Outpatient therapy with low molecular weight heparin for the treatment of venous thromboembolism: a review of efficacy, safety, and costs

Development and Evaluation of a Pharmacist-Driven Screening Tool to Identify Patients Presenting to the Emergency Department Who Are Eligible for Outpatient Treatment of Deep Vein Thrombosis

BACKGROUND

Deep vein thrombosis (DVT) is a critical and costly health issue. Treatment in the outpatient setting is preferred compared to the inpatient setting. However, there is a lack of evidence regarding how best to identify patients who are ideal for outpatient DVT treatment.

OBJECTIVE

To design and evaluate a pharmacist-driven screening tool for the identification of patients presenting to the emergency department (ED) at a community hospital with DVT who are appropriate for outpatient treatment.

METHODS

This study was conducted in sequential phases: compilation and vetting of screening criteria, descriptive evaluation of criteria through retrospective chart review, and quantification of potential cost savings by avoiding admissions. Criteria were collected via literature search and assembled into a screening tool, which was applied retroactively to a cohort of ED patients admitted with DVT diagnosis.

RESULTS

A screening tool was developed with multidisciplinary input and consisted of 5 categories with individual patient and disease state criteria. The majority (91%) of patients reviewed would not have qualified for outpatient DVT treatment based on the retrospective application of the screening tool. The most common disqualification criteria category was high risk of bleeding/clotting (n = 81), and the most frequently represented parameter within that category was antithrombotic therapy prior to admission (n = 53).

CONCLUSION

A screening tool may not be the most efficient method for health-care practitioners such as pharmacists to identify ED patients appropriate for outpatient management of DVT. Other avenues should be explored for improving the cost-effective management of these patients.

Deep vein thrombosis: pathogenesis, diagnosis, and medical management

Deep vein thrombosis (DVT) is a major preventable cause of morbidity and mortality worldwide. Venous thromboembolism (VTE), which includes DVT and pulmonary embolism (PE), affects an estimated 1 per 1,000 people and contributes to 60,000-100,000 deaths annually. Normal blood physiology hinges on a delicate balance between pro- and anti-coagulant factors. Virchow's Triad distills the multitude of risk factors for DVT into three basic elements favoring thrombus formation: venous stasis, vascular injury, and hypercoagulability. Clinical, biochemical, and radiological tests are used to increase the sensitivity and specificity for diagnosing DVT. Anticoagulation therapy is essential for the treatment of DVT. With few exceptions, the standard therapy for DVT has been vitamin K-antagonists (VKAs) such as warfarin with heparin or fractionated heparin bridging. More recently, a number of large-scale clinical trials have validated the use of direct oral anticoagulants (DOACs) in place of warfarin in select cases. In this review, we summarize the pathogenesis, diagnosis, and medical management of DVT, with particular emphasis on anticoagulation therapy and the role of DOACs in the current treatment algorithm.

Outpatient Treatment of Deep Vein Thrombosis in the United States: The Reasons for Geographic and Racial Differences in Stroke Study

OBJECTIVE

To describe the uptake of outpatient DVT treatment in the United States and understand how comorbidities and socioeconomic conditions impact the decision to treat as an outpatient.

DESIGN/SETTING

The Reasons for Geographic and Racial Differences in Stroke cohort study recruited 30,329 participants between 2003 and 2007. DVT events were ascertained through 2011.

MEASUREMENTS

Multivariable logistic regression was used to determine the correlates of outpatient treatment of DVT accounting for age, sex, race, education, income, urban or rural residence, and region of residence.

RESULTS

Of 379 venous thromboembolism events, 141 participants had a DVT without diagnosed pulmonary embolism and that did not occur during hospitalization. Overall, 28% (39 of 141) of participants with DVT were treated as outpatients. In a multivariable model, the odds ratio for outpatient versus inpatient DVT treatment was 4.16 (95% confidence interval [CI], 1.25-13.79) for urban versus rural dwellers, 3.29 (95% CI, 1.30-8.30) for white versus black patients, 2.41 (95% CI, 1.06-5.47) for women versus men, and 1.90 (95% CI, 1.19-3.02) for every 10 years younger in age. Living outside the southeastern United States and having higher education and income were not statistically significantly associated with outpatient treatment.

CONCLUSIONS

Despite known safety and efficacy, only 28% of participants with DVT received outpatient treatment. This study highlights populations in which efforts could be made to reduce hospital admissions.

Management of venous thromboembolism: an update

Venous thromboembolism (VTE), which constitutes pulmonary embolism and deep vein thrombosis, is a common disorder associated with significant morbidity and mortality. Landmark trials have shown that direct oral anticoagulants (DOACs) are as effective as conventional anticoagulation with vitamin K antagonists (VKA) in prevention of VTE recurrence and associated with less bleeding. This has paved the way for the recently published guidelines to change their recommendations in favor of DOACs in acute and long-term treatment of VTE in patients without cancer. The recommended treatment of VTE in cancer patients remains low-molecular-weight heparin. The initial management of pulmonary embolism (PE) should be directed based on established risk stratification scores. Thrombolysis is an available option for patients with hemodynamically significant PE. Recent data suggests that low-risk patients with acute PE can safely be treated as outpatients if home circumstances are adequate. There is lack of support for use of inferior vena cava filters in patients on anticoagulation. This review describes the acute, long-term, and extended treatment of VTE and recent evidence on the management of sub-segmental PE.

Clinical outcomes and patient satisfaction of a pharmacist-managed, emergency department–based outpatient treatment program for venous thromboembolic disease

Objective:

The purpose of this study was to evaluate the efficacy, safety and patient satisfaction outcomes of our pharmacist-managed, emergency department (ED)–based outpatient treatment program for venous thromboembolism (VTE) disease.

Methods:

We conducted a prospective cohort study of all patients who were enrolled in the Vancouver General Hospital (VGH) outpatient VTE treatment program over a 7-year period (1999–2006). Efficacy outcomes include recurrent VTE events at 3 and 6 months following discharge from the program. Safety evaluation included major and minor bleeding complications and the development of thrombocytopenia during the acute phase of therapy. Patient satisfaction was assessed using an 18-question patient satisfaction survey, which was mailed to all patients following discharge from the program.

Results:

Overall, 305 patients were included in the study. Of the 260 evaluable patients, 2 patients (0.8%, 95% confidence interval [CI] 0.2–2.7) experienced a recurrent VTE at 3 months and 5 patients (1.9%, 95% CI 0.8–4.4) had a recurrence at 6 months. One patient (0.3%, 95% CI 0.1–1.8) experienced a major bleeding complication. Seven patients (2.3%, 95% CI 1.1–4.7) experienced a minor bleeding complication and no patient developed thrombocytopenia. Overall, 96.1% were comfortable having their condition treated as an outpatient and 85.7% felt it was more convenient to return to hospital daily for medications and assessment than to be admitted to hospital. Finally, 96.9% of respondents were very satisfied or satisfied with the treatment they received in the outpatient program, and 96.1% would enroll again if future treatment was indicated.

Conclusion:

Our pharmacist-managed, ED-based outpatient treatment program for VTE disease is safe, effective and achieves a high level of patient satisfaction.

Facilitating anticoagulation for safer transitions: preliminary outcomes from an emergency department deep vein thrombosis discharge program

INTRODUCTION

Patients presenting to the emergency department (ED) with an acute uncomplicated deep vein thrombosis (DVT) may be eligible for outpatient treatment. This study aims to establish a transition of care program in the ED for patients with DVT presenting with an acute uncomplicated DVT.

METHODS

This article specifies the transition of care program for DVT patients in the ED. Data was collected on patients admitted and discharged from the ED who had an acute DVT both prior to the initiation of facilitating anticoagulation for safer transitions (FAST) and after initiation of FAST. Follow-up phone calls were made to patients discharged from the ED after the initiation of FAST, and data were collected on follow-up appointments, anticoagulation adherence, readmission rates, and patient satisfaction.

RESULTS

The FAST program has been successfully implemented. By the 30-day follow-up phone call, 100% of patients had attended a follow-up appointment. The average time to the follow-up appointment post-discharge was 4.4 days (range, 1-7 days). None of the patients at the 3- to 5-day follow-up phone call and 30-day phone call had any issues taking their anticoagulant, and none reported side effects of significant bleeding. One patient was re-admitted after discharge with a pulmonary embolism. Patient satisfaction has also been very high with the program, with all patients indicating at the 30-day phone call that they would recommend the program to a friend or family member. The educational components of this program also improved the discharge process for this population compared with patients discharged prior to the initiation of FAST.

CONCLUSION

The FAST program is an example of a successful transition-of-care program for discharging DVT patients from the ED. Reassessment and improvements to the program are underway to ensure it remains current, sustainable, and provider friendly.

A review on state-of-the-art data regarding safe early discharge following admission for pulmonary embolism: what do we know?

BACKGROUND

Although most patients with acute pulmonary embolism (PE) remain hospitalized during initial therapy, some may be suitable for partial or complete outpatient management, which may have a significant impact on healthcare costs.

HYPOTHESIS

This article reviews the state-of-the-art data regarding recognition of very-low-risk PE patients who are potentially eligible for outpatient treatment, along with the safety, management, and cost-effectiveness of this strategy. We propose an algorithm based on collected data that may be useful/practical for identifying patients truly eligible for early discharge.

METHODS

Comprehensive review of scientific data collected from the MEDLINE and Cochrane databases. Studies selected based on potential scientific interest. Qualitative information extracted regarding feasibility, safety, and cost-effectiveness of outpatient treatment, postdischarge management, and selection of truly low-risk patients.

RESULTS

Early discharge of low-risk patients seems feasible, safe, and particularly cost-effective. Several risk scores have been developed and/or tested as prediction tools for the recognition of low-risk individuals: the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva score, the Low-Risk Pulmonary Embolism Decision rule, and the Global Registry of Acute Cardiac Events, among others. PESI is the most well-validated model, offering the safest approach at the current time, especially when combined with additional parameters such as troponin I, N-terminal prohormone of brain natriuretic peptide, and echocardiographic markers of right-ventricular dysfunction.

CONCLUSIONS

Recognition of truly low-risk patients entitled to early hospital discharge and outpatient treatment is possible with current risk-stratification schemes along with selected prognostic parameters, and it may have a colossal impact on healthcare costs.

Modest response in translation to home management of deep venous thrombosis

BACKGROUND

years may elapse between the publication of results of rigorous randomized trials and changes in clinical practice. It is not often that a definitive time interval can be identified that shows the time taken for published clinical trials to affect clinical practice. In the present study, we track the timelines of evidence for home treatment of deep venous thrombosis and its eventual impact on hospitalizations and early discharge.

METHODS

the number of patients discharged from short-stay hospitals throughout the United States between 1979 and 2006 with a principal diagnosis of deep venous thrombosis and the proportion discharged in ≤ 2 days was determined from The National Hospital Discharge Survey. We also attempted to identify all published articles that reported home treatment of deep venous thrombosis in unselected populations.

RESULTS

eleven years after demonstration of the safety and efficacy of home treatment, there was only a 21% decrease in the population-based incidence of hospitalizations of patients with a principal diagnosis of deep venous thrombosis. The proportion of patients with a principal diagnosis of deep venous thrombosis who were discharged in ≤ 2 days began to increase prominently after the 1996 publication of trials showing the safety and efficacy of home treatment, and continued to increase through 2006. However, the proportion discharged early remained modest (21% to 25%).

CONCLUSIONS

whether the slow implementation of home treatment reflects a cautious approach accompanied by a gradual testing of shortened hospitalization for deep venous thrombosis or other factors is uncertain.

Safety of catheter-directed thrombolysis for deep venous thrombosis in cancer patients

BACKGROUND

The current study was conducted to demonstrate that catheter-directed thrombolysis for upper and lower extremity deep vein thrombosis is equally safe in patients with and without cancer.

METHODS

A retrospective cohort of consecutive patients with acute iliofemoral or brachiosubclavian deep vein thrombosis treated with catheter-directed thrombolysis was identified. Demographic characteristics and clinical outcomes were compared between patients with cancer and without cancer.

RESULTS

Catheter-directed thrombolysis was used to treat 202 limbs in 178 patients (75 limbs in 61 cancer patients and 127 limbs in 117 patients without cancer). The mean treatment duration for patients with cancer (29.7 +/- 21.2 hours) and without cancer (28.8 +/- 22.2 hours) was similar (P = .7774). Catheter-directed thrombolysis achieved grade III clot lysis in a similar proportion of cancer patients (50 of 75 limbs, 66.7%) and patients without cancer (82 of 127 limbs, 64.6%; P = .7619). Grade II clot lysis also was achieved in equal numbers of patients with (20 of 75 limbs, 26.7%) and without cancer (34 of 127 limbs, 26.8%; P = .9872). Three cancer patients (4.9%) and four noncancer patients (3.4%) experienced major bleeding during catheter-directed thrombolysis (P = .6924). Pulmonary embolism occurred in 1.6% (1 of 61) of cancer patients and in 1.7% (2 of 117) of patients without cancer (P = .9999) during catheter-directed thrombolysis. Patients aged > or =70 years had an increased risk of major bleeding.

CONCLUSION

Percutaneous catheter-directed thrombolysis is equally safe for patients with and without cancer who have acute symptomatic deep vein thrombosis.

Outpatient management of stable acute pulmonary embolism: proposed accelerated pathway for risk stratification

Pulmonary embolism (PE) is a major health problem and a cause of worldwide morbidity and mortality. The current standard therapy for acute PE encourages admitting patients to the hospital for administration of parenteral anticoagulation therapy as a bridge to oral vitamin K antagonists. Prognostic models that identify patients with stable (nonmassive) acute PE (SPE) who are at low risk for adverse outcome have recently been reported. Based on these risk stratification models, hospital-based therapy is warranted for patients with PE who meet the criteria associated with a high risk for adverse outcome. However, a growing body of evidence suggests the feasibility of partial outpatient management and accelerated hospital discharge (AHD) in a subset of patients with SPE. Prospective validation of these risk stratification models for predicting patient suitability for AHD is needed.

Adjunctive Percutaneous Mechanical Thrombectomy for Lower-extremity Deep Vein Thrombosis: Clinical and Economic Outcomes

PURPOSE

To assess the clinical and economic benefits of catheter-directed thrombolysis (CDT) alone versus CDT with rheolytic percutaneous mechanical thrombectomy (PMT) for lower-extremity deep vein thrombosis (DVT).

MATERIALS AND METHODS

Consecutive patients with acute iliofemoral DVT treated with CDT with urokinase between 1997 and 2003 were identified. Demographic characteristics and clinical and economic outcomes were compared between patients treated with CDT alone versus CDT plus PMT.

RESULTS

Twenty-six limbs in 23 patients received CDT with urokinase, whereas 19 limbs in 14 patients were treated with CDT plus PMT. Mean treatment duration for CDT was 56.5 +/- 27.4 hours, compared with 30.3 +/- 17.8 hours for CDT plus PMT (P = .001). Mean urokinase dose for CDT was 6.70 +/- 5.9 million U compared with 2.95 +/- 1.82 million U for CDT plus PMT (P = .011). Urokinase CDT achieved complete clot lysis in 80.7% of limbs (n = 21) compared with 84.2% of limbs (n = 16) treated with CDT plus PMT (P = .764). The incidences of major bleeding (CDT, 7.7%; CDT plus PMT, 5.3%; P = .749) and pulmonary embolism (CDT, 3.8%; CDT plus PMT, 5.3%; P = .818) were similar. The mean urokinase and PMT device cost for CDT alone was $10,127 compared with $5,128 for CDT plus PMT (P = .026).

CONCLUSIONS

Percutaneous CDT with rheolytic PMT is as effective as CDT alone for acute iliofemoral DVT but requires significantly shorter treatment and lower lytic agent dose, resulting in lower costs. Randomized studies to confirm the benefits of pharmacomechanical thrombolysis in the treatment of DVT are warranted.

Mobilization versus immobilization in the treatment of acute proximal deep venous thrombosis: a prospective, randomized, open, multicentre trial

OBJECTIVE

The aim of prescribing strict bed rest for acute deep venous thrombosis is to reduce the risk of pulmonary embolism and pain in the legs, as well as swelling. This study was performed in order to compare outcome of mobilization against 5 days of strict bed rest in patients with acute proximal deep venous thrombosis (DVT).

METHODS

103 in-patients with proximal DVT or patients admitted to the hospital because of proximal DVT were recruited to a randomized study. All patients were treated in hospital and given a lower leg and thigh compression bandage as well as therapeutic doses of the low molecular weight heparin, dalteparin-sodium (Fragmin).

RESULTS

Seven of 52 patients (13.5%) in the mobile group versus 14 of 50 patients (28.0%) in the immobile group suffered at least one of the outcomes defined under the combined primary endpoint (clinically relevant pulmonary embolisms, pulmonary embolisms detectable by scintigraphy or computer tomography, progression of thrombosis or new thrombosis, nosocomial infections and/or serious adverse events) (p = 0.088), whereby serious adverse events occurred once in the mobile group and three times in the immobile group. New pulmonary embolisms over the course were seen in 10 of 50 patients (20%) with a perfusion disorder at baseline scintigraphy, while such was ascertained only in one of 52 patients (1.9%) without a perfusion disorder at baseline scintigraphy. Leg pain was reduced from 54.1 (+/-30.4) to 20.7 (+/-19.2) in the mobilized group and from 41.0 (+/-26.8) to 14.0 (+/-11.1) in the immobilized patients. Leg pain was assessed using the visual analogue scale (0 = no pain, 100 = maximum pain). More immobilized patients complained of increasing back pain (23% versus 6%) and disturbed micturition (10% versus 2%) as well as defecation (13% versus 6%) on day 5. More patients in the mobile group reported increased stress from the thrombosis and its treatment (15% versus 6%).

CONCLUSIONS

No benefit of prescribing bed rest in patients with deep venous thrombosis could be detected in this study. Based on data available, strict bed rest for at least 5 days is not justified if adequate therapy with low molecular weight heparin and adequate compression is assured. It remains open whether patients with initial signs of pulmonary embolism might profit from a brief immobilization.

Cost-effectiveness of low-molecular-weight heparin for treatment of pulmonary embolism

BACKGROUND

Low-molecular-weight heparin (LMWH) appears to be safe and effective for treating pulmonary embolism (PE), but its cost-effectiveness has not been assessed.

METHODS

We built a Markov state-transition model to evaluate the medical and economic outcomes of a 6-day course with fixed-dose LMWH or adjusted-dose unfractionated heparin (UFH) in a hypothetical cohort of 60-year-old patients with acute submassive PE. Probabilities for clinical outcomes were obtained from a meta-analysis of clinical trials. Cost estimates were derived from Medicare reimbursement data and other sources. The base-case analysis used an inpatient setting, whereas secondary analyses examined early discharge and outpatient treatment with LMWH. Using a societal perspective, strategies were compared based on lifetime costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio.

RESULTS

Inpatient treatment costs were higher for LMWH treatment than for UFH (dollar 13,001 vs dollar 12,780), but LMWH yielded a greater number of QALYs than did UFH (7.677 QALYs vs 7.493 QALYs). The incremental costs of dollar 221 and the corresponding incremental effectiveness of 0.184 QALYs resulted in an incremental cost-effectiveness ratio of dollar 1,209/QALY. Our results were highly robust in sensitivity analyses. LMWH became cost-saving if the daily pharmacy costs for LMWH were < dollar 51, if > or = 8% of patients were eligible for early discharge, or if > or = 5% of patients could be treated entirely as outpatients.

CONCLUSION

For inpatient treatment of PE, the use of LMWH is cost-effective compared to UFH. Early discharge or outpatient treatment in suitable patients with PE would lead to substantial cost savings.

Treatment of venous thromboembolism: Adherence to guidelines and impact of physician knowledge, attitudes, and beliefs

OBJECTIVES

To assess the treatment of venous thromboembolism (VTE) in hospitalized patients enrolled in a national, multicenter database.

METHODS

This was a retrospective, cohort study that randomly selected VTE patients from 38 academic/teaching, community, and Veterans Administration (VA) hospitals. The study included a physician survey component. The patients selected were those treated between January 2002 and June 2003 who had an ICD-9-CM code for pulmonary embolus (PE), deep vein thrombosis (DVT), or pregnancy-related PE or DVT.

RESULTS

The study included 939 patients: 52.7% with DVT, 28.4% with PE, and 18.8% with PE and DVT. Mean age was 59.5 years. Risk factors included obesity (body mass index > 30) in 30.1%, history of VTE in 28.0%, malignancy in 27.4%, surgery in 21.1%, and immobility in 18.5%. Only 56.1% of patients were treated with low-molecular-weight heparin (LMWH). Bridging from LMWH or unfractionated heparin (UFH) to warfarin was completed during hospitalization in 486 (68.6%), but only 246 (50.6%) had an international normalized ratio (INR) > or = 2 for 48 hours before discontinuation of the injectable anticoagulant. Length of stay in patients discharged on bridge therapy was 4.0 +/- 3.7 days vs 8.1 +/- 5.8 days for patients discharged on warfarin therapy (P < .001). Ninety-two (10.1%) patients were discharged with neither oral nor injectable anticoagulation and had a mean duration of treatment of only 10.6 +/- 16.2 days. Of 245 physicians surveyed from participating hospitals, 84% and 53%, respectively, indicated that LMWH was their preferred agent for treatment of DVT and treatment of PE. With regard to warfarin, 30% did not believe it was necessary to have a therapeutic INR for > or = 2 days before discontinuing LMWH or UFH, and 27% responded that it was necessary to keep DVT patients in the hospital until they were therapeutic.

CONCLUSIONS

In this cross-section of United States hospitals, lower than anticipated use of LMWH, insufficient bridging from UFH or LMWH to warfarin, and continuation of anticoagulation after hospitalization were all problems discovered with the treatment of VTE. Physician knowledge, attitudes, and beliefs are partially responsible for the gap between actual practice and international guidelines. These results suggest that hospitals should evaluate their adherence to international VTE treatment guidelines and develop strategies to optimize antithrombotic therapy.

Implementation of outpatient treatment of deep-vein thrombosis in private practices in Germany

OBJECTIVE

Implementation of outpatient treatment (OT) of deep-vein thrombosis (DVT) is slow despite clear evidence that it is effective, safe and cost-efficient.

DESIGN AND METHOD

An initiative was launched with the help of the Professional Association of Phlebologists of Germany and the industry to familiarize physicians in private practice who had no prior experience with OT of DVT. Data on quality of treatment with the low-molecular-weight heparin tinzaparin and phenprocoumon, compliance, clinical outcome, venous ultrasound, patients' satisfaction and quality of life were collected in a registry, which was open from July 1999 to December 2000. The results were published and their impact on further management of patients was assessed in second survey reported here. Patients of both series were followed-up clinically and with ultrasound over the 1st month of treatment.

RESULTS

Of 67 physicians entering 827 patients into the registry 26 answered a questionnaire on how they treated further patients. Their case load had increased by 450% and data were provided on 540 consecutive patients managed between January and June 2002. OT increased overall from 76 to 92%, that of popliteo-femoral DVT from 71 to 92%, and that of pelvic DVT from 38 to 65%. Medical reasons to decide against OT decreased from 89 to 56% (p<.01). Immediate leg compression was changed from bandaging to medical compression stockings in 20 of the 26 centres (p<.05). In total, data were gathered from OT of 1124 patients. No secondary hospitalisations were required and only one patient had a documented progression of the DVT.

CONCLUSIONS

OT was successfully implemented in private practices through the initiative of individual physicians with support of the professional association and sponsoring by the industry-to the benefit of the providers but as much of the patients and their cost bearers.

Deep vein thrombosis

Deep vein thrombosis and its sequelae pulmonary embolism and post-thrombotic syndrome are some of the most common disorders. A thrombus either arises spontaneously or is caused by clinical conditions including surgery, trauma, or prolonged bed rest. In these instances, prophylaxis with low-dose anticoagulation is effective. Diagnosis of deep vein thrombosis relies on imaging techniques such as ultrasonography or venography. Only about 25% of symptomatic patients have a thrombus. Thus, clinical risk assessment and D-dimer measurement are used to rule out deep vein thrombosis. Thrombus progression and embolisation can be prevented by low-molecular-weight heparin followed by vitamin K antagonists. Use of these antagonists for 3-6 months is sufficient for many patients. Those with antithrombin deficiency, the lupus anticoagulant, homozygous or combined defects, or with previous deep vein thrombosis can benefit from indefinite anticoagulation. In cancer patients, low-molecular-weight heparin is more effective than and is at least as safe as vitamin K antagonists. Women seem to have a lower thrombosis risk than men, but pregnancy or use of oral contraceptives or hormone replacement therapy represent important risk factors.

Pharmacologic therapy for the management of thrombosis: Unfractionated heparin or low-molecular-weight heparin?

Heparin and heparin-derived drugs play a major therapeutic role in thrombotic and cardiovascular disorders. Infusion of unfractionated heparin (UFH) followed by warfarin has traditionally been the standard pharmacologic therapy for treatment of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism, and for initial therapy of non-ST-elevation (NSTE) acute coronary syndrome (ACS). More recently, low-molecular-weight heparins (LMWHs) have been shown to provide at least as good efficacy and safety outcomes as UFH regimens for prevention of these conditions. In addition to good efficacy outcomes with LMWHs compared with UFH, LMWHs have other advantages over UFH, including improved bioavailability, QD administration, more predictable anticoagulant response, lack of the need for monitoring, and suitability for outpatient use, thereby increasing convenience, reducing cost, and improving cost-to-benefit ratios. In carefully screened and managed patients, LMWH offers a cost-effective, convenient, and safe alternative to UFH for thrombosis management. The aim of this article is to summarize efficacy, safety, and pharmacoeconomic considerations when selecting LMWH versus UFH for thrombosis management in VTE and NSTE ACS.

Traitement de la maladie thromboembolique veineuse chez les patients souffrant de cancers

PURPOSE

Venous tromboembolic treatment in patients with cancer can be a clinical dilemma. Comorbid conditions, significant risk of recurrence of bleeding associated with warfarin, difficult venous access, are some of the factors that often complicate anticoagulants therapy in patients with cancer.

EXEGESIS

Low molecular weight heparin has replaced unfractionated heparin as the first line treatment in the majority of patients with venous thromboembolism and cancer, in hospital or safely at home. Recent trial demonstrated that long-term low molecular weight heparin administrated over a 6-month period reduced the rate of recurrence venous thromboembolism with non increase in bleeding compared with oral anticoagulant therapy. Placement of an inferior vena caval filter should be reserved for patients with active or very high risk of bleeding, but oncologist should consider these sobering results in such patients. Whether anticoagulants might also improve cancer survival rates independent of their effect on thromboembolism deserves further investigation.

PERSPECTIVE

In future, new antithrombotic agents such as oral direct thrombin or long-acting synthetic factor Xa inhibitor may be useful in these patients.