Stephan Moll, MD writes (Dec 17, 2014)… The American Society of Hematology (ASH) published last week two things that physicians dealing with DVT, PE and blood thinners should avoid [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 joined the Choosing Wisely® campaign and in 2013 identified five hematologic topics for this campaign, three of which dealt with DVT, PE and anticoagulants [ref 1] – these have previously been discussed on Clot Connect (link here). Five additional topics were identified this year, two of which deal with thrombosis topics [ref 2].
THE TWO NEW RECOMMENDATIONS
1. Length of Blood Thinner Therapy for DVT and PE
- ASH recommendation: “Do not treat with a blood thinner for more than 3 months in a patient with a first DVT or PE occurring in the setting of a major transient risk factor”.
- Comments: This recommendation is in keeping with existing evidence-based guidelines. A “major risk factor” is considered to be major surgery, such as hip or knee replacement, pelvic or abdominal surgery, or major trauma or long-term (several days) of bed-ridden state. This ASH Choosing Wisely® recommendation to treat for only 3 months does NOT necessarily apply to patients whose DVT or PE was triggered by a minor risk factor (such as contraceptives, estrogen replacement therapy or pregnancy, minor surgery, minor immobility such as long-distance travel) or occurred completely out of the blue without any triggering factor. The risk of another clot may be higher in these patients and longer treatment with blood thinners may be appropriate in such patients’ individualized treatment decisions need to be made. Therefore, the Choosing Wisely® recommendation to treat for no-longer than 3 months is referring only to DVT or PE associated with a major transient risk factor.
2. Heparin-induced thrombocytopenia (HIT)
- ASH recommendation: “Do not test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT”.
- Comment: This recommendation when to test or treat for the heparin “allergy” called HIT is relevant for hospital clinicians, but not for , as they are not involved in this decision process. Thus, the topic is not discussed here, but rather in the health care professional blog (link here).
- Hicks LK et al. Five hematologic tests and treatments to question. Blood 2013, Dec 4;124(24):3524-8.
- Hicks LK et al. Five hematologic tests and treatments to question. Hematology 2014:599-603.
- Kearon C et al. Antithrombotic Therapy for VTE Disease Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2)(Suppl):e419S–e494S.
- Le Gal G et al. Risk of recurrent venous thromboembolism after a first oestrogen-associated episode. Data from the REVERSE cohort study. Thromb Haemost. 2010;104(3):498-503.
- Iorio A et al. Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. Arch Intern Med. 2010;170(19):1710-1716.
Last updated: Dec 17,2014