Patients' experience and compliance with extended low molecular weight heparin prophylaxis post-surgery for gynecological cancer: a prospective observational study

Avoiding the needle: A quality improvement program introducing apixaban for extended thromboprophylaxis after major gynecologic cancer surgery

OBJECTIVE

Patients undergoing gynecologic cancer surgery at our centre are recommended up to 28 days of enoxaparin for extended post-operative thromboprophylaxis (EP). Baseline survey revealed 92% patient adherence, but highlighted negative effects on patient experience due to the injectable route of administration. We aimed to improve patient experience by reducing pain and bruising by 50%, increasing adherence by 5%, and reducing out-of-pocket cost after introducing apixaban as an oral alternative for EP.

METHODS

In this interrupted time series quality improvement study, gynecologic cancer patients were offered a choice between apixaban (2.5 mg orally twice daily) or enoxaparin (40 mg subcutaneously once daily) at time of discharge. A multidisciplinary team informed project design, implementation, and evaluation. Process interventions included standardized orders, patient and care team education programs. Telephone survey at 1 and 6 weeks and chart audit informed outcome, process, and balancing measures.

RESULTS

From August to October 2022, 127 consecutive patients were included. Apixaban was chosen by 84%. Survey response rate was 74%. Patients who chose apixaban reported significantly reduced pain, bruising, increased confidence with administration, and less negative impact of the medication (p < 0.0001 for all). Adherence was unchanged (92%). The proportion of patients paying less than $125 (apixaban cost threshold) increased from 45% to 91%. There was no difference in bleeding and no VTE events.

CONCLUSIONS

Introduction of apixaban for EP was associated with significant improvement in patient-reported quality measures and reduced financial toxicity with no effect on adherence or balancing measures. Apixaban is the preferred anticoagulant for EP at our centre.

Direct oral anticoagulants (DOACs) use for prolonged venous thromboembolism prophylaxis following surgery for gynaecological malignancies in Australia and New Zealand - A clinician survey

BACKGROUND

Current international guidelines recommend 28 days of enoxaparin as venous thromboembolism (VTE) prophylaxis after surgery for gynaecologic cancer. Direct oral anticoagulants (DOACs) have been investigated as an alternative to enoxaparin for post-operative VTE prophylaxis. High-quality evidence to demonstrate safety and efficacy is lacking.

AIMS

We aim to investigate the current practice regarding VTE prophylaxis among gynaecological oncologists in Australia and New Zealand following laparotomy for gynaecological malignancy, in particular the use of DOACs for VTE prophylaxis.

MATERIALS AND METHODS

Sixty-seven practising gynaecologic oncologists (GO) were identified through Royal Australia and New Zealand College of Obstetricians and Gynaecologists database and emailed online surveys that asked about VTE prophylaxis practice and views of DOACs in this setting. Data were then collected through Survey Monkey and evaluated.

RESULTS

The majority (77.1%) routinely prescribed 28 days of enoxaparin following laparotomy for gynaecological malignancies. In clinical circumstance such as laparoscopy for gynaecological malignancies and surgery for vulva malignancies, there was variation in thromboprophylaxis practices. No GO reported routine use of DOACs in any clinical circumstance. There were 56% of GOs who used a DOAC in their practice at some point. Barriers to routine use of DOACs in current practice included insufficient evidence (68%), issue with cost (40.4%) and concerns about safety (29.7%).

CONCLUSIONS

Enoxaparin prescribed for 28 days remains the current clinical practice in preventing VTE following laparotomy for gynaecological malignancy. The main barrier to routine DOAC use as post-operative thromboprophylaxis is a lack of evidence which reflects the need for a larger prospective study.

Is It Safe to Resume Direct Oral Anticoagulants upon Discharge after Hip Fracture Surgery? A Retrospective Study

This study aimed to examine the incidence rate of early reoperations following hip fracture surgery and determine the safety of resuming direct oral anticoagulants. Many orthopedic surgeons are reluctant to resume chronic anticoagulation therapy for patients after surgical intervention for hip fractures. One of the main reasons is the potential for reoperation in the case of surgical complications. We conducted a retrospective cohort study at an Academic Level I trauma center, reviewing the records of 425 geriatric patients (age > 60) who underwent hip fracture surgery between 2018 and 2020, including a subgroup treated with direct oral anticoagulants prior to hospitalization. The study assessed the incidence rate of complications requiring early reoperation. Out of the 425 patients, only nine (2%) required reoperation within a month after discharge, with two (0.5%) on chronic anticoagulation therapy. None of the reoperations were urgent, and all were performed at least 24 h after re-admission. The findings revealed a very low incidence rate of reoperations in patients who underwent hip fracture surgery, with no reoperations performed within 24 h of re-admission. Consequently, we believe that resuming chronic direct oral anticoagulants is a safe and effective approach when discharging patients after hip fracture surgery.

Adherence to Extended Venous Thromboembolism Prophylaxis and Outcomes After Complex Gastrointestinal Oncologic Surgery

BACKGROUND

Clinical guidelines recommend extended venous thromboembolism (VTE) prophylaxis for cancer patients after major gastrointestinal (GI) operations. However, adherence to the guidelines has been low, and the clinical outcomes not well defined.

METHODS

This study retrospectively analyzed a random 10 % sample of the 2009-2022 IQVIA LifeLink PharMetrics Plus database, an administrative claims database representative of the commercially insured population of the United States. The study selected cancer patients undergoing major pancreas, liver, gastric, or esophageal surgery. The primary outcomes were 90-day post-discharge VTE and bleeding.

RESULTS

The study identified 2296 unique eligible operations. During the index hospitalization, 52 patients (2.2 %) experienced VTE, 74 patients (3.2 %) had postoperative bleeding, and 140 patients (6.1 %) had a hospital stay of at least 28 days. The remaining 2069 operations comprised 833 pancreatectomies, 664 hepatectomies, 295 gastrectomies, and 277 esophagectomies. The median age of the patients was 49 years, and 44 % were female. Extended VTE prophylaxis prescriptions were filled for 176 patients (10.4 % for pancreas, 8.1 % for liver, 5.8 % for gastric cancer, and 6.5 % for esophageal cancer), and the most used agent was enoxaparin (96 % of the patients). After discharge, VTE occurred for 5.2 % and bleeding for 5.2 % of the patients. The findings showed no association of extended VTE prophylaxis with post-discharge VTE (odds ratio [OR], 1.54; 95 % confidence interval [CI], 0.81-2.96) or bleeding (OR, 0.72, 95 % CI, 0.32-1.61).

CONCLUSIONS

The majority of the cancer patients undergoing complex GI surgery did not receive extended VTE prophylaxis according to the current guidelines, and their VTE rate was not higher than for the patients who received it.

Apixaban for extended postoperative thromboprophylaxis in gynecologic oncology patients undergoing laparotomy

INTRODUCTION

Venous thromboembolic events represent the second most frequent cause of mortality in cancer patients. Recent literature shows that direct oral anticoagulants (DOAC) are at least as effective and safe as low molecular weight heparin for postoperative thromboprophylaxis. However, this practice has not been broadly adopted in gynecologic oncology. The aim of this study was to evaluate clinical effectiveness and safety of apixaban for extended thromboprophylaxis in comparison to enoxaparin after laparotomies for gynecologic oncology patients.

METHODS

The Gynecologic Oncology Division at a large tertiary center transitioned from enoxaparin 40 mg daily to apixaban 2.5 mg BID for 28 days after laparotomies for gynecologic malignancies in November 2020. This real-world study compared patients post-transition (November 2020 to July 2021 (n = 112)) to a historical cohort (January to November 2020 (n = 144)), using the institutional National Surgical Quality Improvement Program (NSQIP) database. All Canadian gynecologic oncology centers were surveyed to assess postoperative DOAC utilization.

RESULTS

Patient characteristics were similar between groups. No difference was found between total venous thromboembolism rates (4% vs. 3%, p = 0.49). No difference was found in postoperative readmission (5% vs. 6%, p = 0.50). Of the 7 readmissions in the enoxaparin group, one was due to bleeding requiring transfusion; there were no readmissions for bleeding in the apixaban group. No patient required a reoperation for bleeding. Thirteen percent of the 20 Canadian centers have transitioned to extended apixaban thromboprophylaxis.

CONCLUSIONS

Apixaban for 28-day postoperative thromboprophylaxis was found to be an effective and safe alternative to enoxaparin after laparotomies in a real-world cohort of gynecologic oncology patients.

Adherence to apixaban for extended thromboprophylaxis after major abdominal or pelvic surgery for cancer: A prospective cohort study

BACKGROUND

Due to lack of data, direct oral anticoagulants are not considered by guidelines for venous thromboembolism (VTE) prophylaxis after cancer surgery. Adherence to low-molecular-weight heparin injections in this setting is sometimes poor.

AIM

Analysis of adherence to oral apixaban for extended thromboprophylaxis.

METHODS

Consecutive patients discharged after major surgery for abdominal/pelvic cancer and considered eligible for extended prophylaxis were offered apixaban 2.5 mg twice daily. Primary outcomes were adherence metrics-proportion of prescriptions filled, persistence (not prematurely discontinued), proportion of days covered (PDC) based on apixaban pill counts, and modified Morisky medication adherence scale at Days 28-30. Secondary outcomes were bleeding, VTE, and serious adverse events until Day 90.

RESULTS

We included 53 patients, 51 were analyzed. Of 45 patients with prescriptions all had it filled (95% confidence interval [CI], 92%-100%). Persistence was 98% (95% CI, 90%-100%). PDC was ≥80% for 48 patients (94%; 95% CI, 84%-99%). We found good adherence (0/6 answers "yes") in 75% and moderate (1/6 answers "yes") in 25%. No major bleed or VTE occurred while on apixaban.

CONCLUSION

Our results support good adherence with apixaban for VTE prophylaxis up to 28 days after major abdominal or pelvic cancer surgery.

Use of direct oral anticoagulants for postoperative venous thromboembolism prophylaxis after surgery for gynecologic malignancies

Venous thromboembolism is a preventable cause of postoperative mortality in patients undergoing surgery for malignancy. Current standard of care based on international guideline recommends 28 days of extended thromboprophylaxis after major abdominal and pelvic surgery for malignancies with unfractionated heparin or low molecular weight heparin. Direct oral anticoagulants have been approved for the treatment of venous thromboembolism in the general population. This regimen has a significant advantage over other types of anticoagulation regimens, particularly being administered by non-parenteral routes and without the need for laboratory monitoring. In this review, we evaluate the role of direct anticoagulation and provide an update on completed and ongoing clinical trials.

A network meta-analysis of direct oral anticoagulants for portal vein thrombosis in cirrhosis

BACKGROUND

Current guidelines have limited consensus on the approach to portal venous thrombosis (PVT) in cirrhotic patients. While there is rising interest in direct oral anticoagulants (DOACs) use for PVT, current evidence is limited by small sample size and lack of comparisons to traditional anticoagulants. Thus, a network meta-analysis was conducted to compare the use of DOACs with traditional anticoagulants.

METHODS

Medline and Embase were searched for articles about anticoagulation use in cirrhotic patients with nontumorous PVT for articles on DOACs, warfarin, low-molecular weight heparin (LMWH) or antithrombin III. A network analysis was conducted using risk ratios (RR) with surface under the cumulative ranking curve (SUCRA). A single-arm meta-analysis was used to summarize the outcomes of DOAC treatment.

RESULTS

A total of 10 articles were included in the study. 79.5% (CI 38.8-95.9) of DOACs patients achieved complete or partial recanalization and 9.80% (CI 4.50-20.0) experienced a bleeding event. DOACs were superior to LMWH (RR 2.299, CI 1.037-5.093, p = 0.040), warfarin (RR 1.762, CI 1.017-3.053, p = 0.043) and no treatment (RR 3.489, CI 1.394-8.733, p = 0.008) in complete recanalization. For partial recanalization, while DOACs were not superior to any treatment, they had the highest probability in achieving partial recanalization in SUCRA analysis. Bleeding risk and mortality were similar compared to other treatments.

CONCLUSION

The network analysis supports the use of DOACs in cirrhotic patients, with significant rates of complete recanalization compared to other treatments without increasing bleeding risk. DOACs can potentially be considered for nontumorous PVT in cirrhosis.

Patient's compliance is a contributor to failure of extended antithrombotic prophylaxis in colorectal surgery: prospective cohort study

BACKGROUND

Venous thromboembolic events (VTE) continue to be a major source of morbidity following colorectal surgery. Selective extended VTE prophylaxis for high-risk patients is recommended; however, provider compliance is low. The purpose of this study is to evaluate whether the "global" extended use of enoxaparin in all colorectal patients is feasible and safe.

METHODS

This is a prospective study conducted at a tertiary care center. All Patients undergoing elective colorectal procedures from November 1, 2017 to October 31, 2018 were discharged on 30 days of enoxaparin. Safety of use and patient compliance were examined.

RESULTS

Total of 270 patients received extended prophylaxis during the study period (100% of intended patients) with five VTE recorded (1.85%). There was no significant difference in rates of VTE or complications when compared to years of selective prophylaxis (1.26% for 2016, 2.32% for 2017). Only 64% of patients reported full compliance.

CONCLUSION

Global use of extended enoxaparin prophylaxis is safe, but does not decrease rates of VTE when compared to selective use. Patient's non-adherence is likely a significant contributing factor.

Incidence of venous thromboembolism among patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer

OBJECTIVES

Neoadjuvant chemotherapy may be considered for women with epithelial ovarian cancer who have poor performance status or a disease burden not amenable to primary cytoreductive surgery. Overlap exists between indications for neoadjuvant chemotherapy and known risk factors for venous thromboembolism, including impaired mobility, increasing age, and advanced malignancy. The objective of this study was to determine the rate of venous thromboembolism among women receiving neoadjuvant chemotherapy for epithelial ovarian cancer.

METHODS

A multi-institutional, observational study of patients receiving neoadjuvant chemotherapy for primary epithelial ovarian, fallopian tube, or peritoneal cancer was conducted. Primary outcome was rate of venous thromboembolism during neoadjuvant chemotherapy. Secondary outcomes included rates of venous thromboembolism at other stages of treatment (diagnosis, following interval debulking surgery, during adjuvant chemotherapy, or during treatment for recurrence) and associations between occurrence of venous thromboembolism during neoadjuvant chemotherapy, subject characteristics, and interval debulking outcomes. Venous thromboembolism was defined as deep vein thrombosis in the upper or lower extremities or in association with peripherally inserted central catheters or ports, pulmonary embolism, or concurrent deep vein thrombosis and pulmonary embolism. Both symptomatic and asymptomatic venous thromboembolism were reported.

RESULTS

A total of 230 patients receiving neoadjuvant chemotherapy were included; 63 (27%) patients overall experienced a venous thromboembolism. The primary outcome of venous thromboembolism during neoadjuvant chemotherapy occurred in 16 (7.7%) patients. Of the remaining venous thromboembolism events, 22 were at diagnosis (9.6%), six post-operatively (3%), five during adjuvant chemotherapy (3%), and 14 during treatment for recurrence (12%). Patients experiencing a venous thromboembolism during neoadjuvant chemotherapy had a longer mean time to interval debulking and were less likely to undergo optimal cytoreduction (50% vs 80.2%, p=0.02).

CONCLUSIONS

Patients with advanced ovarian cancer are at high risk for venous thromboembolism while receiving neoadjuvant chemotherapy. Consideration of thromboprophylaxis may be warranted.