Management and adherence to VTE treatment guidelines in a national prospective cohort study in the Canadian outpatient setting

Efficacy and safety of direct oral anticoagulants for preventing venous thromboembolism in hospitalized cancer patients: a national multicenter retrospective cohort study

Introduction

Studies on the use of direct oral anticoagulants (DOACs) for preventing venous thromboembolism (VTE) in hospitalized cancer patients are lacking. Therefore, we conducted a multicenter retrospective cohort study to evaluate the efficacy and safety of DOACs versus low-molecular-weight heparin (LMWH) for the primary prevention of VTE in hospitalized cancer patients.

Methods

Clinical outcomes included thrombosis, VTE, other thrombosis, all bleeding, major bleeding, nonmajor bleeding, and all-cause death. A 1:1 cohort of rivaroxaban and LMWH patients was created by propensity score matching.

Results

A total of 2,385 cancer patients were included in this study. During the 3-month follow-up period, 129 (5.4%) thrombosis events occurred, 63 (2.7%) of which were VTEs and 66 (2.8%) of which were other thrombosis events. All bleeding occurred in 163 (6.8%) patients, 68 (2.9%) had major bleeding, and 95 (4.0%) had nonmajor bleeding. All-cause deaths occurred in 113 (4.7%) patients. After adjusting for various confounders, the incidence of thrombosis and other thromboses was significantly lower in the rivaroxaban group than in the LMWH group [OR 0.543, 95% CI (0.343-0.859), p = 0.009; OR 0.461, 95% CI (0.241-0.883), p = 0.020]. There were no significant differences in incidence of VTE, total bleeding, major bleeding, nonmajor bleeding, or all-cause death.

Conclusion

In oncology patients receiving thromboprophylaxis, rivaroxaban has a lower incidence of thrombosis and other thrombosis and a similar incidence of VTE as LMWH and does not increase the risk of bleeding. Rivaroxaban may be an attractive alternative to LMWH for preventing VTE in hospitalized cancer patients.

The Role of Direct Oral Anticoagulants in the Treatment of Cancer-Associated Venous Thromboembolism: Review by Middle East and North African Experts

Venous thromboembolism is a leading cause of morbidity and mortality in patients with active cancer who require anticoagulation treatment. Choice of anticoagulant is based on careful balancing of the risks and benefits of available classes of treatment: vitamin K antagonists, low-molecular-weight heparin (LMWH), and direct oral anticoagulants (DOACs). Results from randomized controlled trials have shown the consistent efficacy of DOACs versus LMWH in the treatment of cancer-associated venous thromboembolism (VTE). However, increased major gastrointestinal bleeding was observed for edoxaban and rivaroxaban, but not apixaban, compared with LMWH dalteparin. Most guidelines recommend DOACs for the treatment of cancer-associated VTE in patients without gastrointestinal or genitourinary cancer, and with considerations for renal impairment and drug-drug interactions. These updates represent a major paradigm shift for clinicians in the Middle East and North Africa. The decision to prescribe a DOAC for a patient with cancer is not always straightforward, particularly in challenging subgroups of patients with an increased risk of bleeding. In patients with gastrointestinal malignancies who are at high risk of major gastrointestinal bleeds, apixaban may be the preferred DOAC; however, caution should be exercised if patients have upper or unresected lower gastrointestinal tumors. In patients with gastrointestinal malignancies and upper or unresected lower gastrointestinal tumors, LMWH may be preferred. Vitamin K antagonists should be used only when DOACs and LMWH are unavailable or unsuitable. In this review, we discuss the overall evidence for DOACs in the treatment of cancer-associated VTE and provide treatment suggestions for challenging subgroups of patients with cancer associated VTE.

Comparison of the Efficacy and Safety of Rivaroxaban and Low Molecular Heparin in Preventing Venous Thromboembolism in Inpatient Cancer Patients

BACKGROUND

There are few studies on using rivaroxaban and low molecular heparin (LMWH) to prevent venous thromboembolism (VTE) in hospitalized cancer patients.

OBJECTIVE

We conducted a retrospective study to evaluate the efficacy and safety of rivaroxaban versus LMWH for the primary prevention of VTE in inpatient cancer patients.

METHODS

Information on patients was collected through 6-month follow-up and medical record inquiries. Clinical outcomes included VTE, total bleeding, thrombosis, major bleeding, minor bleeding, all-cause death, and a composite endpoint of bleeding, thrombosis, and death.

RESULTS

A total of 602 hospitalized cancer patients were included in this study. During 6 months of follow-up, there were 26 VTE events (8.6%), 42 total bleeding events (7.0%), 62 all-cause deaths (10.3%), and 140 composite endpoints (23.3%). After adjusting for various confounding factors, there were no significant differences between the rivaroxaban and LMWH for VTE events (OR = 0.851, 95% CI [0.387-1.872], P=0.688), total bleeding (OR = 1.690, 95% CI [0.768-3.719], P = 0.192], thrombosis events (OR = 0.919, 95% CI [0.520-1.624], P = 0.772], major bleeding (OR = 0.276, 95% CI [0.037-2.059], P = 0.209), all-cause death (OR = 0.994, 95% CI [0.492-2.009], P = 0.987), and composite endpoints (OR = 0.994, 95% CI [0.492-2.009], P = 0.987), while minor bleeding (OR = 3.661 95% CI [1.000-7.083], P = 0.050) was significantly higher in the rivaroxaban than in the LMWH.

CONCLUSIONS AND RELEVANCE

In thromboprophylaxis in inpatient cancer patients, rivaroxaban has a similar rate of VTE and bleeding events as LMWH. Our results may provide a reference for the clinical use of rivaroxaban to prevent VTE in hospitalized cancer patients.

Care pathways for patients with cancer-associated thrombosis: From diagnosis to long-term follow-up

Venous thromboembolism (VTE) in patients with cancer is associated with a high risk of bleeding complications and hospitalisation, as well as with increased mortality. Good practice recommendations for diagnosis and treatment of VTE in patients with cancer have been developed by a number of professional bodies. Although these guidelines provide consistent recommendations on what treatment should be offered to patients presenting with cancer-associated thromboembolism (CAT), many questions remain unanswered, in particular about the modalities of management (Who? When? Where?) and, for this reason, we have developed a consensus proposal for an appropriate multidisciplinary care pathway for patients with CAT, which is presented in this article. The proposal was informed by the recent scientific literature retrieved through a systematic literature review. This proposal is centred on the development of a shared care plan individualised to each patient's needs and expectations, patient information and shared decision-making to promote adherence, involvement of all relevant hospital- and community- based healthcare providers in the development and implementation of the care plan, and regular re-evaluation of the treatment strategy.

Non-Vitamin K Antagonist Oral Anticoagulants versus Low Molecular Weight Heparin for Cancer-Related Venous Thromboembolic Events: Individual Patient Data Meta-Analysis

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients. Low molecular weight heparin (LMWH) has been the standard of care but new guidelines have approved the use of non-vitamin K antagonist oral anticoagulants (NOAC). By conducting an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) comparing the outcomes of NOAC versus LMWH in cancer patients, we aim to determine an ideal strategy for the prophylaxis of VTE and prevention of VTE recurrence. Three databases were searched from inception until 19 October 2022. IPD was reconstructed from Kaplan-Meier curves. Shared frailty, stratified Cox and Royston-Parmar models were fit to compare the outcomes of venous thromboembolism recurrence and major bleeding. For studies without Kaplan-Meier curves, aggregate data meta-analysis was conducted using random-effects models. Eleven RCTs involving 4844 patients were included. Aggregate data meta-analysis showed that administering NOACs led to a significantly lower risk of recurrent VTE (RR = 0.65; 95%CI: 0.50-0.84) and deep vein thrombosis (DVT) (RR = 0.60; 95%CI: 0.40-0.90). In the IPD meta-analysis, NOAC when compared with LMWH has an HR of 0.65 (95%CI: 0.49-0.86) for VTE recurrence. Stratified Cox and Royston-Parmar models demonstrated similar results. In reducing risks of recurrent VTE and DVT among cancer patients, NOACs are superior to LMWHs without increased major bleeding.

Direct oral anticoagulants for venous thromboembolism in cancer patients: a systematic review and network meta-analysis

BACKGROUND

The efficacy and safety of direct oral anticoagulants (DOACs), including dabigatran, apixaban, rivaroxaban, and edoxaban, for preventing and treating venous thromboembolism (VTE) in patients with cancer is unclear.

METHODS

We searched the PubMed, Embase, Web of Science, and Cochrane Library databases from the establishment to November 30, 2021. In the frequency-based network meta-analysis, the odds ratio with a 95% confidence interval was reported. The relative ranking probability of each group was generated based on the surface under the cumulative ranking curve (SUCRA).

RESULTS

We included 15 randomized controlled trials involving a total of 6162 patients. Apixaban reduced the risk of VTE compared with low-molecular heparin [OR = 0.53, 95% CI (0.32, 0.89)]. The efficacy of drugs was ranked from highest to lowest as follows: apixaban (SUCRA, 81.0), rivaroxaban (73.0), edoxaban (65.9), dabigatran (51.4), warfarin (30.8), and low-molecular-weight heparin (LMWH) (27.4). Edoxaban increased the risk of major bleeding compared with LMWH [OR = 1.83, 95% CI (1.04, 3.22)]. The safety of drugs was ranked from highest to lowest as follows: major bleeding-apixaban (SUCRA, 68.5), LMWH (55.1), rivaroxaban (53.0), warfarin (35.9), dabigatran (29.2), edoxaban (16.5) and clinically relevant non-major bleeding-LMWH (73.0), apixaban (57.8), edoxaban (45.8), rivaroxaban (35.3), and warfarin (10.8).

CONCLUSIONS

For preventing and treating VTE, in terms of VTE occurrence and major bleeding, apixaban had the lowest risk; in terms of clinically relevant non-major bleeding, LMWH had the lowest risk, followed by apixaban. Generally, apixaban is the most efficient and safest DOAC and presents better efficacy and relatively low bleeding risk among the VTE prevention and treatment drugs for patients with cancer.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Reducing emergency department visits in patients with deep vein thrombosis: introducing a standardised outpatient treatment pathway

Deep vein thrombosis (DVT) is an acute medical condition that requires urgent diagnosis and treatment to prevent significant morbidity and mortality. Patients with DVT frequently present to the emergency department (ED) because the necessary diagnostic investigations and medical treatment for successful outpatient management are not readily accessible in the outpatient clinics. A collaborative quality improvement project was undertaken to implement and evaluate a standardised outpatient treatment pathway designed to direct patients with a newly diagnosed DVT from the ultrasound department to the thrombosis clinic, where guideline-based management for DVT can be accomplished without ED visits. During the baseline period (1 February 2017 to 31 January 2019), the number of ED visits for DVT was 383 with an average of 16 visits per month. During the intervention period (1 February 2019 to 31 January 2020), the number of ED visits for DVT was 106 with an average of 8.8 visits per month. This represents almost a 50% reduction in the average ED visits during the intervention period. A standardised outpatient treatment pathway can significantly reduce the number of ED visits in patients with DVT, potentially improving patient care and reducing ED overcrowding.

Oral Anticoagulation Therapy for Venous Thromboembolism in Norway: Time Trends and Treatment Patterns

PURPOSE

Data describing treatment patterns of patients with venous thromboembolism (VTE) patients in Scandinavia are scarce. This study sought to address this scarcity by describing demographic and clinical characteristics, trends in the use of oral anticoagulants (OACs), and treatment patterns in patients treated for VTE in Norway between 2013 and 2017.

METHODS

Using data from Norway's nationwide registries, a cohort study included patients newly (after 2008) treated OACs who were diagnosed with VTE between January 2013 and December 2017 and were dispensed an OAC (warfarin, apixaban, rivaroxaban, dabigatran, or edoxaban) within 30 days. Patient characteristics and the percentage of patients with VTE who initiated treatment with each OAC for each calendar year were reported. Initial therapy persistence was assessed using Kaplan-Meier curves and compared between the OAC groups using the log-rank test.

FINDINGS

The comorbidity burden was similar between patients taking warfarin and those taking apixaban but lower among patients taking rivaroxaban. Direct oral anticoagulant (DOAC) use increased from 33.2% to 93.6% during the study period, whereas warfarin use decreased. Persistence was higher in the apixaban cohort compared with the warfarin cohort, with the difference mostly apparent after 6 months, whereas persistence was similar between the patients taking rivaroxaban and those taking warfarin.

IMPLICATIONS

Between 2013 and 2017, DOAC use among patients with VTEs increased markedly in Norway, whereas the use of warfarin decreased. Patients taking apixaban had higher persistence compared with those taking warfarin, whereas patients taking warfarin and those taking rivaroxaban had similar persistence. Further studies with longer follow-up are required to examine the use of extended OAC treatment for VTE.

Delayed anticoagulation in venous thromboembolism: Reasons and associated outcomes

OBJECTIVE

We assessed the number of cases with delayed anticoagulation initiation, explored the reasons for the delay, and its impact on outcome in patients with acute venous thromboembolism (VTE) treated in an organized setting of treatment initiation and continuous, prospective follow-up.

METHODS

Patients with anticoagulation initiation delay >24 hours were identified within the cohort of patients with acute VTE enrolled in the Mayo Clinic Venous Thromboembolism Registry between 2013 and 2020. The reasons for treatment delay were explored by reviewing the electronic database. VTE recurrence, all-cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were compared to those with no anticoagulation delay.

RESULTS

Of 2378 patients with acute VTE, 100 (4.2%) experienced an anticoagulation delay. We identified seven reasons for treatment delays: deferring anticoagulation initiation to specialists (n = 38), thrombocytopenia (n = 10), planned or recent procedure (n = 16), active or recent bleeding (n = 12), missed diagnosis (n = 7), logistics (n = 6), and patient decision (n = 4). In seven cases, no reason was identified. We identified modifiable reasons for anticoagulation delay in 55%. At 90-day follow-up, patients with anticoagulation delay had a higher rate of mortality and major bleeding. VTE recurrence and CRNMB were not statistically different compared to those without anticoagulation delay. After adjustment for age, weight, and cancer, hazard ratios (HRs) for VTE recurrence and major bleeding remained elevated but not to a statistically significant level.

CONCLUSION

In the setting of a highly organized system of anticoagulation initiation, the incidence of treatment delay is low. Yet most delays could be avoided. A low number of cases provide insufficient power to evaluate the clinical consequences of anticoagulation initiation delay; however, elevated HR for VTE recurrence and major bleeding suggest association and need for further investigation.

Clinical guidelines versus current clinical practice for the management of deep vein thrombosis

BACKGROUND

Deep vein thrombosis (DVT) is one of the major health problems worldwide with potentially serious outcomes related to mortality and morbidity. We provide a current view on how patients with DVT are managed in routine practice compared with the recommendations of published clinical guidelines.

METHODS

A literature review was conducted on studies reporting diagnostic and treatment patterns for acute DVT. Four dimensions were evaluated to compare the differences between clinical practice and clinical guidelines recommendations: diagnostic pathway, prescription of pharmacologic treatment and related duration, and prescription of compression therapy. For each aspect, the agreement with the corresponding guideline has been estimated as a percentage ranging from 0% (no agreement) to 100% (full agreement).

RESULTS

Sixteen studies reported clinical practices in 10 countries. Among them, Japan showed the highest agreement with guidelines, followed by the UK and Switzerland. Hong Kong showed the highest agreement with diagnosis guidelines, Spain for drug treatment, UK for treatment duration, and France for compression therapy. Conversely, Germany reported a complete disagreement with guidelines for diagnosis, followed by low agreement level by UK and Italy, and Switzerland reported a lower agreement level with prescription of compression therapy.

CONCLUSIONS

The implementation of clinical guidelines for the management of patients with DVT varies among countries from strict adherence to a complete lack of adherence. In this context, registries may be a useful tool to analyze clinical practice and produce findings that may be generalizable across populations.

Clinical patterns and significance of non-compliance with guideline-recommended treatment of acute pulmonary embolism

BACKGROUND

Evidence-based clinical practice guidelines define initial management of acute pulmonary embolism (PE) according to risk stratification for early death.

AIMS

The aims of the present study were to investigate patterns of non-compliance with guidelines for the acute PE treatment, and the associated risk of adverse events.

METHODS

We performed an observational, multicentre, cohort study of acute PE. Inclusion criteria were all patients with pulmonary embolism admitted to the participating centres between January 2011 and April 2017. The measure of 100% compliance was used to allocate patients in the compliant or non-compliant groups. The primary outcome was all-cause death at 6 months. Secondary outcomes included recurrent venous thromboembolism and major bleeding.

RESULTS

In total, 1285 patients were included. Treatment was not in compliance with the guidelines in 172 patients (13.4%). Four factors were identified to be related to non-compliance with the guidelines: shock or hypotension (relative risk [RR] 5.23, 95% confidence interval [CI] 2.64-10.30; P<0.001), renal insufficiency (RR 1.80, 95% CI 1.41-2.28; P<0.001), active cancer (RR 1.35, 95% CI 1.24-1.48; P<0.001) and right ventricular dysfunction at admission (RR 1.06, 95% CI 1.01-1.11; P=0.01). The primary endpoint of all-cause death at 6 months occurred in 62 of 172 patients (36.0%) in the non-compliant group and in 131 of 1113 patients (11.8%) in the compliant group (hazard ratio 2.02, 95% CI 1.45-2.81; P<0.001). The rates of recurrent venous thromboembolism (8.7% vs 1.1%; P<0.001) and major bleeding (13.4% vs 4.9%, P=0.04) from admission to 6-month follow-up were higher in the non-compliant group.

CONCLUSION

Non-compliance with guidelines was independently associated with worse outcomes, including death, recurrent venous thromboembolism and bleeding.

Extended treatment with edoxaban in cancer patients with venous thromboembolism: A post-hoc analysis of the Hokusai-VTE Cancer study

BACKGROUND

Patients with active cancer and venous thromboembolism (VTE) are at high risk of recurrence. Therefore, continued anticoagulant therapy beyond the initial 6 months is suggested in this patient population, but evidence supporting this approach is limited.

METHODS

The Hokusai VTE Cancer trial compared edoxaban with dalteparin for VTE treatment in patients with active cancer. This post hoc analysis focused on the follow-up period from 6 to 12 months. The primary outcome was the composite of adjudicated first recurrent VTE or major bleeding. Secondary outcomes included recurrent VTE, major bleeding, and clinically relevant bleeding.

RESULTS

Of the 522 and 524 patients randomized to edoxaban or dalteparin, 294 (56%) received edoxaban and 273 (52%) received dalteparin for more than 6 months (median duration of 318 and 211 days, respectively). Between 6 and 12 months, the primary outcome during study treatment occurred in seven patients (2.4%) in the edoxaban group and six patients (2.2%) in the dalteparin group (unadjusted hazard ratio 1.05; 95% confidence interval, 0.36-3.05). Recurrent VTE occurred in two patients (0.7%) in the edoxaban group and in three patients (1.1%) in the dalteparin group, whereas major bleeding occurred in 5 (1.7%) and three patients (1.1%), respectively.

CONCLUSIONS

The rates of recurrent VTE or major bleeding are relatively low among patients with active cancer receiving extended anticoagulant therapy beyond 6 months. Extended treatment with oral edoxaban appears as effective and safe as subcutaneous dalteparin.

Treatment of Cancer-Associated Thrombosis: Beyond HOKUSAI

Direct oral anticoagulants (DOACs) represent an attractive alternative to low-molecular-weight heparins (LMWHs) for the long-term treatment of cancer-associated thrombosis (CT) since they avoid the burden of daily injections. Analyses in subgroups of cancer patients from large randomized trials suggested that DOACs were at least as effective as vitamin K antagonists, while indirect comparisons suggested that DOACs' efficacy and safety profile were comparable to those of LMWHs. In the randomized controlled HOKUSAI-VTE Cancer study, currently the only completed phase III trial on DOACs in CT patients, edoxaban was shown noninferior to dalteparin on the composite primary endpoint of time to first recurrent venous thromboembolism or major bleeding during the 12 months after randomization. Study results suggest that both agents had comparable benefit/risk ratio in patients with CT. Even though this conclusion was valid from a strict statistical viewpoint, it was potentially misleading when interpreting benefit/risk ratios. Besides the obvious heterogeneity of the study population (e.g., 23% of patients no longer had cancer) and significantly different treatment durations between arms, secondary outcomes for efficacy were in favor of edoxaban for recurrent deep-vein thrombosis but not for recurrent pulmonary embolism, and major bleeding episodes were significantly more frequent in the edoxaban group, with an excess of gastrointestinal (GI) bleeding episodes observed mainly but not only in patients with GI cancers. More research is needed regarding specific patients' profiles, cancer types, and treatment period to better clarify the respective roles of DOACs and LMWHs in CT patients.

Etiology and Management of Upper-Extremity Catheter-Related Thrombosis in Cancer Patients

Central venous access devices are a critical instrument in the treatment and supportive care delivery for oncology patients. Catheter-related thrombosis (CRT) is a common complication of central venous access devices in oncology patients. Risk factors for CRT include patient-, device-, and treatment-related risk factors. Treatment of CRT is indicated to reduce symptoms, prevent catheter malfunction, prevent recurrent DVT or thromboembolic pulmonary embolism, and minimize the risk of post-thrombotic syndrome. Minimal prospective data exist on the prevention and treatment of catheter-related thromboses in cancer patients. As such recommendations largely are derived from data in the lower-extremity DVT and PE studies in cancer and non-cancer patients. Based on the available literature, primary pharmacologic prophylaxis against CRT is not recommended in cancer patients. Treatment options for CRT include catheter removal, anticoagulation, catheter-directed thrombolysis, or surgical thrombectomy. Current evidence-based guidelines recommend LMWH as the anticoagulant of choice. However, recent data showing efficacy and safety of DOACs in cancer-related VTE may be extrapolated to treatment of CRT in cancer patients. In patients with CRT, catheter removal should be pursued if continued vascular access is no longer needed, the catheter is dysfunctional, a catheter-associated infection is present, or if CRT symptoms do not resolve with anticoagulation alone. Catheter-directed thrombolysis is reserved for rare severe cases of CRT. Herein we discuss the pathophysiology, clinical presentation, diagnosis, and general management of CRT in cancer patients.

Update on extended treatment for venous thromboembolism

The importance of assessing the probability of venous thromboembolism recurrence, a condition that includes deep vein thrombosis and pulmonary embolism, lies in the fact that it is the most important factor in deciding the duration of anticoagulant treatment. Risk of recurrence depends mostly on the presence of a risk factor for developing venous thromboembolism, with patients with unprovoked events being at the higher risk of recurrence. The risk of recurrence needs to be balanced with the risk of bleeding and the potential severity of these thrombotic and hemorrhagic events. In patients with an unprovoked venous thromboembolism who complete treatment for the acute (first 10 days) and post-acute phase of the disease (from day 10 to 3-6 months), the decision has to be made regarding prolonged antithrombotic therapy to prevent recurrences. The main goal of extended treatment is preventing recurrences with a safety profile in terms of bleeding risk. Many therapeutic options are now available for these patients, including antiplatelet therapy with aspirin or direct oral anticoagulants. Moreover, apixaban and rivaroxaban at prophylactic doses have demonstrated efficacy in preventing recurrences with a low risk of bleeding. Key messages Extending treatment (longer than 3-6 months) is challenging in patients with venous thromboembolism (VTE) and depend on the risk of venous thromboembolism recurrence, the bleeding risk and patient and physician preferences. Anticoagulation treatment should be stopped in patients with provoked VTE and in those with unprovoked VTE and a high bleeding risk after an initial period of 3-6 months. There are some therapeutic alternatives (including Aspirin and low dose of some NOACs) to reduce venous thromboembolism recurrence risk in patients with unprovoked VTE and a low bleeding risk for extended treatment of VTE (after an initial period of 3-6 months).

[Venous thromboembolism and urological cancer: Epidemiology and therapeutically management]

INTRODUCTION

Active cancer is a risk factor in the occurrence of venous thromboembolism (VTE). This is the second cause of death for these patients. In onco-urology, some cancers are associated with an increased risk of VTE. The aim of this study was to propose a focus of epidemiology and VTE therapy management.

MATERIAL AND METHODS

A systematic analysis of the PubMed^® database was performed through the PRISMA methodology using the followings keywords : "neoplasm", "venous thromboembolism", "prophylaxis", "pulmonary embolism", "urology". The original papers were included with a priority on: meta-analyzes, literature reviews, randomized controlled trials and good-level proof cohort studies. Only publications in English or French have been selected.

RESULTS

The incidence of VTE was more important in case of renal carcinomas (3.5%/year). When surgery was proposed cystectomy was the riskiest procedure (2.6 to 11.6% VTE). Chemotherapy alone was an important risk factor increasing by a factor of six the occurrence of VTE. Hormonotherapy also increased this risk by induced hypogonadism. The curative treatment for VTE associated with cancers has to be performed through the injection of low molecular weight heparin. The implantation of a prophylactic treatment was not systematic among patients diagnosed with urological cancer.

CONCLUSION

The understanding of mechanisms associated with the occurrence of VTE among these patients has enabled to improve patient management, especially those suffering from urological cancer. Undeniably, frequency of VTE is probably underestimated by urologists during clinical practice.

Antithrombotic therapy for venous thromboembolism in patients with cancer: expert guidance

INTRODUCTION

Most of the current clinical guidelines recommend the use of Low-Molecular-Weight Heparins (LMWHs) for cancer-associated thrombosis (CAT). The Hokusai VTE-cancer trial reported the first results of a direct comparison between a direct oral anticoagulant (DOAC), edoxaban, and LMWH in this setting.

AREAS COVERED

This review aims to critically appraise the currently available evidence on the efficacy and safety of anticoagulant agents for the long-term treatment of CAT and to provide an expert opinion and guidance in this field.

EXPERT OPINION

Based on the available evidence, DOACs represent a valid alternative to LMWH for the treatment of CAT for the majority of patients with active cancer. Currently, most solid evidence comes from the Hokusai VTE-cancer study, which showed that edoxaban is non-inferior to the LMWH dalteparin, with a trend toward fewer recurrent venous thromboembolic events, but with more major bleeding events. Similar findings were reported with rivaroxaban, although the study was not sufficiently powered to allow definitive conclusions. The majority of bleeding events occurred in the upper gastrointestinal tract and in patients with gastrointestinal cancer. Thus, LMWH remains the preferred option for patients with gastrointestinal cancer. Additional studies aimed to confirm these findings with other DOACs are now warranted.

[Thrombosis and cancer: Awareness of private practitioners and patients in Poitou-Charentes, a French region]

OBJECTIVE

The purpose of this study was to enhance awareness among healthcare professionals about the application of guidelines relating to the management of venous thromboembolism (VTE) in cancer patients.

METHODS

This collective approach involved: the Regional Health Agency (ARS), the Unions of Representatives of Healthcare Professionals (URPS), the Observatory of Drugs, the Medical Devices and Therapeutic Innovation agency (OMEDIT), the regional Oncology Network and specialist physicians. Performance indicators were defined to evaluate the actions performed.

RESULTS

Multidisciplinary information meetings were organized. A standardized patient's folder was proposed in all healthcare institutions dealing with cancer, as a link between healthcare professionals and patients. Information brochures were prepared for healthcare professionals and patients. Web-based surveys were taken among healthcare professionals to evaluate changes in their knowledge and practices before and after the first actions taken.

CONCLUSION

This collective approach improved the awareness of health professionals about care practices for VTE in cancer patients.

Real-Life Management of Venous Thromboembolism With Rivaroxaban: Results From EXperience VTE, an Italian Epidemiological Survey

Two large randomized controlled trials examined the efficacy and safety of rivaroxaban for the treatment of venous thromboembolism (VTE). The aim of this epidemiological study was to analyze a cohort of Italian patients affected by VTE who were treated with rivaroxaban in clinical practice. The data were collected by physicians using an online electronic questionnaire. The study was performed during a 6-month period from January to June 2014. We analyzed the clinical characteristics, risk factors for VTE, comorbidities, diagnostic techniques, and treatments in the whole population and in the subgroups with deep vein thrombosis (DVT) only, pulmonary embolism (PE) only, and DVT+PE. Overall, 75.9% of patients were affected by DVT; 20% of patients had DVT and PE; and 4.8% of patients had only PE. Approximately 90% of patients were symptomatic upon diagnosis, and 46.3% of patients required hospitalization. More than half of the patients switched to rivaroxaban after receiving another anticoagulant therapy. The main reasons for changing treatment included difficulties in managing vitamin K antagonists, patient choice, and prothrombin time-international normalized ratio (PT-INR) instability. The switch to rivaroxaban occurred after a mean of 1.8 PT-INR measurements. Clinical characteristic were overall similar to those of patients enrolled in prior clinical trials evaluating the safety and efficacy of rivaroxaban.

Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism

BACKGROUND

Low-molecular-weight heparin is the standard treatment for cancer-associated venous thromboembolism. The role of treatment with direct oral anticoagulant agents is unclear.

METHODS

In this open-label, noninferiority trial, we randomly assigned patients with cancer who had acute symptomatic or incidental venous thromboembolism to receive either low-molecular-weight heparin for at least 5 days followed by oral edoxaban at a dose of 60 mg once daily (edoxaban group) or subcutaneous dalteparin at a dose of 200 IU per kilogram of body weight once daily for 1 month followed by dalteparin at a dose of 150 IU per kilogram once daily (dalteparin group). Treatment was given for at least 6 months and up to 12 months. The primary outcome was a composite of recurrent venous thromboembolism or major bleeding during the 12 months after randomization, regardless of treatment duration.

RESULTS

Of the 1050 patients who underwent randomization, 1046 were included in the modified intention-to-treat analysis. A primary-outcome event occurred in 67 of the 522 patients (12.8%) in the edoxaban group as compared with 71 of the 524 patients (13.5%) in the dalteparin group (hazard ratio, 0.97; 95% confidence interval [CI], 0.70 to 1.36; P=0.006 for noninferiority; P=0.87 for superiority). Recurrent venous thromboembolism occurred in 41 patients (7.9%) in the edoxaban group and in 59 patients (11.3%) in the dalteparin group (difference in risk, -3.4 percentage points; 95% CI, -7.0 to 0.2). Major bleeding occurred in 36 patients (6.9%) in the edoxaban group and in 21 patients (4.0%) in the dalteparin group (difference in risk, 2.9 percentage points; 95% CI, 0.1 to 5.6).

CONCLUSIONS

Oral edoxaban was noninferior to subcutaneous dalteparin with respect to the composite outcome of recurrent venous thromboembolism or major bleeding. The rate of recurrent venous thromboembolism was lower but the rate of major bleeding was higher with edoxaban than with dalteparin. (Funded by Daiichi Sankyo; Hokusai VTE Cancer ClinicalTrials.gov number, NCT02073682 .).

Secondary prophylaxis decision-making in venous thromboembolism: interviews on clinical practice in thirteen countries

OBJECTIVES

Secondary prevention of venous thromboembolism (VTE) remains a topical and contentious point of debate for thrombosis experts around the globe. This discussion centers around two aspects: optimum treatment duration and which type and dosage of thromboprophylaxis to prescribe. Collectives of thrombosis experts have tried to steer the debate by issuing periodical best-practice guidelines. However, the lack of adherence to said guidelines is such that there is a growing body of research devoted to this very problem. Most of the studies on the subject retrospectively observe a single setting, which leaves important questions as to the generalizability of their findings. As each setting appears to face its own unique challenges, the overarching question of why there is so much variance between physicians when it comes to the secondary prevention of VTE is never fully addressed.

METHODS

For this study, we asked thirteen senior-level physicians representing equally as many countries about the current state of clinical practice regarding the secondary prevention of VTE.

RESULTS

The discussion identifies several barriers to adequate VTE prevention, and hints at area-specific idiosyncrasies that may explain why physicians from different locales treat VTE patients differently.

CONCLUSION

Universal treatment guidelines may not fully translate to clinical practice in many areas, and that promoting local guidelines to supplement the universal guidelines may be beneficial.

Continuation of low-molecular-weight heparin treatment for cancer-related venous thromboembolism: a prospective cohort study in daily clinical practice

Essentials Low-molecular-weight heparin (LMWH) injections for venous thromboembolism (VTE) may be burdensome. Patients with active cancer and confirmed VTE were included to evaluate LMWH continuation. The cumulative incidence of discontinuation was 21% after a median period of 90 days. One out of five patients discontinued LMWH injections because of side effects.

SUMMARY

Background Current guidelines recommend low-molecular-weight heparin (LMWH) monotherapy for 3-6 months as the first-line treatment for cancer-associated venous thromboembolism (VTE). However, although daily administration of LMWH injections over a course of several months may be burdensome, the number of patients who stop treatment because of LMWH side-effects is unknown. Objectives To evaluate the continuation rate and complications of daily LMWH injections in patients with cancer-associated VTE. Methods Consecutive patients with active cancer and objectively confirmed symptomatic proximal deep vein thrombosis and/or pulmonary embolism, treated at three Dutch hospitals and one Spanish hospital, were included to evaluate continuation LMWH therapy during LMWH treatment. Patients were excluded when they received other anticoagulants, were lost to follow-up, or experienced a venous catheter-associated thrombosis. Results A total of 372 patients were analyzed during LMWH treatment for a maximum of 180 days. The cumulative incidence of discontinuation was 21% (95% confidence interval [CI] 17-25) after a median period of 90 days (interquartile range 60-120 days). Only female sex was found to be significantly associated with premature LMWH discontinuation (odds ratio 1.6; 95% CI 1.03-2.5). Thirty patients (8.1%) developed recurrent VTE, 30 patients (8.3%) suffered a major bleed, and 106 patients (28%) died. Conclusion Our study reveals that one of five patients with cancer-associated VTE stopped LMWH injections because of side-effects. This finding provides relevant background information for current clinical trials investigating the efficacy and safety of direct oral anticoagulants as compared with LMWH.

Factors influencing adherence to clinical guidelines in the management of cancer-associated thrombosis

International academic and regulatory guidelines consistently recommend the long-term use of low-molecular-weight heparins (LMWHs) as the standard for the treatment of cancer-associated thrombosis (CAT). However, both physicians and patients are reluctant to follow established guidelines. Insufficient compliance with treatment recommendations among care physicians represents a loss of opportunity for patients at very high risk of recurrence of venous thromboembolism (VTE) and death. Few data are available regarding adherence to CAT clinical practice guidelines. Based on published data, we aimed to review the gap between guidelines and practice to draw a more precise picture of current practice in order to precisely identify the extent to which patient management is currently lacking with respect to treatment guidelines. Published observational studies, registries and surveys on cancer-associated VTE treatment were reviewed. In spite of evidence from randomized controlled trials (RCTs) showing the usefulness of long-term LMWH, only approximately 50% of patients are managed according to established guideline recommendations. Patient profiles and co-morbidities influence compliance with standard guidelines. A better knowledge of physician and patient-related factors that influence therapeutic decisions may improve the implementation of clinical practice guidelines. Efficient awareness programs including a multidisciplinary approach are necessary to implement guidelines aimed at optimizing the therapeutic management of cancer-associated VTE.

Venous thromboembolism prophylaxis in patients undergoing abdominal and pelvic cancer surgery: adherence and compliance to ACCP guidelines in DIONYS registry

BACKGROUND

Venous thromboembolism (VTE) is a major health care problem resulting in significant mortality, morbidity and increase in medical expenses. Patients with malignant diseases represent a high risk population for VTE. The American College of Chest Physicians (ACCP) proposed, since 1986, prophylaxis guidelines that are unequally respected in surgical practice.

METHODS

DIONYS is a multinational, longitudinal and non-interventional registry including patients having undergone abdominal or pelvic surgery for cancer in Latin America, Africa and the Middle East. Patients were evaluated with regard to VTE prophylaxis, during three consecutive visits, for their adherence to ACCP 2008 guidelines. Data were collected on type and duration of VTE prophylaxis, adherence to guidelines, and compliance with prescriptions, complications and possible reasons for omission of prophylaxis.

RESULTS

Between 2011 and June 2012, 921 adult patients were included and divided into abdominal (435), pelvic (390) and combined abdominal and pelvic surgery (96), 65.4 % being females. VTE prophylaxis was prescribed to 90 % of patients during hospitalization and to 28.3 % after hospital discharge. Prescriptions adhered to ACCP guidelines in 73.9 % of patients during hospitalization and 18.9 % after discharge. The reason of non-adherence was mainly the clinical judgment by the physician that the patient did not need a prophylaxis. The most commonly prescribed type of prophylaxis was pharmacological (low molecular weight heparin).

CONCLUSION

A wide gap exists between VTE prophylaxis in daily practice and the ACCP 2008 guidelines, in abdominal and pelvic cancer surgery. A better awareness of surgeons is probably the best guarantee for improvement of VTE prophylaxis in surgical wards.

Low-molecular-weight heparins for cancer-associated thrombosis: Adherence to clinical practice guidelines and patient perception in TROPIQUE, a 409-patient prospective observational study

PURPOSE

Data on long-term treatment with low-molecular-weight heparins (LMWH) in cancer patients treated for venous thromboembolism are scarce. Study objectives were to document the long-term clinical use of LMWH and patient perception in this setting.

METHODS

Adult cancer patients receiving antineoplastic treatment or palliative care and LMWH for cancer associated venous thromboembolism (CAT) were eligible to participate in this prospective observational study. Main outcome was adherence to clinical practice guidelines based on recommended LMWH treatment doses for at least 3months in the absence of severe renal insufficiency. Patients' perception of the treatment was assessed in an ancillary study using the Perception Anticoagulant Treatment Questionnaire (PACT-Q).

RESULTS

Among 409 included cancer patients aged 65±12.1years, overall adherence to practice guidelines as defined in the protocol was 55.3% (226 patients). However, 98.0% of patients received a prescription for 3months or more and mean LMWH treatment duration for VTE was 6.27±0.15months which meets guidelines recommendations. Main patients' expectations scored on a 1-5 scale were blood clots prevention (mean 3.94±0.75), symptom relief (mean 3.98±1.04) and ease of use (mean 4.22±0.9). LMWH treatment appeared convenient (global score 79.7±17.1 on a 0 to 100 scale) and 69.1% of patients were satisfied or very satisfied.

CONCLUSION

Despite incomplete strict adherence to guidelines, treatment duration with LMWH was adequate showing substantial progress in the management of CAT patients. Patients expectations were high while treatment was perceived convenient with a high degree of satisfaction.

Clinical and economic benefits of extended treatment with apixaban for the treatment and prevention of recurrent venous thromboembolism in Canada

Background and objective Venous thromboembolism (VTE) is associated with long-term clinical and economic burden. Clinical guidelines generally recommend at least 3 months of anticoagulation, but, in clinical practice, concerns over bleeding risk often limit extended treatment. Apixaban was studied for extended VTE treatment in the AMPLIFY-EXT trial, demonstrating superiority to placebo in VTE reduction without increasing risk of major bleeding. This study assessed the long-term clinical and economic benefits of extending treatment with apixaban when clinical equipoise exists compared to standard of care with enoxaparin/warfarin and other novel oral anti-coagulants (NOACs) for the treatment and prevention of recurrent VTE in Canada. Methods A Markov model was developed to follow patients with VTE over their lifetimes. Efficacy and safety for apixaban and enoxaparin/warfarin were based on AMPLIFY and AMPLIFY-EXT, while relative efficacy to other NOACs was synthesized by network meta-analysis (NMA). Dosages for NOACs and enoxaparin/warfarin were based on their respective trials and were given up to 18 months and up to 6 months, followed by no treatment, respectively. Patient quality adjusted life years (QALYs) were based on published studies, and costs for resource utilization were from a Ministry of Health perspective, expressed as 2014 CAD ($). Results Extended treatment with apixaban compared to enoxaparin/warfarin resulted in fewer recurrent VTEs, VTE-related deaths, and bleeding events, but at slightly increased cost. The incremental cost-effectiveness ratio was $4828 per QALY gained. Compared to other NOACs, apixaban had the fewest bleeding events, similar recurrent VTE events, and the lowest overall cost, which was driven by the strong bleeding profile. In scenario analyses of acute and lifetime treatments, apixaban was cost-effective against all strategies. Conclusions Extended treatment with apixaban can offer substantial clinical benefits and is a cost-effective alternative to enoxaparin/warfarin and other NOACs.

Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular & Pulmonary and Acute Care sections of APTA, have developed this clinical practice guideline to assist physical therapists in their decision-making process when treating patients at risk for venous thromboembolism (VTE) or diagnosed with a lower extremity deep vein thrombosis (LE DVT). No matter the practice setting, physical therapists work with patients who are at risk for or have a history of VTE. This document will guide physical therapist practice in the prevention of, screening for, and treatment of patients at risk for or diagnosed with LE DVT. Through a systematic review of published studies and a structured appraisal process, key action statements were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms, based on the key action statements, were developed that can assist with clinical decision making. Physical therapists, along with other members of the health care team, should work to implement these key action statements to decrease the incidence of VTE, improve the diagnosis and acute management of LE DVT, and reduce the long-term complications of LE DVT.

Variable support for ASCO recommendations for the prevention and treatment of cancer-associated venous thromboembolism

Objectives: To determine the attitude of physicians towards the ASCO evidence-based clinical practice guidelines for venous thromboembolism (VTE) prophylaxis and treatment in patients with cancer.

Methods: The ASCO guideline was published in Jan. 2015. Two specialists in in the field assembled a list of arguments for and against each of the ASCO recommendations. ASCO recommendations and pro & con arguments were presented to physicians attending 3 educational seminars on hemostasis in cancer patients. After the presentation each attendee was asked to fill out a questionnaire on how much he agreed with the recommendations and the pro & con arguments.

Results: A total of 89 physicians attended the three meetings. 56 questionnaires were returned. The ASCO recommendation with the highest degree of support was that patients undergoing major cancer surgery should receive prophylaxis for 7–10 days and for four weeks after major abdominal or pelvic surgery with high-risk features (84 % Pro). The recommendation with the lowest degree of support was that anticoagulation should not be used to extend survival of patients with cancer in the absence of other indications (56 % Pro = indifference). Arguments based on A) the scientific evidence underlying each recommendation, B) on clinical practicability and patients’ preferences/adherence, C) on the desire to avoid toxicity, malpractice litigation, and cost concerns, ranked equally.

Conclusion: The degree of support for ASCO guideline recommendations on prophylaxis and treatment of VTE in cancer is variable. For some key recommendations it is close to indifference. Scientific evidence for a recommendation is just one decision factor among others. Our study underscores the need to further promote educational activities on VTE prophylaxis and treatment in cancer patients particularly among all physicians caring for cancer patients.

Long-Term Anticoagulant Therapy of Patients with Venous Thromboembolism. What Are the Practices?

Current guidelines of antithrombotic therapy suggest early initiation of vitamin K antagonists (VKA) in non-cancer patients with venous thromboembolism (VTE), and long-term therapy with low-molecular weight heparin (LMWH) for those with cancer. We used data from RIETE (international registry of patients with VTE) to report the use of long-term anticoagulant therapy over time and to identify predictors of anticoagulant choice (regarding international guidelines) in patients with- and without cancer. Among 35,280 patients without cancer, 82% received long-term VKA (but 17% started after the first week). Among 4,378 patients with cancer, 66% received long term LMWH as monotherapy. In patients without cancer, recent bleeding (odds ratio [OR] 2.70, 95% CI 2.26–3.23), age >70 years (OR 1.15, 95% CI 1.06–1.24), immobility (OR 2.06, 95% CI 1.93–2.19), renal insufficiency (OR 2.42, 95% CI 2.15–2.71) and anemia (OR 1.75, 95% CI 1.65–1.87) predicted poor adherence to guidelines. In those with cancer, anemia (OR 1.83, 95% CI 1.64–2.06), immobility (OR 1.51, 95% CI 1.30–1.76) and metastases (OR 3.22, 95% CI 2.87–3.61) predicted long-term LMWH therapy. In conclusion, we report practices of VTE therapy in real life and found that a significant proportion of patients did not receive the recommended treatment. The perceived increased risk for bleeding has an impact on anticoagulant treatment decision.

Clinical Outcomes and Adherence to Guideline Recommendations During the Initial Treatment of Acute Venous Thromboembolism

Background: Adherence to American College of Chest Physicians (CHEST) guidelines for treatment of acute venous thromboembolism (VTE) has not been formally assessed in the United States, specifically in the subset of patients with renal impairment. Objective: Evaluate adherence to CHEST VTE treatment guidelines. Methods: This retrospective cohort study evaluated patients with acute VTE between January 1, 2010, and December 31, 2011, for the primary outcome of adherence to CHEST VTE treatment guidelines defined as (1) patients receiving an appropriate parenteral anticoagulant and dose based on renal function and weight, (2) at least 5 days of parenteral anticoagulation during warfarin initiation, and (3) an international normalized ratio (INR) value ≥2 documented before discontinuing parenteral agents. Secondary outcomes included recurrent thromboembolism and major bleeding across renal function categories. Results: Of the 1683 patients included in the final analysis, 1483 (88%) had complete data for all 3 elements of the primary outcome (dose, overlap duration, and INR ≥2.0). VTE guideline adherence was identified in 95% (1408/1483) of these patients. There were 20 major bleeds overall, which occurred in 1.1%, 1.1%, and 1.3% in patients with CrCl <30 mL/min, 30 to 59 mL/min, and ≥60 mL/min, respectively ( P = 0.929). Also, 7 recurrent VTE events occurred—3 in patients with CrCl values of 30 to 59 mL/min (0.5%) and 4 in patients with CrCl ≥60 mL/min (0.4%; P = 0.797 across groups). Conclusions: Adherence to CHEST guidelines was high and resulted in low rates of bleeding and recurrent VTE complications across renal function categories. Further studies of patients with CrCl <30 mL/min are needed.

The cost of thromboembolic events in hospitalized patients with breast or prostate cancer in France

AIMS

The aim of the present study was to determine the number of admissions and the cost of hospital management of venous thromboembolism (VTE) events occurring in patients with breast cancer (BC) or prostate cancer (PC).

METHODS

The French national hospital database (PMSI) was analyzed to identify patients diagnosed with BC or PC in 2010 and followed for 2 years. The number of admissions for VTE (or with VTE occurring during hospitalization) and the corresponding number of patients hospitalized were determined using disease-specific International Classification of Diseases, 10th revision (ICD-10) codes. Associated hospital costs were estimated from the healthcare payer perspective, using the French official tariffs.

RESULTS

62,365 and 45,551 patients diagnosed with BC and PC, respectively, in 2010 were identified from PMSI data; 1,271 (2.0%) and 997 (2.2%) were hospitalized for or had VTE during hospitalization. During the 2 years of follow-up, 346 patients (15%) presented a recurrence of thrombosis requiring hospitalization. A total of 1,604 and 1,210 inpatient VTE-related admissions (stays) in the BC and PC cohorts, respectively, were analyzed. Pulmonary embolism (PE) was the most frequent diagnosis leading to hospital admission in those cancer patients, followed by deep venous thrombosis. Mean cost per admission was €3,302 and €2,916 for first event and recurrence, respectively, in BC patients (total cost €1.98 million over 2 years) and €3,611 and €3,363 for first event and recurrence in PC patients (total cost €1.43 million over 2 years). In patients who had at least one recurrence, mean hospitalization cost was €5,545 and €5,692 in BC and PC, respectively.

CONCLUSION

The burden of VTE in cancer patients is important; costs should be reduced by decreasing the occurrence of thrombotic recurrences. In this respect, better prevention and follow-up measures may reduce recurrence and VTE costs.

Treatment options for venous thromboembolism: lessons learnt from clinical trials

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism, is a common condition associated with a significant clinical and economic burden. Anticoagulant therapy is the mainstay of treatment for VTE, having been shown to reduce the risk of death in patients with pulmonary embolism, and recurrence or extension of thrombi in patients with deep vein thrombosis during the initial treatment period. Long-term anticoagulation is indicated in some individuals with VTE, depending on individual risk of VTE recurrence and anticoagulant-related bleeding. Management of VTE in clinical practice is often complex because patients' characteristics and treatment needs may differ considerably from those encountered in clinical trials. Current guidelines recommend the use of either low molecular weight heparins or fondaparinux overlapping with and followed by a vitamin K antagonist for the initial treatment of VTE, with the vitamin K antagonist continued when long-term anticoagulation is required. These traditional anticoagulants have practical limitations that have led to the development of direct oral anticoagulants that directly target either Factor Xa or thrombin and are administered at a fixed dose without the need for routine coagulation monitoring. This review discusses practical considerations for hospital physicians and haematologists in the management of VTE treatment, including the potential for the direct oral anticoagulants to simplify treatment.

The adherence to initial processes of care in elderly patients with acute venous thromboembolism

BACKGROUND

We aimed to assess whether elderly patients with acute venous thromboembolism (VTE) receive recommended initial processes of care and to identify predictors of process adherence.

METHODS

We prospectively studied in- and outpatients aged ≥65 years with acute symptomatic VTE in a multicenter cohort study from nine Swiss university- and non-university hospitals between September 2009 and March 2011. We systematically assessed whether initial processes of care, which are recommended by the 2008 American College of Chest Physicians guidelines, were performed in each patient. We used multivariable logistic models to identify patient factors independently associated with process adherence.

RESULTS

Our cohort comprised 950 patients (mean age 76 years). Of these, 86% (645/750) received parenteral anticoagulation for ≥5 days, 54% (405/750) had oral anticoagulation started on the first treatment day, and 37% (274/750) had an international normalized ratio (INR) ≥2 for ≥24 hours before parenteral anticoagulation was discontinued. Overall, 35% (53/153) of patients with cancer received low-molecular-weight heparin monotherapy and 72% (304/423) of patients with symptomatic deep vein thrombosis were prescribed compression stockings. In multivariate analyses, symptomatic pulmonary embolism, hospital-acquired VTE, and concomitant antiplatelet therapy were associated with a significantly lower anticoagulation-related process adherence.

CONCLUSIONS

Adherence to several recommended processes of care was suboptimal in elderly patients with VTE. Quality of care interventions should particularly focus on processes with low adherence, such as the prescription of continued low-molecular-weight heparin therapy in patients with cancer and the achievement of an INR ≥2 for ≥24 hours before parenteral anticoagulants are stopped.

The disparate management of superficial venous thrombosis in primary and secondary care

OBJECTIVES

Superficial venous thrombosis is common and traditionally considered a benign condition requiring only symptomatic treatment. Recent evidence, however, advocates more aggressive management. Extensive guidance is available but actual practice is unknown. This study aimed to assess the management of superficial venous thrombosis by general practitioners (primary care physicians) and vascular surgeons.

METHODS

A 19-question validated electronic survey was created and circulated by e-mail to general practitioners and vascular surgeons in the United Kingdom. The survey evaluated presentation, investigation and treatment of superficial venous thrombosis.

RESULTS

Three hundred sixty-nine surveys were returned from 197 vascular surgeons and 172 general practitioners. Most clinicians saw less than 20 cases a year, with 40% of clinicians not performing any investigations. Venous duplex was the investigation of choice in over 55%. Treatment with anti-inflammatory drugs was widespread, but anticoagulation and compression were seldom prescribed. Follow-up and treatment duration were disparate.

DISCUSSION

The management of superficial venous thrombosis varies widely despite good levels of evidence and guidance. Investigation and treatment of superficial venous thrombosis show marked differences both between and within groups. Improvements in education are required to optimise the treatment pathway and advance patient care.