Stephan Moll, MD writes… The American Society of Hematology (ASH) has identified 3 things that physicians dealing with DVT, PE and blood thinners (anticoagulants) should avoid – published this week in the journal Blood [ref 1].
CHOOSING WISELY® INITIATIVE
The Choosing Wisely® campaign is a quality improvement initiative of the ABIM (American Board of Internal Medicine) Foundation. The goal of this initiative is to (a) identify tests and medical practices that are not supported by evidence and that may lead to adverse outcomes and financial costs and (b) encourage physicians and patients to question such tests, procedures and treatments.
ASH has joined the Choosing Wisely® campaign and identified five hematologic topics, three of which deal with DVT, PE and blood thinners [ref 1]. A systematic review of the evidence on these topics was performed by experts in the field which then lead to the following conclusions and recommendations.
THE 3 RECOMMENDATIONS
1. Thrombophilia Testing
- ASH Recommendation: ASH recommends against testing for clotting disorders (= thrombophilias) in adult patients diagnosed with venous thromboembolism (VTE = DVT or PE) triggered by a strong (also referred to as “major”) transient VTE risk factor, such as surgery, trauma or prolonged immobility. In this scenario, thrombophilia testing does not influence duration or intensity of treatment with blood thinners.
- Comment: This recommendation is in regards to VTE associated with “major” risk factors. This recommendation does not apply to other VTE risk factors that are referred to as weaker, mild, or “minor” risk factors, such as contraceptives, pregnancy, hormonal therapy, airline travel, minor surgery (arthroscopic surgeries, etc.) or partial immobility (boot immobilizer, etc.). Patients who develop VTE associated with such “minor” VTE risk factors may be candidates for thrombophilia testing, as may patients with unprovoked (=idiopathic) DVT or PE. Such patients should seek guidance from an expert in VTE.
2. IVC Filters
- ASH Recommendation: ASH recommends against the routine use of IVC filters – filters in the big vein in the abdomen (also sometimes referred to as “Greenfield filters”) that may catch clots that break off from leg DVTs and prevent them from travelling to the lung. The recommendation against routine placement of such filters is because (a) there are no solid data supporting their use and benefit, and (b) they can be associated with complications and adverse outcomes (they may puncture the blood vessel leading to internal bleeding; the filter may fracture or dislodge and travel to the lung; blood clots may form around the filter).
- Comment: The main indication for an IVC filter is the presence of an acute DVT in a patient who cannot be safely treated with blood thinners. When IVC filters are necessary, retrievable filters are strongly recommended over permanent filters.
3. Use of plasma transfusions to reverse warfarin in the absence of bleeding or emergencies
- ASH Recommendation: ASH recommends against the use of plasma (called fresh frozen plasma = FFP) or clotting factor concentrate (called prothrombin complex concentrate = PCC) to reverse warfarin and an elevated INR (which is the test that measures warfarin’s effect) in the absence of bleeding, emergent surgery, or emergent invasive procedures. This is because (a) FFP and PCC expose the patient to potentially harmful transfusions, (b) there is little likelihood of benefit from such transfusions in these circumstances, and (c) the treatment increases cost.
- Comment: Most non-bleeding patients can be managed by interrupting or reducing warfarin, or giving small doses of vitamin K. The story is different in patients who have major and life-threatening bleeding on warfarin: these patients should get PCCs (Kcentra®) and, if PCCs are not available, FFP. They should also be treated with vitamin K.
- Hicks LK et al. The ASH Choosing Wisely® Campaign: Five Hematologic Tests and Treatments to Question. Blood. Pre-published on the web, Dec 4th, 2013.
Disclosure: No relevant disclosures.
Last updated: Dec 4th, 2013