American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism

Abstract Background: Despite an increasing incidence of venous thromboembolism (VTE) in pediatric patients in tertiary care settings, relatively few pediatric physicians have experience with antithrombotic interventions. Objective: These guidelines of the American Society of Hematology (ASH), based on the best available evidence, are intended to support patients, clinicians, and other health care professionals in their decisions about management of pediatric VTE. Methods: ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews (up to April of 2017). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on 30 recommendations, covering symptomatic and asymptomatic deep vein thrombosis, with specific focus on management of central venous access device–associated VTE. The panel also addressed renal and portal vein thrombosis, cerebral sino venous thrombosis, and homozygous protein C deficiency. Conclusions: Although the panel offered many recommendations, additional research is required. Priorities include understanding the natural history of asymptomatic thrombosis, determining subgroup boundaries that enable risk stratification of children for escalation of treatment, and appropriate study of newer anticoagulant agents in children.

Download Full-text

American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy

Blood Advances ◽

10.1182/bloodadvances.2018024802 ◽

2018 ◽

Vol 2 (22) ◽

pp. 3317-3359 ◽

Cited By ~ 92

Author(s):

Shannon M. Bates ◽

Anita Rajasekhar ◽

Saskia Middeldorp ◽

Claire McLintock ◽

Marc A. Rodger ◽

...

Keyword(s):

Venous Thromboembolism ◽

Conflicts Of Interest ◽

Guideline Development ◽

Factor Xa ◽

Thrombosis Prophylaxis ◽

Strong Recommendation ◽

Vein Thrombosis ◽

Superficial Vein Thrombosis ◽

Anticoagulant Prophylaxis ◽

American Society

Abstract Background: Venous thromboembolism (VTE) complicates ∼1.2 of every 1000 deliveries. Despite these low absolute risks, pregnancy-associated VTE is a leading cause of maternal morbidity and mortality. Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and others in decisions about the prevention and management of pregnancy-associated VTE. Methods: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations. Results: The panel agreed on 31 recommendations related to the treatment of VTE and superficial vein thrombosis, diagnosis of VTE, and thrombosis prophylaxis. Conclusions: There was a strong recommendation for low-molecular-weight heparin (LWMH) over unfractionated heparin for acute VTE. Most recommendations were conditional, including those for either twice-per-day or once-per-day LMWH dosing for the treatment of acute VTE and initial outpatient therapy over hospital admission with low-risk acute VTE, as well as against routine anti-factor Xa (FXa) monitoring to guide dosing with LMWH for VTE treatment. There was a strong recommendation (low certainty in evidence) for antepartum anticoagulant prophylaxis with a history of unprovoked or hormonally associated VTE and a conditional recommendation against antepartum anticoagulant prophylaxis with prior VTE associated with a resolved nonhormonal provoking risk factor.

Download Full-text

American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia

Blood Advances ◽

10.1182/bloodadvances.2018024489 ◽

2018 ◽

Vol 2 (22) ◽

pp. 3360-3392 ◽

Cited By ~ 124

Author(s):

Adam Cuker ◽

Gowthami M. Arepally ◽

Beng H. Chong ◽

Douglas B. Cines ◽

Andreas Greinacher ◽

...

Keyword(s):

Venous Thromboembolism ◽

Health Care Professionals ◽

Conflicts Of Interest ◽

Guideline Development ◽

Oral Anticoagulants ◽

Platelet Factor ◽

Heparin Induced Thrombocytopenia ◽

Asymptomatic Patients ◽

Increased Risk ◽

American Society

AbstractBackground:Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction mediated by platelet-activating antibodies that target complexes of platelet factor 4 and heparin. Patients are at markedly increased risk of thromboembolism.Objective:These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about diagnosis and management of HIT.Methods:ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.Results:The panel agreed on 33 recommendations. The recommendations address screening of asymptomatic patients for HIT, diagnosis and initial management of patients with suspected HIT, treatment of acute HIT, and special situations in patients with acute HIT or a history of HIT, including cardiovascular surgery, percutaneous cardiovascular intervention, renal replacement therapy, and venous thromboembolism prophylaxis.Conclusions:Strong recommendations include use of the 4Ts score rather than a gestalt approach for estimating the pretest probability of HIT and avoidance of HIT laboratory testing and empiric treatment of HIT in patients with a low-probability 4Ts score. Conditional recommendations include the choice among non-heparin anticoagulants (argatroban, bivalirudin, danaparoid, fondaparinux, direct oral anticoagulants) for treatment of acute HIT.

Download Full-text

American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy

Blood Advances ◽

10.1182/bloodadvances.2018024893 ◽

2018 ◽

Vol 2 (22) ◽

pp. 3257-3291 ◽

Cited By ~ 115

Author(s):

Daniel M. Witt ◽

Robby Nieuwlaat ◽

Nathan P. Clark ◽

Jack Ansell ◽

Anne Holbrook ◽

...

Keyword(s):

Venous Thromboembolism ◽

Health Care Professionals ◽

Conflicts Of Interest ◽

Guideline Development ◽

Point Of Care ◽

Good Practice ◽

Anticoagulation Therapy ◽

International Normalized Ratio ◽

Anticoagulation Management ◽

American Society

Abstract Background: Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. Methods: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. Conclusions: Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti–factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.

Download Full-text

American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: July 2021 update on post-discharge thromboprophylaxis

Blood Advances ◽

10.1182/bloodadvances.2021005945 ◽

2021 ◽

Author(s):

Adam Cuker ◽

Eric K. Tseng ◽

Robby Nieuwlaat ◽

Pantep Angchaisuksiri ◽

Clifton Blair ◽

...

Keyword(s):

Health Care Professionals ◽

Conflicts Of Interest ◽

Guideline Development ◽

Research Priorities ◽

Post Discharge ◽

Assessment Development ◽

Increased Risk ◽

Patient Representatives ◽

Anticoagulant Prophylaxis ◽

American Society

Background: COVID-19 related acute illness is associated with an increased risk of venous thromboembolism (VTE). Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis in patients with COVID-19 who do not have confirmed or suspected VTE. Methods: ASH formed a multidisciplinary guideline panel, including three patient representatives, and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including performing systematic evidence reviews (up to March 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on one additional recommendation. The panel issued a conditional recommendation against the use of outpatient anticoagulant prophylaxis in patients with COVID-19 being discharged from the hospital who do not have suspected or confirmed VTE or another indication for anticoagulation. Conclusions: This recommendation was based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials assessing the role of post-discharge thromboprophylaxis. Other key research priorities include better evidence on assessing risk of thrombosis and bleeding outcomes in patients with COVID-19 after hospital discharge.

Download Full-text

American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: May 2021 update on the use of intermediate intensity anticoagulation in critically ill patients

Blood Advances ◽

10.1182/bloodadvances.2021005493 ◽

2021 ◽

Author(s):

Adam Cuker ◽

Eric K. Tseng ◽

Robby Nieuwlaat ◽

Pantep Angchaisuksiri ◽

Clifton Blair ◽

...

Keyword(s):

Critical Illness ◽

Critically Ill ◽

Critically Ill Patients ◽

Health Care Professionals ◽

Conflicts Of Interest ◽

Guideline Development ◽

Thrombotic Risk ◽

Increased Risk ◽

American Society ◽

The Impact

Background: COVID-19 related critical illness is associated with an increased risk of venous thromboembolism (VTE). Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis in patients with COVID-19-related critical illness who do not have confirmed or suspected VTE. Methods: ASH formed a multidisciplinary guideline panel, including three patient representatives, and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including performing systematic evidence reviews (up to March 5, 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. This is an update on guidelines published in February 2021. Results: The panel agreed on one additional recommendation. The panel issued a conditional recommendation in favor of prophylactic-intensity over intermediate-intensity anticoagulation in patients with COVID-19 related-critical illness who do not have confirmed or suspected VTE. Conclusions: This recommendation was based on low certainty in the evidence, underscoring the need for further high-quality, randomized controlled trials comparing different intensities of anticoagulation in critically ill patients. Other key research priorities include better evidence on predictors of thrombosis and bleeding risk in critically ill patients with COVID-19 and the impact of non-anticoagulant therapies (e.g., antiviral agents, corticosteroids) on thrombotic risk.

Download Full-text

American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism

Blood Advances ◽

10.1182/bloodadvances.2020001830 ◽

2020 ◽

Vol 4 (19) ◽

pp. 4693-4738 ◽

Cited By ~ 2

Author(s):

Thomas L. Ortel ◽

Ignacio Neumann ◽

Walter Ageno ◽

Rebecca Beyth ◽

Nathan P. Clark ◽

...

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Venous Thromboembolism ◽

Secondary Prevention ◽

Conflicts Of Interest ◽

The United States ◽

Primary Treatment ◽

Vein Thrombosis ◽

American Society ◽

Deep Vein

Background: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. Objective: These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. Methods: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. Conclusions: Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.

Download Full-text

Treatment of venous thromboembolism in pediatric patients

Blood ◽

10.1182/blood.2019001847 ◽

2020 ◽

Vol 135 (5) ◽

pp. 335-343 ◽

Cited By ~ 2

Author(s):

Char Witmer ◽

Leslie Raffini

Keyword(s):

Clinical Trials ◽

Venous Thromboembolism ◽

Randomized Clinical Trials ◽

Central Venous Access ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Venous Access ◽

Renal Vein Thrombosis ◽

Healthy Children ◽

Vein Thrombosis

Abstract Venous thromboembolism (VTE) is rare in healthy children, but is an increasing problem in children with underlying medical conditions. Pediatric VTE encompasses a highly heterogenous population, with variation in age, thrombosis location, and underlying medical comorbidities. Evidence from pediatric clinical trials to guide treatment of VTE is lacking so treatment is often extrapolated from adult trials and expert consensus opinion. Aspects unique to children include developmental hemostasis and the major role of central venous access devices. There is an absence of information regarding the optimal target levels of anticoagulation for neonates and infants and lack of suitable drug formulations. Anticoagulants, primarily low-molecular-weight heparin and warfarin, are used to treat children with symptomatic VTE. These drugs have significant limitations, including the need for subcutaneous injections and frequent monitoring. Randomized clinical trials of direct oral anticoagulants in pediatric VTE are ongoing, with results anticipated soon. These trials will provide new evidence and options for therapy that have the potential to improve care. International collaborative registries offer the ability to study outcomes of rare subgroups of pediatric VTE (eg, renal vein thrombosis), and will be important to ultimately guide therapy in a more disease-specific manner.

Download Full-text

American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19

Blood Advances ◽

10.1182/bloodadvances.2020003763 ◽

2021 ◽

Vol 5 (3) ◽

pp. 872-888 ◽

Cited By ~ 7

Author(s):

Adam Cuker ◽

Eric K. Tseng ◽

Robby Nieuwlaat ◽

Pantep Angchaisuksiri ◽

Clifton Blair ◽

...

Keyword(s):

Critical Illness ◽

Health Care Professionals ◽

Conflicts Of Interest ◽

Guideline Development ◽

Management Strategies ◽

Acute Illness ◽

Assessment Development ◽

Patient Representatives ◽

American Society ◽

Therapeutic Intensity

Background: Coronavirus disease 2019 (COVID-19)–related critical illness and acute illness are associated with a risk of venous thromboembolism (VTE). Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis for patients with COVID-19–related critical illness and acute illness who do not have confirmed or suspected VTE. Methods: ASH formed a multidisciplinary guideline panel and applied strict management strategies to minimize potential bias from conflicts of interest. The panel included 3 patient representatives. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic evidence reviews (up to 19 August 2020). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on 2 recommendations. The panel issued conditional recommendations in favor of prophylactic-intensity anticoagulation over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related critical illness or acute illness who do not have confirmed or suspected VTE. Conclusions: These recommendations were based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials comparing different intensities of anticoagulation. They will be updated using a living recommendation approach as new evidence becomes available.

Download Full-text

Risk factors determining central venous access device-associated deep vein thrombosis resolution in children: a retrospective study

European Journal of Pediatrics ◽

10.1007/s00431-021-03985-5 ◽

2021 ◽

Author(s):

Miguel García-Boyano ◽

José Manuel Caballero-Caballero ◽

Marta García Fernández de Villalta ◽

Mar Gutiérrez Alvariño ◽

María Jesús Blanco Bañares ◽

...

Keyword(s):

Risk Factors ◽

Deep Vein Thrombosis ◽

Central Venous Access ◽

Venous Access ◽

Central Venous ◽

Central Venous Access Device ◽

Access Device ◽

Vein Thrombosis ◽

Venous Access Device ◽

Deep Vein

Download Full-text

Apixaban Anti-Xa Level Monitoring in Treatment of Provoked Acute Upper Extremity Deep Vein Thrombosis for Patient on Dialysis: A Case Report

Blood ◽

10.1182/blood-2020-141911 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 14-14

Author(s):

Guillaume Roberge ◽

Philip S. Wells

Keyword(s):

Deep Vein Thrombosis ◽

Venous Thromboembolism ◽

Upper Extremity ◽

Conflicts Of Interest ◽

Subcutaneous Fat ◽

Chronic Hemodialysis ◽

Vein Thrombosis ◽

Acute Venous Thromboembolism ◽

Deep Vein ◽

Trough Levels

Background. Patients with end stage renal disease on dialysis are at higher risk of major bleeding and recurrent thrombosis and as such, treatment of acute venous thromboembolism (VTE) is challenging. Ideally, treatment would avoid inpatient admission as for most other patients with acute VTE. DOACs represent the easiest option but there are concerns over bioaccumulation increasing bleeding risk. Despite the absence of a standardized therapeutic range, anti-Xa trough level is measured to monitor potential DOACs bioaccumulation and thus, used for safety surveillance. Methods. We describe a case of a 51 yo female, 36 kg, on chronic hemodialysis with a provoked acute upper extremity deep vein thrombosis. Due to a lack of subcutaneous fat and calciphylaxis we were reluctant to use low molecular weight heparin and warfarin. She was treated with apixaban 2,5 mg twice daily for 6 weeks. Over 4 weeks, the apixaban anti-Xa trough levels were measured on dialysis days 12 hours after the morning dose. Results. The anti-Xa trough levels ranged from 58 to 84 ng/mL, similar to what is expected in patients with normal kidney function. There were no adverse events in the 3 months after anticoagulation initiation. Conclusion. We saw no evidence of bioaccumulation. This indicates a potential role for apixaban low doses in acute venous thromboembolism for patients on dialysis. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: The use of Apixaban for treatment of acute venous thromboembolism in patient on dialysis has not been approved.

Download Full-text