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Tudu M, Samanta A. Natural polysaccharides: Chemical properties and application in pharmaceutical formulations. Eur Polym J 2022. [DOI: 10.1016/j.eurpolymj.2022.111801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Antic D, Lefkou E, Otasevic V, Banfic L, Dimakakos E, Olinic D, Milić D, Miljić P, Xhepa S, Stojkovski I, Kozak M, Dimulescu DR, Preradović TK, Nancheva J, Pazvanska EE, Tratar G, Gerotziafas GT. Position Paper on the Management of Pregnancy-Associated Superficial Venous Thrombosis. Balkan Working Group for Prevention and Treatment of Venous Thromboembolism. Clin Appl Thromb Hemost 2022; 28:1076029620939181. [PMID: 35187959 PMCID: PMC8864277 DOI: 10.1177/1076029620939181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Venous thromboembolism (VTE) is a multifactorial disease that can possibly affect
any part of venous circulation. The risk of VTE increases by about 2 fold in
pregnant women and VTE is one of the major causes of maternal morbidity and
mortality. For decades superficial vein thrombosis (SVT) has been considered as
benign, self-limiting condition, primarily local event consequently being out of
scope of well conducted epidemiological and clinical studies. Recently, the
approach on SVT has significantly changed considering that prevalence of lower
limb SVT is twice higher than both deep vein thrombosis (DVT) and pulmonary
embolism (PE). The clinical severity of SVT largely depends on the localization
of thrombosis, when it concerns the major superficial vein vessels of the lower
limb and particularly the great saphenous vein. If untreated or inadequately
treated, SVT can potentially cause DVT or PE. The purpose of this review is to
discuss the complex interconnection between SVT and risk factors in pregnancy
and to provide evidence-based considerations, suggestions, and recommendations
for the diagnosis and treatment of this precarious and delicate clinical
entity.
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Affiliation(s)
- Darko Antic
- University Clinical Center of Serbia
- University of Belgrade, Faculty of Medicine, Belgrade, Serbia
| | - Eleftheria Lefkou
- Sorbonne University, INSERM, UMR_S 938, Research Group “Cancer,
Biology and Therapeutics - Cancer, Haemostasis, Angiogenesis” Centre de recherche
Saint-Antoine (CRSA), Institut Universitaire de Cancérologie, Paris, France
| | | | - Ljiljana Banfic
- Department of Cardiovascular Diseases, Zagreb University Hospital
Centre, School of Medicine, Croatia
| | - Evangelos Dimakakos
- Vascular Unit of 3rd Internal Medicine Department of the University
of Athens-Sotiria General Hospital, Athens, Greece
| | - Dan Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy,
Cluj-Napoca, Romania
| | | | - Predrag Miljić
- University Clinical Center of Serbia
- University of Belgrade, Faculty of Medicine, Belgrade, Serbia
| | - Sokol Xhepa
- Service of Vascular Surgery, University Hospital Center “Mother
Theresa” of Tirana, Albania
| | - Igor Stojkovski
- University Clinic for Oncology and Radiotherapy, Faculty of
Medicine, Ss Cyril and Methodius University of Skopje, Republic of North
Macedonia
| | - Matija Kozak
- University Medical Centre Ljubljana, Department for Vascular
Diseases, Ljubljana, Slovenia
| | - Doina Ruxandra Dimulescu
- University of Medicine and Pharmacy “Carol Davila” Bucharest,
Ponderas Academic Hospital Bucharest, Cardiology Department, Romania
| | | | - Jasminka Nancheva
- University Clinic for Orthopedic Diseases, Medical Faculty,
University “Ss. Cyril and Methodius” Skopje, Republic of North Macedonia
| | | | - Gregor Tratar
- Department of Angiology, University Medical Centre, Ljubljana,
Slovenia
| | - Grigoris T. Gerotziafas
- Sorbonne University, INSERM, UMR_S 938, Research Group “Cancer,
Biology and Therapeutics - Cancer, Haemostasis, Angiogenesis” Centre de recherche
Saint-Antoine (CRSA), Institut Universitaire de Cancérologie, Paris, France
- Sorbonne University, INSERM, UMR_S 938, Research Group "Cancer,
Biology and Therapeutics - Cancer, Haemostasis, Angiogenesis" Centre de recherche
Saint-Antoine (CRSA), Institut Universitaire de Cancõrologie, Paris, France
- Grigoris T. Gerotziafas, MD, PhD, INSERM
U938 Bâtiment Kourilsky, 34 rue Crozatier, Hôpital Saint Antoine, Paris, Cedex
75012, France.
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Wienert V, Gerontopoulou SA, Rass K. Oberflächliche Venenthrombose der Beinvenen – Eine systematische Übersicht – Teil 2: Therapie. PHLEBOLOGIE 2021. [DOI: 10.1055/a-1238-6645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Zusammenfassung
Einleitung Die oberflächliche Venenthrombose (OVT) der Beinvenen ist mit einer Inzidenz von 0,5–1/1000 Einwohner/Jahr ein häufiges und mit einer Frequenz assoziierter thromboembolischer Ereignisse in bis zu 25 % der Fälle ein ernst zu nehmendes Krankheitsbild. In der vorliegenden Übersichtsarbeit sollen alle relevanten Aspekte der OVT basierend auf der aktuellen wissenschaftlichen Literatur behandelt werden.
Methoden Die systematische Übersicht umfasst das Wissen über die OVT basierend auf dem gesamten, systemisch recherchierten Erkenntnismaterial in den Datenbanken PubMed und Google Scholar. Eine Literaturrecherche in PubMed von Publikationen (1968–2018) mit den Suchbegriffen „Superficial vein thrombosis; thrombophlebitis“ ergab 102 aussagekräftige Arbeiten, die nach Vorlage der Originalarbeit ausgewertet wurden. Teil 2 der Arbeit behandelt Aspekte zur Therapie.
Ergebnisse Die Bewertungskriterien der Therapie der OVT sind in den einzelnen Leitlinien und Übersichtsarbeiten z. T. unterschiedlich. Andererseits ist in den letzten Jahren eine zunehmende Stringenz in den Therapieempfehlungen festzustellen, die vom Ausprägungsgrad der OVT abhängig sind. Zu deren Prinzipien gehören die Mobilisation des Patienten und das Tragen eines medizinischen Kompressionsstrumpfes der Kompressionsklasse II. Die medikamentöse Therapie umfasst den Einsatz von Fondaparinux oder niedermolekularen Heparinen. Fondaparinux ist derzeit das einzig zugelassene Medikament für diese Indikation ab einer Thrombusausdehnung von mindestens 5 cm. Rivaroxaban in einer Tagesdosis von 10 mg war gegenüber Fondaparinux in einer randomisierten Studie nicht unterlegen; dies führte jedoch nicht zu einer Zulassung für die Indikation der OVT. Eine therapeutische Antikoagulation hingegen wird empfohlen, sobald sich das proximale Thrombusende 3 cm oder näher zum Übergang in das tiefe Venensystem befindet. Nichtsteroidale Antirheumatika reduzieren das Risiko einer OVT-Extension oder eines Rezidivs und wirken schmerzlindernd. Die Therapie mit Externa bietet nur lokale symptomlindernde Effekte. Eine operative Therapie der OVT kann in bestimmten Situationen erwogen werden, um Varizen, Schmerzen und das Risiko einer Thrombusaszension in einem Behandlungsschritt zu beseitigen.
Schlussfolgerung Aufgrund der Häufigkeit und des Risikos potenziell lebensbedrohender Komplikationen sollte der OVT der Beinvenen eine größere Beachtung zukommen, insbesondere mit Blick auf eine auf den individuellen Befund ausgerichtete Stadien-adaptierte Therapie.
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Affiliation(s)
- Volker Wienert
- Klinik für Dermatologie und Allergologie, Universitätsklinikum RWTH Aachen, Aachen
| | | | - Knuth Rass
- Eifelklinik St. Brigida, Zentrum für Venen und periphere Arterien, Simmerath
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum des Saarlandes, Homburg
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Hoogevest P, Tiemessen H, Metselaar JM, Drescher S, Fahr A. The Use of Phospholipids to Make Pharmaceutical Form Line Extensions. EUR J LIPID SCI TECH 2021. [DOI: 10.1002/ejlt.202000297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Peter Hoogevest
- Phospholipid Research Center Im Neuenheimer Feld 515 Heidelberg 69120D‐69120 Germany
| | - Harry Tiemessen
- Technical & Research Development PHAD PDU Specialty Novartis Campus Physical Garden (WSJ 177) 2.14 Basel CH‐4002 Switzerland
| | - Josbert M. Metselaar
- Institute for Experimental Molecular Imaging, RWTH Aachen University Clinic Aachen D‐52074 Germany
- Institute for Biomedical Engineering, Faculty of Medicine RWTH Aachen University Aachen D‐52074 Germany
| | - Simon Drescher
- Phospholipid Research Center Im Neuenheimer Feld 515 Heidelberg D‐69120 Germany
| | - Alfred Fahr
- Professor Emeritus, Pharmaceutical Technology Friedrich‐Schiller‐University Jena Jena Germany
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5
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Sevestre MA, Galanaud JP, Sanchez O. [What is the management of superficial venous thromboses?]. Rev Mal Respir 2019; 38 Suppl 1:e171-e174. [PMID: 31699456 DOI: 10.1016/j.rmr.2019.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- M-A Sevestre
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Eloi, 34295 Montpellier cedex 5, France
| | - J P Galanaud
- Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Eloi, 34295 Montpellier cedex 5, France; Department of medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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6
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Abstract
BACKGROUND The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. This is the third update of a review first published in 2007. OBJECTIVES To assess the efficacy and safety of topical, medical, and surgical treatments for ST of the leg in improving local symptoms and decreasing thromboembolic complications. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (March 2017), CENTRAL (2017, Issue 2), and trials registries (March 2017). We handsearched the reference lists of relevant papers and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating topical, medical, and surgical treatments for ST of the legs that included people with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in a superficial vein. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were independently extracted from the included studies and any disagreements resolved by consensus. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We identified three additional trials (613 participants), therefore this update considered 33 studies involving 7296 people with ST of the legs. Treatment included fondaparinux; rivaroxaban; low molecular weight heparin (LMWH); unfractionated heparin (UFH); non-steroidal anti-inflammatory drugs (NSAIDs); compression stockings; and topical, intramuscular, or intravenous treatment to surgical interventions such as thrombectomy or ligation. Only a minority of trials compared treatment with placebo rather than an alternative treatment and many studies were small and of poor quality. Pooling of the data was possible for few outcomes, and none were part of a placebo-controlled trial. In one large, placebo-controlled RCT of 3002 participants, subcutaneous fondaparinux was associated with a significant reduction in symptomatic VTE (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.04 to 0.50; moderate-quality evidence), ST extension (RR 0.08, 95% CI 0.03 to 0.22; moderate-quality evidence), and ST recurrence (RR 0.21, 95% CI 0.08 to 0.54; moderate-quality evidence) relative to placebo. Major bleeding was infrequent in both groups with very wide CIs around risk estimate (RR 0.99, 95% CI 0.06 to 15.86; moderate-quality evidence). In one RCT on 472 high-risk participants with ST, fondaparinux was associated with a non-significant reduction of symptomatic VTE compared to rivaroxaban 10 mg (RR 0.33, 95% CI 0.03 to 3.18; low-quality evidence). There were no major bleeding events in either group (low-quality evidence). In another placebo-controlled trial, both prophylactic and therapeutic doses of LMWH (prophylactic: RR 0.44, 95% CI 0.26 to 0.74; therapeutic: RR 0.46, 95% CI 0.27 to 0.77) and NSAIDs (RR 0.46, 95% CI 0.27 to 0.78) reduced the extension (low-quality evidence) and recurrence of ST (low-quality evidence) in comparison to placebo, with no significant effects on symptomatic VTE (low-quality evidence) or major bleeding (low-quality evidence). Overall, topical treatments improved local symptoms compared with placebo, but no data were provided on the effects on VTE and ST extension. Surgical treatment combined with elastic stockings was associated with a lower VTE rate and ST progression compared with elastic stockings alone. However, the majority of studies that compared different oral treatments, topical treatments, or surgery did not report VTE, ST progression, adverse events, or treatment adverse effects. AUTHORS' CONCLUSIONS Prophylactic dose fondaparinux given for 45 days appears to be a valid therapeutic option for ST of the legs for most people. The evidence on topical treatment or surgery is too limited and does not inform clinical practice about the effects of these treatments in terms of VTE. Further research is needed to assess the role of rivaroxaban and other direct oral factor-X or thrombin inhibitors, LMWH, and NSAIDs; the optimal doses and duration of treatment in people at various risk of recurrence; and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.
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Affiliation(s)
- Marcello Di Nisio
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medicine and Ageing SciencesVia dei Vestini 31Chieti ScaloItaly66013
- Academic Medical CenterDepartment of Vascular MedicineAmsterdamNetherlands
| | - Iris M Wichers
- The Dutch College of General PractitionersUtrechtNetherlands
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineAmsterdamNetherlands
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El-Mowafi H, El Araby A, Kandil Y, Zaghloul A. Randomized, double-blind, placebo-controlled, interventional phase IV investigation to assess the efficacy and safety of r-hirudin gel (1120I.U) in patients with hematomas. Res Pract Thromb Haemost 2017; 2:139-146. [PMID: 30046714 PMCID: PMC6055561 DOI: 10.1002/rth2.12049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/12/2017] [Indexed: 11/21/2022] Open
Abstract
Essentials Efficacy and safety data on recombinant hirudin gels for the treatment of hematomas is limited. We assessed the clinical efficacy of a topical r‐hirudin gel in 199 patients with hematomas. Treated patients exhibited significant reductions in hematoma size and flare within 16 days. r‐hirudin gel treatment induces a complete resolution of hematomas and associated edema in 98%, and 99% of patients, respectively.
Background Hirudin is the most potent direct thrombin inhibitor, and recombinant forms are routinely used in anticoagulation therapy. Recombinant hirudin gels are commercially available for the treatment of hematomas and associated symptoms. Objectives To assess the efficacy and safety of a topically administered recombinant hirudin gel in patients with hematomas. Patients/Methods This double‐blind, placebo‐controlled, phase IV investigation recruited patients presenting with at least one hematoma. Subjects were randomly assigned (1:1) recombinant hirudin gel (1120 IU/100 g) or a placebo, administered 2‐3 times daily for 16 days. Changes in hematoma size, flare, and the proportion of patients achieving complete resolution of hematomas and associated edemas were investigated. Results By study end, a greater proportion of subjects in the treatment group achieved a complete resolution of hematomas versus placebo (98.0% vs 71.9%; P < .001) and edemas (99% vs 50%; P < .001). Patients in the recombinant hirudin group exhibited a marginally larger, yet significant, reduction in mean hematoma size versus placebo (99.9% vs 96.6%; P < .001) and flare (93.6% vs 78.6%; P < .001). Median time to hematoma resolution for the recombinant hirudin and placebo administered cohorts was 8 and 16 days, respectively (P < .001). No adverse events were reported for the recombinant hirudin cohort. Conclusions Topical recombinant hirudin is an effective, safe, and well tolerated intervention for the symptomatic treatment of hematomas. This trial was registered at http://www.clinicaltrials.gov as NCT01960569.
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Affiliation(s)
- Hani El-Mowafi
- Orthopedic Surgery Department Mansoura University Mansoura Egypt
| | - Ahmed El Araby
- Orthopedic Surgery Department Mansoura University Mansoura Egypt
| | - Yasser Kandil
- Orthopedic Surgery Department Mansoura University Mansoura Egypt
| | - Ahmed Zaghloul
- Orthopedic Surgery Department Mansoura University Mansoura Egypt
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Katzenschlager R, Ugurlouglu A, Sipos G, Bihari I, Anyova EB, Hirschl M, Maruszynski M, Noszczyk W, Rybak Z, Cencora A. Efficacy and Tolerability of Liposomal Heparin Spraygel as an Add-on Treatment in the Management of Superficial Venous Thrombosis. Angiology 2016; 58 Suppl 1:27S-35S. [PMID: 17478880 DOI: 10.1177/0003319706297741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Superficial venous thrombosis usually resolves spontaneously in a few weeks. In most cases, treatment includes peroral analgesics or nonsteroidal anti-inflammatory drugs accompanied by the recommendation to wear elastic stockings and perform regular mild ambulation. In contrast to this “standard treatment,” a recent ACCP guideline has recommended that patients affected by spontaneous superficial thrombophlebitis be treated with intermediate doses of unfractionated or low-molecular-weight heparin. This study was designed to assess the efficacy of topically applied heparin spraygel in terms of reduction of local symptoms and signs of superficial venous thrombosis.
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Di Nisio M, Peinemann F, Porreca E, Rutjes AWS. Treatment for superficial infusion thrombophlebitis of the upper extremity. Cochrane Database Syst Rev 2015; 2015:CD011015. [PMID: 26588711 PMCID: PMC6885032 DOI: 10.1002/14651858.cd011015.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although superficial thrombophlebitis of the upper extremity represents a frequent complication of intravenous catheters inserted into the peripheral veins of the forearm or hand, no consensus exists on the optimal management of this condition in clinical practice. OBJECTIVES To summarise the evidence from randomised clinical trials (RCTs) concerning the efficacy and safety of (topical, oral or parenteral) medical therapy of superficial thrombophlebitis of the upper extremity. SEARCH METHODS The Cochrane Vascular Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (2015, Issue 3). Clinical trials registries were searched up to April 2015. SELECTION CRITERIA RCTs comparing any (topical, oral or parenteral) medical treatment to no intervention or placebo, or comparing two different medical interventions (e.g. a different variant scheme or regimen of the same intervention or a different pharmacological type of treatment). DATA COLLECTION AND ANALYSIS We extracted data on methodological quality, patient characteristics, interventions and outcomes, including improvement of signs and symptoms as the primary effectiveness outcome, and number of participants experiencing side effects of the study treatments as the primary safety outcome. MAIN RESULTS We identified 13 studies (917 participants). The evaluated treatment modalities consisted of a topical treatment (11 studies), an oral treatment (2 studies) and a parenteral treatment (2 studies). Seven studies used a placebo or no intervention control group, whereas all others also or solely compared active treatment groups. No study evaluated the effects of ice or the application of cold or hot bandages. Overall, the risk of bias in individual trials was moderate to high, although poor reporting hampered a full appreciation of the risk in most studies. The overall quality of the evidence for each of the outcomes varied from low to moderate mainly due to risk of bias and imprecision, with only single trials contributing to most comparisons. Data on primary outcomes improvement of signs and symptoms and side effects attributed to the study treatment could not be statistically pooled because of the between-study differences in comparisons, outcomes and type of instruments to measure outcomes.An array of topical treatments, such as heparinoid or diclofenac gels, improved pain compared to placebo or no intervention. Compared to placebo, oral non-steroidal anti-inflammatory drugs reduced signs and symptoms intensity. Safety issues were reported sparsely and were not available for some interventions, such as notoginseny creams, parenteral low-molecular-weight heparin or defibrotide. Although several trials reported on adverse events with topical heparinoid creams, Essaven gel or phlebolan versus control, the trials were underpowered to adequately measure any differences between treatment modalities. Where reported, adverse events with topical treatments consisted mainly of local allergic reactions. Only one study of 15 participants assessed thrombus extension and symptomatic venous thromboembolism with either oral non-steroidal anti-inflammatory drugs or low-molecular-weight heparin, and it reported no cases of either. No study reported on the development of suppurative phlebitis, catheter-related bloodstream infections or quality of life. AUTHORS' CONCLUSIONS The evidence about the treatment of acute infusion superficial thrombophlebitis is limited and of low quality. Data appear too preliminary to assess the effectiveness and safety of topical treatments, systemic anticoagulation or oral non-steroidal anti-inflammatory drugs.
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Affiliation(s)
| | - Frank Peinemann
- University of CologneChildren's HospitalKerpener Str. 62CologneGermany50937
| | - Ettore Porreca
- "University G. D'Annunzio" FoundationDepartment of Medicine and Aging; Centre for Aging Sciences (Ce.S.I.), Internal Medicine Unit31 Via dei VestiniChietiItaly66100
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Ng L, Monagle K, Monagle P, Newall F, Ignjatovic V. Topical use of antithrombotics: review of literature. Thromb Res 2015; 135:575-81. [PMID: 25704903 DOI: 10.1016/j.thromres.2015.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/26/2014] [Accepted: 01/02/2015] [Indexed: 12/17/2022]
Abstract
While antithrombotics are usually administered intravenously, subcutaneously or orally, there are a number of publications reporting topical application of anticoagulation therapy. This paper aims to review the available literature regarding clinical conditions, the details of the topical antithrombotic treatment, as well as positive or adverse effects in an attempt to ascertain the safety and efficacy of this form of treatment. Published literature was searched to identify publications reporting the use of antithrombotic treatments administered via topical application between 1st January 1990 and 1st January 2013. There were 43 studies reported in 10 different clinical conditions. Majority of the studies were randomized controlled trials (51.2%), prospective studies (18.6%) or case reports (11.6%). The clinical conditions in which topical antithrombotics were administered included: microangiopathy, acute haemorrhoids, periodontitis, dermatitis, burns, ocular conditions and surgery, blunt force impact, scars, as well as clinical conditions associated with superficial venous thrombosis (SVT). The most commonly used topical antithrombotic was heparin (79.1% of studies). The respective dosage of different antithrombotics varied depending on specific clinical conditions. While most studies reported mean improvements or resolution of symptoms/condition in patients, the patient outcomes were variable. This review demonstrates that topical antithrombotic treatment is used according to a wide variety of protocols, with a subsequent variability in patient outcomes. Specific guidelines for the use of topical antithrombotics should be developed to standardize this form of treatment and ensure the best possible outcomes for patients.
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Affiliation(s)
- Leanne Ng
- Haematology Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Paediatrics, The University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Kate Monagle
- Haematology Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Paediatrics, The University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Paediatrics, The University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia; Department of Clinical Haematology, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia
| | - Fiona Newall
- Haematology Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Paediatrics, The University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia; Department of Clinical Haematology, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Nursing Research, Royal Children's Hospital, Parkville, VIC 3052, Australia; Department of Nursing, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Paediatrics, The University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia.
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11
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Abstract
BACKGROUND The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. This is the second update of a review first published in 2007. OBJECTIVES To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs. SEARCH METHODS For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2012) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11). We handsearched the reference lists of relevant papers and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating topical, medical, and surgical treatments for ST of the legs that included participants with a clinical diagnosis of ST of the legs or an objective diagnosis of a thrombus in a superficial vein. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were independently extracted from the included studies and any disagreements resolved by consensus. MAIN RESULTS We identified four additional trials (986 patients), so this update considered 30 studies involving 6507 participants with ST of the legs.Treatment ranged from fondaparinux, low molecular weight heparin (LMWH), unfractionated heparin (UFH), non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, oral treatment, intramuscular treatment, and intravenous treatment to surgery. Only a minority of trials compared treatment with placebo rather than an alternative treatment, none evaluated the same treatment comparisons on the same study outcomes (which precluded meta-analysis), and many of the studies were small and of poor quality. In one large, placebo-controlled RCT of about 3000 patients, subcutaneous fondaparinux was associated with a significant reduction in symptomatic VTE (RR 0.15; 95% CI 0.04 to 0.50), ST extension (RR 0.08; 95% CI 0.03 to 0.22), and ST recurrence (RR 0.21; 95% CI 0.08 to 0.54) with comparable rates of major bleeding (RR 0.99; 95% CI 0.06 to 15.86) relative to placebo. In a further placebo-controlled trial, both prophylactic and therapeutic doses of LMWH (RR 0.40; 95% CI 0.22 to 0.72 and RR 0.42; 95% CI 0.23 to 0.75, respectively) and NSAIDs (RR 0.41; 95% CI 0.23 to 0.75) reduced the extension and recurrence of ST in comparison to placebo, with no significant effects on symptomatic VTE nor major bleeding. Overall, topical treatments improved local symptoms compared with placebo but no data were provided on the effects on VTE and ST extension. Surgical treatment combined with elastic stockings was associated with a lower VTE rate and ST progression compared with elastic stockings alone. However, the majority of studies that compared different oral treatment, topical treatment, or surgery did not report VTE, ST progression, adverse events, or treatment side effects. AUTHORS' CONCLUSIONS Prophylactic dose fondaparinux given for six weeks appears to be a valid therapeutic option for ST of the legs. The evidence on oral treatments, topical treatment, or surgery is too limited and does not inform clinical practice about the effects of these treatments in terms of VTE and ST progression. Further research is needed to assess the role of the new oral direct thrombin and activated factor-X inhibitors, LMWH, and NSAIDs; the optimal doses and duration of treatment; and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medical,Oral and Biotechnological Sciences,University “G.D’Annunzio” of Chieti-Pescara,Chieti, Italy.
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Decousus H, Frappé P, Accassat S, Bertoletti L, Buchmuller A, Seffert B, Merah A, Becker F, Queré I, Leizorovicz A. Epidemiology, diagnosis, treatment and management of superficial-vein thrombosis of the legs. Best Pract Res Clin Haematol 2012; 25:275-84. [DOI: 10.1016/j.beha.2012.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Abstract
BACKGROUND The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. This is an update of a review first published in 2007. OBJECTIVES To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched 29 November 2011) and CENTRAL (2011, Issue 4). We handsearched reference lists of relevant papers and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating topical, medical, and surgical treatments for ST of the leg that included participants with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in the superficial vein. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were independently extracted from the included studies and any disagreements resolved by consensus. MAIN RESULTS Twenty-six studies involving 5521 participants with ST of the legs were included in this review. The methodological quality of most of the trials was poor. Treatment ranged from fondaparinux, low molecular weight heparin (LMWH), unfractionated heparin (UFH), non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, oral treatment, intramuscular treatment, and intravenous treatment to surgery. In a placebo-controlled RCT of about 3000 patients, fondaparinux was associated with a significant reduction in symptomatic VTE (RR 0.15; 95% CI 0.04 to 0.50), extension (RR 0.08; 95% CI 0.03 to 0.22), and recurrence of ST (RR 0.21; 95% CI 0.08 to 0.54) with comparable rates of major bleeding (RR 0.99; 95% CI 0.06 to 15.86) relative to placebo. Both prophylactic and therapeutic doses of LMWH (RR 0.40; 95% CI 0.22 to 0.72 and RR 0.42; 95% CI 0.23 to 0.75, respectively) and NSAIDs (RR 0.41; 95% CI 0.23 to 0.75) reduced the extension and recurrence of ST in comparison to placebo, with no significant effects on symptomatic VTE nor major bleeding. Overall, topical treatments improved local symptoms. However, no data were provided on the effects of these treatments on VTE and ST extension. Surgical treatment combined with elastic stockings in ST was associated with a lower VTE rate and ST progression compared with elastic stockings alone. AUTHORS' CONCLUSIONS Prophylactic dose fondaparinux given for six weeks appears to be a valid therapeutic option for ST of the legs. Further research is needed to assess the role of new oral direct thrombin and activated factor-X inhibitors, LMWH, NSAIDs; the optimal doses and duration of treatment; and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medicine and Aging; Centre for Aging Sciences (Ce.S.I.), Internal Medicine Unit, “University G. D’Annunzio” Foundation, Chieti, Italy.
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Décousus H, Bertoletti L, Frappé P, Becker F, Jaouhari AE, Mismetti P, Moulin N, Presles E, Quéré I, Leizorovicz A. Recent findings in the epidemiology, diagnosis and treatment of superficial-vein thrombosis. Thromb Res 2011; 127 Suppl 3:S81-5. [DOI: 10.1016/s0049-3848(11)70022-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Bai S, Ahsan F. Inhalable Liposomes of Low Molecular Weight Heparin for the Treatment of Venous Thromboembolism. J Pharm Sci 2010; 99:4554-64. [DOI: 10.1002/jps.22160] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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Zhao Y, Brown MB, Jones SA. Engineering novel topical foams using hydrofluroalkane emulsions stabilised with pluronic surfactants. Eur J Pharm Sci 2009; 37:370-7. [DOI: 10.1016/j.ejps.2009.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 03/12/2009] [Indexed: 10/21/2022]
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17
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Sen S, Meteoglu I, Ogurlu M, Sen S, Derincegoz OO, Derinceoz OO, Barutca S. Topical heparin: a promising agent for the prevention of tracheal stenosis in airway surgery. J Surg Res 2009; 157:e23-9. [PMID: 19524938 DOI: 10.1016/j.jss.2009.01.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Revised: 01/06/2009] [Accepted: 01/20/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND The protective effects of topical mitomycin-C (MMC) have been well documented for tracheal stenosis; however, to the best of our knowledge, the use of heparin as an anti-inflammatory agent to support wound healing in upper airway surgery was not studied before. The aim of this study was to investigate the efficacy of topical heparin for healing of tracheal re-implants in a rabbit's model and its resultant histological changes compared with that of MMC. METHODS In a rabbit model (n = 21), an elliptically shaped portion of the anterior tracheal wall was excised (3-4 tracheal cartilages) under anesthesia and immersed in an isotonic saline solution containing 0.4 mg/mL (0.04%) MMC (n = 7), heparin (liquemine) 5000 U/mL (n = 7), or none (n = 7) for 2 min and then re-implanted. The follow-up period was 2 wk for all animals and then both the larynx and the trachea were excised for histological evaluation. Hematoxylin-eosin (H and E) staining was applied to the excised tissues for microscopic evaluation. RESULTS Compared with controls, the granulation tissue formation score in MMC group (P = 0.03), and epithelial regeneration and inflammation scores in heparin group (P = 0.032 and P = 0.022, respectively) were more favorable. The fibrosis index and tracheal lumen ratio values were also more favorable in both MMC (P = 0.019 and P = 0.0028, respectively) and heparin (P = 0.023 and P = 0.0021, respectively) groups compared with controls on the 15th d. CONCLUSIONS Topical heparin application may have favorable effects on healing of tracheal autografts in a rabbit model. We suggest that heparin therapy should be further researched for the prevention of tracheal stenosis in airway surgery.
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Affiliation(s)
- Serdar Sen
- Department of Thoracic Surgery, Adnan Menderes University, Aydin, Turkey.
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18
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SCHLEINING JA, McCLURE SR, EVANS RB, HYDE WG, WULF LW, KIND AJ. Liposome-based diclofenac for the treatment of inflammation in an acute synovitis model in horses. J Vet Pharmacol Ther 2008; 31:554-61. [DOI: 10.1111/j.1365-2885.2008.00994.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:454S-545S. [PMID: 18574272 DOI: 10.1378/chest.08-0658] [Citation(s) in RCA: 1306] [Impact Index Per Article: 81.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This chapter about treatment for venous thromboembolic disease is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see "Grades of Recommendation" chapter). Among the key recommendations in this chapter are the following: for patients with objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE), we recommend anticoagulant therapy with subcutaneous (SC) low-molecular-weight heparin (LMWH), monitored IV, or SC unfractionated heparin (UFH), unmonitored weight-based SC UFH, or SC fondaparinux (all Grade 1A). For patients with a high clinical suspicion of DVT or PE, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C). For patients with confirmed PE, we recommend early evaluation of the risks to benefits of thrombolytic therapy (Grade 1C); for those with hemodynamic compromise, we recommend short-course thrombolytic therapy (Grade 1B); and for those with nonmassive PE, we recommend against the use of thrombolytic therapy (Grade 1B). In acute DVT or PE, we recommend initial treatment with LMWH, UFH or fondaparinux for at least 5 days rather than a shorter period (Grade 1C); and initiation of vitamin K antagonists (VKAs) together with LMWH, UFH, or fondaparinux on the first treatment day, and discontinuation of these heparin preparations when the international normalized ratio (INR) is > or = 2.0 for at least 24 h (Grade 1A). For patients with DVT or PE secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A). For patients with unprovoked DVT or PE, we recommend treatment with a VKA for at least 3 months (Grade 1A), and that all patients are then evaluated for the risks to benefits of indefinite therapy (Grade 1C). We recommend indefinite anticoagulant therapy for patients with a first unprovoked proximal DVT or PE and a low risk of bleeding when this is consistent with the patient's preference (Grade 1A), and for most patients with a second unprovoked DVT (Grade 1A). We recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). We recommend at least 3 months of treatment with LMWH for patients with VTE and cancer (Grade 1A), followed by treatment with LMWH or VKA as long as the cancer is active (Grade 1C). For prevention of postthrombotic syndrome (PTS) after proximal DVT, we recommend use of an elastic compression stocking (Grade 1A). For DVT of the upper extremity, we recommend similar treatment as for DVT of the leg (Grade 1C). Selected patients with lower-extremity (Grade 2B) and upper-extremity (Grade 2C). DVT may be considered for thrombus removal, generally using catheter-based thrombolytic techniques. For extensive superficial vein thrombosis, we recommend treatment with prophylactic or intermediate doses of LMWH or intermediate doses of UFH for 4 weeks (Grade 1B).
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Affiliation(s)
- Clive Kearon
- From McMaster University Clinic, Henderson General Hospital, Hamilton, ON, Canada.
| | - Susan R Kahn
- Thrombosis Clinic and Centre for Clinical Epidemiology and Community Studies, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | | | | | - Gary E Raskob
- College of Public Health, University of Oklahoma Health Science Center, Oklahoma City, OK
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Sobreira ML, Yoshida WB, Lastória S. Tromboflebite superficial: epidemiologia, fisiopatologia, diagnóstico e tratamento. J Vasc Bras 2008. [DOI: 10.1590/s1677-54492008000200007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A tromboflebite superficial de membros inferiores é doença de ocorrência comum, estando associada a diversas condições clínicas e cirúrgicas. Historicamente considerada doença benigna, devido à sua localização superficial e ao fácil diagnóstico, o tratamento foi conservador durante muito tempo, na maioria dos casos. Entretanto, relatos recentes de freqüências altas de complicações tromboembólicas associadas - 22 a 37% para trombose venosa profunda e até 33% para embolia pulmonar - alertaram para a necessidade de abordagens diagnósticas e terapêuticas mais amplas, visando diagnosticar e tratar essas possíveis complicações. A possibilidade da coexistência dessas e de outras desordens sistêmicas (colagenoses, neoplasias, trombofilias) interfere na avaliação e influencia a conduta terapêutica, que pode ser clínica, cirúrgica ou combinada. No entanto, devido à falta de ensaios clínicos controlados e às incertezas quanto a sua história natural, o diagnóstico e o tratamento da tromboflebite superficial continuam indefinidos. Neste trabalho, foi feita uma revisão da literatura analisando-se a epidemiologia, fisiopatologia e estado atual do diagnóstico e tratamento da tromboflebite superficial.
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21
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Vecchio C, Frisinghelli A. Topically Applied Heparins for the Treatment of Vascular Disorders. Clin Drug Investig 2008; 28:603-14. [DOI: 10.2165/00044011-200828100-00001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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22
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The Use of Liposomal Heparin Spray-Gel in the Treatment of Superficial Thrombophlebitis: A Multicenter Clinical Investigation Analysis. POLISH JOURNAL OF SURGERY 2008. [DOI: 10.2478/v10035-008-0006-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Cesarone MR, Belcaro G, Errichi S, Cornelli U, Pellegrini L, Ruffini I, Errichi BM, Ledda A, Vinciguerra G, Ricci A, Gizzi G, Ippolito E, Fano F, Dugall M, Cacchio M, Di Renzo A, Hosoi M, Grossi MG, Stuard S, Corsi M. Topical heparin: new observations. Angiology 2007; 58 Suppl 1:16S-20S. [PMID: 17478878 DOI: 10.1177/0003319706297740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Topical effects of heparins on the skin need deeper investigations. The lack of evidence is mainly due to the lack of large investments in this field. Three main local actions of heparin on the skin can be defined: (a) the anticoagulant action, (b) the microcirculatory-modulatory action determining important control of the microcirculation in case of excessive vasoconstriction or vasodilatation, and (c) the 'facilitatory action' on skin permeability allowing other drugs to diffuse better and faster into the skin (producing a therapeutic effect). These aspects have to be evaluated more extensively in both experimental and clinical conditions. Recent experimental studies demonstrate these effects of locally applied heparin. Therefore, key questions on local heparin administration such as skin penetration and the action on the local thrombi have promising answers. These observations suggest important clinical applications for local liposomal heparin. Both the potentials of local applications of heparin, particularly with new formulations, and some new aspects in the management of superficial vein thrombosis (SVT) can focus on locally applied heparin. SVT is an important clinical condition considering its frequency and the potentially heavy use of local heparin in this clinical problem. Results from new studies and observations presented in this issue of Angiology could be a window for suggesting new significant clinical applications and therapeutic solutions.
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Affiliation(s)
- M R Cesarone
- Irvine2 Vascular Lab and Physiology, Department of Biomedical Sciences, Chieti-Pescara University, Faculty of Motory Sciences, L'Aquila University, San Valentino, Italy
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Abstract
BACKGROUND The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. OBJECTIVES To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs. SEARCH STRATEGY The Cochrane Peripheral Vascular Diseases Group searched their specialized register (last searched 16 February 2007), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 1, 2007. We searched MEDLINE (1966 to January 2006), EMBASE (1980 to January 2006), and handsearched reference lists of relevant papers and conference proceedings. SELECTION CRITERIA Randomized trials evaluating topical, medical, and surgical treatments for ST of the leg including participants with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in the superficial vein. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were extracted independently from the included studies and any disagreements resolved by consensus. MAIN RESULTS Twenty-four studies involving 2469 participants with ST of the legs were included in this review. The methodological quality of most of the trials was poor. Treatment ranged from low molecular weight heparin (LMWH), to non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, surgery, oral, intramuscular, and intravenous treatments. Both LMWH and NSAIDs significantly reduced the incidence of ST extension or recurrences by about 70% compared with placebo and both seemed to have a similar efficacy and safety. Overall, topical treatments improved local symptoms. However, no data were provided on the effects of these treatments on VTE and ST extension. Surgical treatment combined with elastic stockings in ST was associated with a lower VTE rate and ST progression, compared with elastic stockings alone. AUTHORS' CONCLUSIONS Low molecular weight heparin and NSAIDs appear as the current best therapeutic options for ST of the legs. While the available data are too limited to make clear recommendations, an intermediate dose of LMWH for at least a month might be advised. Further research is needed to assess the role of NSAIDs and LMWH, the optimal doses and duration of treatment, and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.
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Affiliation(s)
- M Di Nisio
- Academic Medical Center, Department of Vascular Medicine, F4-138, Meibergdreef, 9 -1100 DD, P.O. Box 22660, Amsterdam, Netherlands, 1105 AZ.
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25
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Abstract
BACKGROUND The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. OBJECTIVES To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs. SEARCH STRATEGY The Cochrane Peripheral Vascular Diseases Group searched their specialized register (last searched October 2006), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 4, 2006. We searched MEDLINE (1966 to January 2006), EMBASE (1980 to January 2006), and handsearched reference lists of relevant papers and conference proceedings. SELECTION CRITERIA Randomized trials evaluating topical, medical, and surgical treatments for ST of the leg including participants with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in the superficial vein. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were extracted independently from the included studies and any disagreements resolved by consensus. MAIN RESULTS Twenty-four studies involving 2469 participants with ST of the legs were included in this review. The methodological quality of most of the trials was poor. Treatment ranged from low molecular weight heparin (LMWH), to non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, surgery, oral, intramuscular, and intravenous treatments. Both LMWH and NSAIDs significantly reduced the incidence of ST extension or recurrences by about 70% compared with placebo and both seemed to have a similar efficacy and safety. Overall, topical treatments improved local symptoms. However, no data were provided on the effects of these treatments on VTE and ST extension. Surgical treatment combined with elastic stockings in ST was associated with a lower VTE rate and ST progression, compared with elastic stockings alone. AUTHORS' CONCLUSIONS Low molecular weight heparin and NSAIDs appear as the current best therapeutic options for ST of the legs. While the available data are too limited to make clear recommendations, an intermediate dose of LMWH for at least a month might be advised. Further research is needed to assess the role of NSAIDs and LMWH, the optimal doses and duration of treatment, and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.
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Affiliation(s)
- M Di Nisio
- Academic Medical Center, Department of Vascular Medicine, F4-138, Meibergdreef, 9 -1100 DD, P.O. Box 22660, Amsterdam, Netherlands, 1105 AZ.
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