Posts Tagged ‘Guideline’
Stephan Moll, MD writes… A new consensus guidance for health care professionals on management of DVT and PE – link here – was published today, Jan 18th, 2016, in the Journal of Thrombosis and Thrombolysis. The publication contains 13 chapters on various aspects of DVT and PE (acute treatment, decisions on length of blood thinner treatment, thrombophilia work-up, management at times of surgery, etc.). It incorporates both evidence-based data and consensus opinion of the 52 international experts who wrote these chapters. It is aimed at any type of health care professional who is involved in the management of DVT and PE – emergency room physicians, hospitalists, internists, cardiologists, hematologists, pharmacists and others.
Last updated: Jan 18th, 2016
The ACCP Chest Guidelines have been the main guide over the last more than 2 decades for evidence-based recommendations on best management of blood thinners for various indications, including DVT and PE. The 10th edition of the chapter on DVT and PE management was published in Jan 2016 [reference]. Unfortunately, the guideline is not available for non-subscribers.
This 38 page document focusses on the best management of DVT and PE. It provides 30 individual recommendations (page 7-19) and a discussion of the evidence behind the guidance. It uses the terms “suggest” and “recommend” for its guidance, depending on the strength of published evidence.
- Choice of blood thinner:
In patients with DVT of the leg or PE (and no cancer) the suggestion is to use one of the newer oral blood thinners (Eliquis, Pradaxa, Savaysa or Xarelto) rather than warfarin (Coumadin, Jantoven) therapy!
- Cancer patients with DVT or PE:
In cancer patients with DVT of the leg or PE an injectable blood thinner called “low molecular weight heparin” (Lovenox = enoxaparin; Fragmin = dalteparin; Innohep = tinzaparin) is suggested rather than an oral drug.
- How long to treat with blood thinners?
- DVT (in veins in the pelvis, thigh or behind the knee, termed “proximal DVT) or PE provoked by surgery: recommend 3 months of blood thinners.
- Proximal DVT or PE provoked by non-surgical transient risk factor (e.g. estrogens, pregnancy, leg injury, flight > 8 hrs): suggest 3 months of blood thinners.
- Unprovoked proximal DVT or PE: suggest long-term blood thinners.
- Distal DVT, i.e. below the knee
- if not severely symptomatic : suggest no blood thinners, but follow-up Doppler ultrasound imaging study
- if severely symptomatic: suggest 3 months of blood thinners.
- Role of aspirin:
In patients with unprovoked proximal DVT or PE who stop blood thinners, aspirin is suggested.
This is a solid guideline and good publication.
Kearon C et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016; 149(2):315-352
Conflict of interest: None
Last updated: Oct 27th, 2016
Stephan Moll, MD writes… The American Society of Hematology (ASH) is embarking on a program to develop clinically useful guidelines on the best management of patients with deep vein thrombosis or pulmonary embolism. ASH appropriately desires input from patients for the development of these guidelines. Any interested patient please see this letter from ASH explaining the goals of the project and what is needed.
Last updated: July 1st, 2015
Stephan Moll, MD writes… Major bleeds on blood thinners (such as Coumadin, Jantoven, Eliquis, Pradaxa, Xarelto) and anti-platelet drugs (like aspirin, Plavix, Brilinta, Effient, etc.) occur every so often. Quick action in Emergency Departments is needed in case of such bleeds. Our medical center (University of North Carolina Hospitals, Chapel Hill) has put together an “Emergent Anticoagulation Reversal Guideline” for our local use as a practical, clinical how-to document (PDF here). Since not every medical institution has pharmacists and MDs with clotting expertise available to develop its own guideline, we are making this document available through Clot Connect and invite colleagues and hospitals to take the document if they like, modify it, and apply it to their institution.
Disclosures: I have been a consultant for CSL Behring and Janssen.
Last updated: June 9th, 2014
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]. Read the rest of this entry »
Stephan Moll, MD writes…
Apixaban (Eliquis) is one of the 3 new oral blood thinners. It is NOT approved at this point to prevent or treat DVT or PE (also referred to as venous thromboembolism or VTE). It is, however, FDA-approved for the use in patients with irregular heart beat (atrial fibrillation) to prevent stroke. As the studies on VTE have not been completed and as the drug is not FDA-approved for VTE, I would NOT use it off label in patients with VTE. However, for the health care professionals who prescribes apixaban for atrial fibrillation, we have made available the apixaban guideline (here) Read the rest of this entry »
Stephan Moll, MD writes…
If you are considering to start therapy with the new oral “blood thinner” Xarelto® (Rivaroxaban), there are a few safety nets that your local hospital and physician may want to establish to make therapy as safe as possible for you Read the rest of this entry »
Two main guidelines exist which many physicians go by to decide whether a particular patient should get DVT prophylaxis after hip or knee replacement surgery, what method (compression device, or drug) to use, and for how long to give prophylaxis. (a) One is the ACCP guideline (American College of Chest Physicians), last published in June 2008 [ref 1]. An updated version is expected to be published around February 2012. (b) The other one is the AAOS guideline Read the rest of this entry »
If you are considering to start therapy with the new oral “blood thinner” Pradaxa®, there are a few safety nets that your local hospital and physician may want to establish to make therapy as safe as possible for you. Issues to be addressed are (a) dosing, (b) management of major bleeding, (c) interruption of therapy for surgery, dental procedures, or other procedures, d) what to do if you missed a dose, and (e) what to do if the pill box has been left open for too long.
These issues are probably best addressed by the establishment of a treatment algorithm/guide/help for the whole hospital or physician practice. As an example, attachedthat we developed for our institution, the University of North Carolina (UNC) Health Care System. Your physicians and pharmacists are free to (a) take the document and modify it to fit their institution/practice or (b) use it as a clinical reference for management issues.
For Health Care Professionals: This same post, written for health care professionals, is posted here.
Disclosure: I have no financial conflict of interest relevant to this educational post.
Last updated: May 1st, 2012
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