention, Control, and Outcome) questions were formulated, and worksheets completed as part of a standardized and systematic literature evaluation. The population of interest included dogs and cats (considered separately) and arterial and venous thrombosis. The interventions assessed were the use of thrombolytics, compared to no thrombolytics, with or without anticoagulants or antiplatelet agents. Specific protocols for recombinant tissue plasminogen activator were also evaluated. Outcomes assessed included efficacy and safety. Relevant articles were categorized according to level of evidence, quality, and as to whether they supported, were neutral to, or opposed the PICO questions. Conclusions from the PICO worksheets were used to draft guidelines, which were subsequently refined via Delphi surveys undertaken by the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) working group. RESULTS Fourteen PICO questions were developed, generating 14 guidelines. The majority of the literature addressing the PICO questions in dogs is experimental studies (level of evidence 3), thus providing insufficient evidence to determine if thrombolysis improves patient-centered outcomes. In cats, literature was more limited and often neutral to the PICO questions, precluding strong evidence-based recommendations for thrombolytic use. Rather, for both species, suggestions are made regarding considerations for when thrombolytic drugs may be considered, the combination of thrombolytics with anticoagulant or antiplatelet drugs, and the choice of thrombolytic agent. CONCLUSIONS Substantial additional research is needed to address the role of thrombolytics for the treatment of arterial and venous thrombosis in dogs and cats. Clinical trials with patient-centered outcomes will be most valuable for addressing knowledge gaps in the field.
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Affiliation(s)
- Claire R Sharp
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
| | - Marie-Claude Blais
- Department of Clinical Sciences, University of Montreal, Saint-Hyacinthe, Quebec, Canada
| | - Corrin J Boyd
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Daniel L Chan
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Armelle de Laforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | - Julien Guillaumin
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Alex Lynch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Erin Mays
- Veterinary Specialty Services, St. Louis, Missouri, USA
| | | | - Tommaso Rosati
- Department for Small Animals, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Elizabeth A Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
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Legos JJ, Tuma RF, Barone FC. Pharmacological interventions for stroke: failures and future. Expert Opin Investig Drugs 2002; 11:603-14. [PMID: 11996643 DOI: 10.1517/13543784.11.5.603] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Given the few options currently available for patients following ischaemic stroke, the recent disappointing failures of several large-scale Phase III clinical trials has made the search for novel therapeutic approaches even more critical. Experimental evidence has suggested that the majority of stroke patients have a slow evolution of brain injury which can occur over several hours. Progressive microcirculatory failure following the initial onset of ischaemia may contribute to the expansion of brain injury. Included among the pathophysiological changes that are speculated to occur as a secondary response to the initial ischaemia are free radical production, excitotoxicity (for example, glutamate) disruption of ionic homeostasis (for example, sodium and calcium influx), enzymatic changes, stimulation of the inflammatory process, endothelin release, activation of platelets and leukocytes, delayed coagulation and endothelial dysfunction. All of these pathophysiological reactions could contribute to an increase in local vascular resistance and therefore cause progressive hypoperfusion of the brain following the onset of stroke. The scope of this review will focus on recent clinical failures in addition to agents currently in clinical development, comparing vascular targets to the common neuroprotective strategies.
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Affiliation(s)
- Jeffrey J Legos
- High Throughput Biology, Discovery Research, GlaxoSmithKline, King of Prussia, PA, USA.
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