Risk assessment for recurrence and optimal agents for extended treatment of venous thromboembolism

Hematology ◽  
2013 ◽  
Vol 2013 (1) ◽  
pp. 471-477 ◽  
Author(s):  
Giancarlo Agnelli ◽  
Cecilia Becattini
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Bleeding Complications ◽  
First Episode ◽  
Anticoagulant Treatment ◽  
Extended Treatment ◽  
Large Phase ◽  
Estimated Risk

Abstract Venous thromboembolism (VTE) has a variable recurrence rate after the discontinuation of anticoagulant treatment. Therefore, the duration of anticoagulation therapy after a first VTE should be tailored to the estimated risk for recurrence. Anticoagulant therapy should be discontinued after the initial 3 to 6 months in those patients who had the first episode in association with temporary risk factors. The duration of anticoagulant therapy in patients who had a first episode of cancer-associated VTE should be reassessed over time based on the persistence of cancer and anticancer therapy. After 3 to 6 months of anticoagulant treatment for VTE, patients with a first unprovoked event and an estimated low risk for bleeding complications should be evaluated for indefinite treatment on an individualized basis. New oral anticoagulants have been evaluated for the extended treatment of VTE. Large phase 3 studies have shown that dabigatran, rivaroxaban, and apixaban are effective and safe in this indication. These agents do not require monitoring for dose adjustment and could make extended treatment more feasible and acceptable to patients.

Duration of Anticoagulation Therapy for Venous Thromboembolism

Hematology ◽  
2008 ◽  
Vol 2008 (1) ◽  
pp. 252-258 ◽  
Author(s):  
Henri Bounameaux ◽  
Arnaud Perrier
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Odds Ratio ◽  
Vitamin K Antagonists ◽  
Initial Period ◽  
Anticoagulation Therapy ◽  
Case Fatality ◽  
Clinical Decision ◽  
Venous Thromboembolic Event ◽  
Anticoagulant Treatment

Abstract Treatment of acute deep vein thrombosis and pulmonary embolism-often denominated together as venous thromboembolism (VTE)- consists of parenteral administration of heparin (usually low-molecular-weight heparin or alternatively unfractionated heparin or fondaparinux) overlapped and followed by oral vitamin K antagonists that are administered for a certain period (usually 3 to 12 months). Recommended or suggested durations differ according to guidelines. Practically, the clinical decision in an individual patient depends upon the estimated risks of VTE recurrence and treatment-induced bleeding. The risk of VTE recurrence is higher in idiopathic events (about 10% per year during the first two years and 3% per year thereafter) (odds ratio of 2.4, compared to secondary events); in male subjects (at least before the age of 60, with an odds ratio of 2–4); in patients with persistently elevated D-dimer level (odds ratio of 2.3, compared with normal level); and during the first two years after discontinuation of treatment. The annual risk of major bleeding on anticoagulant treatment vary largely in observational studies with figures of 2% to 29%, depending on the patient characteristics. The case-fatality rate is 8% (DVT), 12% (PE) for recurrent VTE, and about 10% for major bleed. These figures do not support long-term anticoagulant therapy, except in those patients exhibiting a very high risk of recurrence and/or a very low risk of bleeding. New therapeutic aspects might impact on the duration of anticoagulant therapy after a venous thromboembolic event. They include the possibility of pursuing anticoagulant treatment at a reduced INR after an initial period with an INR 2-3, and the advent of new, more specific and orally active anticoagulants. These features might modify the risk-benefit balance of extending anticoagulant therapy beyond the usual, limited duration.

scholarly journals CURRENT VIEW ON ANTICOAGULANT AND THROMBOLYTIC TREATMENT OF ACUTE PULMONARY EMBOLISM

2019 ◽  
Vol 9 (5) ◽  
pp. 348-366
Author(s):  
G. G. Taradin ◽  
G. A. Ignatenko ◽  
N. T. Vatutin ◽  
I. V. Kanisheva
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Acute Pulmonary Embolism ◽  
Oral Anticoagulants ◽  
Medical Intervention ◽  
Bleeding Complications ◽  
Current View ◽  
Anticoagulant Treatment ◽  
Thrombolytic Treatment ◽  
Systemic Thrombolysis

The presented review concerns contemporary views on specific aspects of anticoagulant and thrombolytic treatment of venous thromboembolism and mostly of acute pulmonary embolism. Modern classifications of patients with acute pulmonary embolism, based on early mortality risk and severity of thromboembolic event, are reproduced. The importance of multidisciplinary approach to the management of patients with pulmonary embolism with the assistance of cardiologist, intensive care specialist, pulmonologist, thoracic and cardiovascular surgeon, aimed at the management of pulmonary embolism at all stages: from clinical suspicion to the selection and performing of any medical intervention, is emphasized. Anticoagulant treatment with the demonstration of results of major trials, devoted to efficacy and safety evaluation of anticoagulants, is highlighted in details. Moreover, characteristics, basic dosage and dosage scheme of direct (new) oral anticoagulants, including apixaban, rivaroxaban, dabigatran, edoxaban and betrixaban are described in the article. In particular, the management of patients with bleeding complications of anticoagulant treatment and its application in cancer patients, who often have venous thromboembolism, is described. Additionally, modern approaches to systemic thrombolysis with intravenous streptokinase, urokinase and tissue plasminogen activators are presented in this review. The indications, contraindications, results of clinical trials devoted to various regimens of thrombolytic therapy, including treatment of pulmonary embolism by lower doses of fibrinolytic agents, are described.

Should the presence of an antiphospholipid antibody affect the duration of anticoagulant treatment in patients with venous thromboembolism?

Hematology ◽  
2013 ◽  
Vol 2013 (1) ◽  
pp. 681-683 ◽  
Author(s):  
David A. Garcia ◽  
Wendy Lim
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Reference Range ◽  
Laboratory Finding ◽  
Anticoagulation Therapy ◽  
Healthy Woman ◽  
Anticardiolipin Antibody ◽  
First Episode ◽  
Antiphospholipid Antibody ◽  
Anticoagulant Treatment

Abstract A 44-year-old otherwise healthy woman has completed 3 months of anticoagulation therapy for a first episode of unprovoked pulmonary embolism. At the time of diagnosis and before the initiation of anticoagulation, she was found to have an elevated IgG anticardiolipin antibody (ACLA), which was measured at 42 IgG phospholipid (GPL) units (reference range, < 15 GPL units) with negative lupus anticoagulant (LAC) testing. Should this laboratory finding affect the recommended duration of anticoagulant therapy?

scholarly journals Control Of Anticoagulation Therapy in Atrial Fibrillation (COAT-AF Study) in Real Clinical Practice

2020 ◽  
Vol 16 (1) ◽  
pp. 19-23
Author(s):  
A. A. Zarudsky ◽  
A. A. Gavrilova ◽  
Т. S. Filinichenko
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Practice ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
First Episode ◽  
Exclusion Criteria ◽  
Cardiology Department ◽  
International Normalization Ratio ◽  
Real Clinical Practice

Aim. To study the frequency of prescribing anticoagulant therapy in outpatients with AF in accordance with clinical guidelines.Material and methods. Control Of Anticoagulation Therapy in Atrial Fibrillation (COAT-AF) observational study was conducted at the Saint Joasaph Belgorod Regional Clinical Hospital from January 1, 2016 to December 31, 2017. Patients with AF represented 15.5% of all patients admitted to cardiology department N1. 429 patients were included into the study: 203 women, 226 men; aged of 62.55±11.12 years. Exclusion criteria were mitral stenosis, mechanic prosthetic valve, first episode of AF. CHA2DS2-VASc score was used in all patients for calculation the risk of ischemic stroke and systemic thromboembolism. For patients that were treated by warfarin international normalization ratio (INR) was assessed at admission and discharge from the hospital.Results. From 429 patients 35 had 1 point according to the CHA2DS2-VASc scale, 393 (91.6%) patients had ≥2 points. Only 1 patient had 0 point. Therefore, most patients had absolute indications to anticoagulant therapy. At admission 60 (14%) patients received new oral anticoagulants (NOACs), 213 (49.6%) – warfarin, 156 (36.4%) – did not take any oral anticoagulant. Among patients receiving warfarin only 36 (8.4%) had target INR at admission. Therefore, effective anticoagulant therapy was observed only in 22.4% of patients in real clinical practice. Analyzing anticoagulant therapy in 2016 and 2017 we found a significant increase in NOAC prescription from 10.4% in 2016 to 18.9% in 2017 (p=0.0193).Conclusion. Our data reflects important gaps of anticoagulant therapy in real clinical practice. We compare our results with other Russian registries that included AF-patients. Data at admission and discharge suggests that there are great possibilities for optimization of anticoagulant therapy mainly with NOACs.

scholarly journals Patients' Satisfaction with Anticoagulant Treatment for Venous Thromboembolism

2018 ◽  
Vol 13 (3) ◽  
pp. 6-14
Author(s):  
Roxanne Dault ◽  
Lucie Blais ◽  
Alain Vanasse ◽  
Paul Farand ◽  
Sylvie Perrault ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Treatment Satisfaction ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Ease Of Use ◽  
Anticoagulant Treatment ◽  
Treatment Expectations ◽  
Similar Treatment

Background: Data on treatment expectation and perception towards vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs), and low molecular weight heparins (LMWH) for the management of venous thromboembolism (VTE) are sparse.Methods: Prospective observational study including subjects admitted to the hospital with a diagnosis of VTE and a prescription of VKA, DOAC, or a LMWH. Treatment expectations, convenience and satisfaction were assessed using the Perception of anticoagulant treatment questionnaire (PACT-Q) at baseline and at three months.Results: A total of 140 patients were included. Treatment expectations regarding ease of use and the ability to self-manage anticoagulation therapy were higher in patients on DOACs. However, overall treatment satisfaction scores were similar at three months between the groups.Conclusion: Patients with VTE who are prescribed an anticoagulant have different expectations at baseline, but appear to have similar treatment satisfaction regardless of the type of anticoagulant prescribed. 

scholarly journals Anticoagulant treatment satisfaction with warfarin and direct oral anticoagulants for venous thromboembolism

2021 ◽  
Author(s):  
Margaret C. Fang ◽  
Alan S. Go ◽  
Priya A. Prasad ◽  
Jin-Wen Hsu ◽  
Dongjie Fan ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Treatment Satisfaction ◽  
Clinical Characteristics ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Treatment Options ◽  
Laboratory Monitoring ◽  
Routine Laboratory ◽  
Anticoagulant Treatment ◽  
The Difference

AbstractTreatment options for patients with venous thromboembolism (VTE) include warfarin and direct oral anticoagulants (DOACs). Although DOACs are easier to administer than warfarin and do not require routine laboratory monitoring, few studies have directly assessed whether patients are more satisfied with DOACs. We surveyed adults from two large integrated health systems taking DOACs or warfarin for incident VTE occurring between January 1, 2015 and June 30, 2018. Treatment satisfaction was assessed using the validated Anti-Clot Treatment Scale (ACTS), divided into the ACTS Burdens and ACTS Benefits scores; higher scores indicate greater satisfaction. Mean treatment satisfaction was compared using multivariable linear regression, adjusting for patient demographic and clinical characteristics. The effect size of the difference in means was calculated using a Cohen’s d (0.20 is considered a small effect and ≥ 0.80 is considered large). We surveyed 2217 patients, 969 taking DOACs and 1248 taking warfarin at the time of survey. Thirty-one point five percent of the cohort was aged ≥ 75 years and 43.1% were women. DOAC users were on average more satisfied with anticoagulant treatment, with higher adjusted mean ACTS Burdens (50.18 v. 48.01, p < 0.0001) and ACTS Benefits scores (10.21 v. 9.84, p = 0.046) for DOACs vs. warfarin, respectively. The magnitude of the difference was small (Cohen’s d of 0.29 for ACTS Burdens and 0.12 for ACTS Benefits). Patients taking DOACs for venous thromboembolism were on average more satisfied with anticoagulant treatment than were warfarin users, although the magnitude of the difference was small.

scholarly journals Anticoagulation Treatment in Cancer-Associated Venous Thromboembolism: Assessment of Patient Preferences Using a Discrete Choice Experiment (COSIMO Study)

2020 ◽  
Author(s):  
Nils Picker ◽  
Agnes Y. Lee ◽  
Alexander T. Cohen ◽  
Anthony Maraveyas ◽  
Jan Beyer-Westendorf ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Oral Administration ◽  
Discrete Choice Experiment ◽  
Discrete Choice ◽  
Patient Preferences ◽  
Choice Experiment ◽  
Oral Anticoagulants ◽  
Daily Intake ◽  
Anticoagulation Therapy ◽  
Route Of Administration

Abstract Introduction Clinical guidelines recommend anticoagulation therapy for the treatment of cancer-associated venous thromboembolism (VTE), but little is known about preferences. Therefore, the objective of this discrete choice experiment (DCE) was to elucidate patient preferences regarding anticoagulation convenience attributes. Methods Adult patients with cancer-associated VTE who switched to direct oral anticoagulants were included in a single-arm study (COSIMO). Patients were asked to decide between hypothetical treatment options based on a combination of the following attributes: route of administration (injection/tablet), frequency of intake (once/twice daily), need for regular controls of the international normalized ratio (INR) at least every 3 to 4 weeks (yes/no), interactions with food/alcohol (yes/no), and distance to treating physician (1 vs. 20 km) as an additional neutral attribute. DCE data were collected by structured telephone interviews and analyzed based on a conditional logit regression. Results Overall, 163 patients (mean age 63.7 years, 49.1% female) were included. They strongly preferred oral administration compared with self-injections (importance of this attribute for overall treatment decisions: 73.8%), and a treatment without dietary restrictions (11.8%). Even if these attributes were less important (7.2% and 6.5%, respectively), patients indicated a preference for a shorter distance to the treating physician and once-daily dosing compared with twice-daily intake. “Need for regular controls of INR at least every 3 to 4 weeks” showed no significant impact on the treatment decision (0.7%). Conclusion This study showed that treatment-related decision making in cancer-associated VTE, assuming comparable effectiveness and safety of anticoagulant treatments, is predominantly driven by “route of administration,” with patients strongly preferring oral administration.

scholarly journals Clinical Outcomes of Multiple Myeloma Patients Treated with Direct Oral Anticoagulants for Immunomodulatory Drug Associated Venous Thromboembolism

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4964-4964 ◽  
Author(s):  
Zachary Crowther ◽  
Jamie Doyle ◽  
Stanford Taylor ◽  
Nadia Ali
Keyword(s):  
Multiple Myeloma ◽  
Venous Thromboembolism ◽  
Clinical Outcomes ◽  
Chart Review ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Direct Result ◽  
Bleeding Complications ◽  
Bleeding Events ◽  
Growing Body

Introduction: Venous thromboembolism (VTE) is a common complication in multiple myeloma (MM) patients for several reasons; hematologic malignancy itself is a VTE risk factor and standard of care immunomodulatory drugs (IMiDs) in combination with dexamethasone (Dex) increase the risk further. This combination therapy has a mean VTE incidence of 21.5% in studies that did not use thromboprophylaxis and is recommended for all patients on IMiDs, although the optimal thromboprophylactic regimen remains uncertain. In clinical practice, aspirin (ASA) is commonly prescribed for VTE prophylaxis due to the ease of use. Despite this, the incidence of VTE remains between 7-14%. There is a growing body of literature supporting the efficacy and safety of direct oral anticoagulants (DOACs) for the treatment of VTE in cancer populations. We wanted to assess the incidence of VTE despite ASA prophylaxis at our institution and to further characterize the role of DOACs in the MM population. To do this, we performed a chart review of all MM patients who had been treated with lenalidomide and a DOAC, assessing for VTE development and patient outcomes. Methods: We conducted a retrospective chart review of patients with the diagnosis of MM treated with lenalidomide therapy at Fox Chase Cancer Center at Temple University Hospital or Cottman Avenue after Jan 1st, 2015 to July 2019. Eligible patients were identified through electronic medical record data mining for patients that had been diagnosed with MM, had been prescribed lenalidomide, had been taking ASA while on lenalidomide, and switched to rivaroxaban, edoxaban or apixaban. For comparison, the number of patients treated with lenalidomide and ASA who did not switch to a DOAC were also identified. Patient charts were reviewed for VTE development and bleeding complications after DOAC administration. Results: 132 patients were identified who had a diagnosis of MM and had been prescribed lenalidomide between Jan 1, 2015 and July 31, 2019. These patients were also prescribed aspirin except for three who were already on a DOAC prior to starting lenalidomide. Of the total 132 patients, only 17 were prescribed a DOAC. Six of the patients were on DOACs for reasons other than VTE (atrial fibrillation N=4, atrial flutter N=1, marantic endocarditis N=1). Eleven patients were started on DOACs for VTE; incidence of 8.3% in our myeloma population. However three of these VTEs occurred within one month of high dose melphalan chemotherapy and autologous stem cell rescue. These three patients had been off lenalidomide for over one month prior to VTE. Eight of the 17 patients with VTE developed clots in the setting of active MM and concurrent therapy with IMiD/Dex, independent of hospitalizations or other provoking factors. This is an incidence of 6.0% for VTE directly attributed to therapy. Six patients were on lenalidomide and Dex, while two patients developed VTE while on pomalidomide and Dex. No patients on lenalidomide experienced recurrent VTEs after being switched to therapeutic dose DOAC. One patient on pomalidomide/Dex did experience recurrent VTE. We examined all 17 patients who were on DOACs, 16 of which had been on IMiD and DOACs concurrently. Three had minor bleeding events which all resolved spontaneously. One patient had a major bleeding event, which was a fatal ruptured cerebral aneurysm while on a DOAC and ASA concurrently. Conclusion: The incidence of VTE in our patient population receiving IMiD/Dex while on ASA prophylaxis therapy was similar to what has been previously reported in the literature. We examined the clinical outcomes of 16 patients treated with IMiDs and DOACs concurrently and found few bleeding events. The one major bleed was likely precipitated by malignant hypertension and not a direct result of being on a DOAC. Taken together these results further support the growing body of evidence that DOACs are effective and safe treatments for VTE in cancer patients, including MM. Moving forward, our clinical experience with treatment dose DOACs supports the use of prophylactic dose DOACs to potentially further reduce the incidence of VTE in this high-risk population. Disclosures No relevant conflicts of interest to declare.

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