Effect of concomitant diseases on the hemostasis system in the perioperative period of non-cardiac surgery

В данном исследовании изучалось влияние клинических факторов и антитромботической терапии на свертывающую систему крови пациентов в периоперационном периоде. В исследование включено 80 пациентов, которым проводилось плановое некардиальное хирургическое вмешательство. Лабораторный контроль осуществлялся с использованием рутинных методов исследования гемостаза (АЧТВ, МНО) и глобального теста исследования гемостаза (тест тромбодинамики). Использование теста тромбодинамики в данном исследовании оказалось более чувствительным методом по сравнению с рутинными тестами и позволило выявить клинические факторы, ассоциированные с гиперкоагуляционными состояниями и снижением эффективности низкомолекулярных гепаринов в послеоперационном периоде: возраст старше 60 лет, фибрилляция предсердий, хроническая ишемическая болезнь сердца, стентирование коронарных артерий в анамнезе, предшествующий прием антитромботической терапии до оперативного вмешательства. У больных с тромбозом глубоких вен нижних конечностей отмечалась гиперкоагуляция в первые сутки после проведения операции по сравнению с остальными пациентами. Использование теста тромбодинамики за сутки до оперативного вмешательства позволило спрогнозировать увеличение объема интраоперационной кровопотери. Назначение периоперационной мост-терапии низкомолекулярными гепаринами у больных с высоким тромботическим риском достоверно ассоциировалось с увеличением трансфузии эритромассы практически в 2 раза по сравнению с остальными пациентами и было связано с повышением риска геморрагических осложнений. Результаты исследования показали, что тест тромбодинамики потенциально может быть применен в дальнейших исследованиях с целью персонификации ведения пациентов в периоперационном периоде при некардиальной хирургии, а также способен прогнозировать возникновение геморрагических и тромботических осложнений. This study examined the effect of clinical factors and antithrombotic therapy on the blood coagulation system of patients in the perioperative period. The study included 80 patients who underwent elective noncardiac surgery. Laboratory control of hemostasis was carried out using routine tests for studying hemostasis (APTT, INR) and a global test for hemostasis (thrombodynamics test). Usage of the thrombodynamics test in this study was more sensitive compared to routine tests and made it possible to identify clinical factors associated with hypercoagulable states and «decreasing in the effectiveness» of low molecular weight heparins in the postoperative period. These factors are: age over 60 years, chronic ischemic heart disease, a history of coronary artery stenting, prior antithrombotic therapy before surgery. Hypercoagulability was found on the first day after surgery in patients with deep vein thrombosis of the lower extremities compared to other patients. The use of a thrombodynamics test a day before surgery allowed to predict an increase of intraoperative blood loss volume. Perioperative bridge therapy with low molecular weight heparins in high thrombotic risk patients was significantly associated with an increase in packed red blood cells transfusion of almost two times compared with other patients and is associated with an increased risk of hemorrhagic complications. The results of the study showed that thrombodynamics test can potentially be used further with the aim of personalizing patients’ management in the non-cardiac surgery perioperative period. It also helps to predict the occurrence of hemorrhagic and thrombotic complications.

Non-anticoagulant and other properties of low molecular weight heparins

Низкомолекулярные гепарины (НМГ) являются уникальными препаратами: образуя одну группу, объединенную антитромботическим действием, каждое МНН (международное непатентованное наименование) дополнительно предоставляет свой спектр плейотропного (неантитромботического) действия со своим профилем клинической эффективности. Из-за различий в структуре этих препаратов не следует переносить результаты, полученные с одним НМГ, на другой. Однако различия между ними не делают какой-то один НМГ лучше или хуже другого. Напротив, они позволяют выбрать если не оптимальный, то наиболее подходящий препарат для конкретного пациента. При выборе НМГ для конкретного пациента необходимо строго руководствоваться инструкцией по медицинскому применению и тщательным подбором индивидуальной дозы препарата, исходя из массы тела пациента, степени тяжести заболевания, сопутствующей патологии, а также принимая во внимание ряд других факторов. Low molecular weight heparins (LMWHs) make one pharmacological group due to their antithrombotic action, but each of their international nonproprietary names provides additionally its own spectrum of pleiotropic (non-antithrombotic) actions with a specific profile for clinical efficacy. Due to the differences in the structure of these medications the results obtained with one LMWH should not be transferred to another. However, differences between LMWHs do not make one better or worse than the other. On the contrary, it allows you to choose if not optimal then the most suitable LMWH for the patient taking into account a number of influencing factors as well.

Prevention and treatment of thrombosis in cancer and oncohematological patients

The purpose of the review is to highlight the current possibilities for the prevention and treatment of venous thrombotic complications in patients with cancer.The data of 52 scientific sources published in the Russian and foreign press in 1997–2020 are considered.Cancer patients are at high risk of thrombotic complications, which worsen the outcome of anticancer treatment and are one of the leading causes of death. Thrombosis in an oncological patient increases the risk of death by 30 times, which is associated with fatal thromboembolism and a more aggressive course of the disease. The leading role in the pathogenesis of thrombotic complications is played by disorders in the hemostasis system caused both by the tumor itself and by therapy. Low molecular weight heparins are considered the basis for specific prophylaxis of thromboembolic complications in cancer patients. The use of low molecular weight heparins after surgery and during chemotherapy effectively reduces the incidence of venous thrombosis. Direct oral anticoagulants are promising drugs for oral administration and are indicated as one of the treatment options for patients with tumor-associated thrombosis with a low risk of bleeding and no drug interactions with ongoing systemic chemotherapy.

How confident are pharmacists in providing pharmaceutical care on anticoagulants? A cross-sectional, self-administered questionnaire study in Borneo, Malaysia

Background Anticoagulants are the cornerstone therapy for the management of venous thromboembolism (VTE) and atrial fibrillation (AF). Pharmacists should be confident and equipped with the skill and updated knowledge in managing anticoagulation therapy. Objective To explore self-reported confidence level of pharmacists, perceived reasons influencing their confidence and socio-demographic associated with high confidence level in the area of anticoagulation. Methods A cross-sectional, self-administered questionnaire survey was carried out among fully registered pharmacists who work in selected government hospitals and clinics in Borneo, Malaysia, from January 2019 to February 2020. Results Overall, responses from 542 fully registered pharmacists were obtained. Proportion of respondents who claimed confident in providing necessary information to patient receiving warfarin (n = 479, 88.3%) was significantly higher (p < 0.001) compared to low molecular weight heparins (n = 317, 58.5%) and direct oral anticoagulants (n = 211, 38.9%). Respondents’ perceived reasons that may influence their confidence level include experience in dealing with anticoagulants’ cases (n = 469, 86.5%), knowledge on anticoagulants (n = 394, 72.7%) and knowledge on diseases needing anticoagulation therapy (n = 311, 57.4%). Practising as ward pharmacist and “always” dealing with anticoagulants during their practice were the socio-demographic that significantly associated with high confidence level of pharmacist in providing pharmaceutical care on all types of anticoagulants (p < 0.05). Conclusion Pharmacists were found more confident in providing pharmaceutical care on warfarin compared to low molecular weight heparins and direct oral anticoagulants. Continuous educational and training programmes on the use of anticoagulants should be carried out to enhance pharmacists’ confidence in supporting patients’ care.

Proposed “COVID-19 Thrombinopathy” cascade and the role of heparins (Preprint)

UNSTRUCTURED Management of life threatening coagulopathy in COVID-19 still remains a clinical challenge. There is still uncertainty regarding the choice and the dose of anticoagulation in Covid-19 coagulopathy especially in critically ill patients. In this article, a new term “COVID-19 thrombinopathy” and a proposed cascade are introduced in order to highlight the non-traditional pathways of thrombin generation which are likely active in COVID-19 (or sepsis), so that the medical community can focus on targeting “thrombin” and “non-traditional thrombin generation” rather than considering general “anticoagulation” based on traditional coagulation pathways. The medical community generalizes unfractionated heparin (UFH) and low molecular weight heparins (LMWH) as “heparins” and also interchanging those in clinical practice. UFH and LMWHs are “heparins” but the targets, therapeutic actions and side effects differ. In addition, during anticoagulation therapy, UFH dosing is based on blood level (therapeutic effect) but LMWH is weight based irrespective of the requirement/underlying clinical condition. Compared to UFH, interestingly and importantly, LMWH has shown to stabilize the clot and make the clot more resistant to breakdown. Preventing platelet activation and its role in traditional and non-traditional thrombogenesis is also essential since it appears to play a major role in COVID-19 thrombinopathy. Further clinical trials are needed to evaluate the benefits of UFH in “COVID-19 thrombinopathy” preferably along with a globally available ADP/P2Y12 blocking anti-platelet agent like Clopidogrel.