The pharmacoeconomics of deep vein thrombosis treatment

Are treatment guides and rational drug use policies adequately exploited in combating respiratory system diseases?

The aim of the present study was to increase awareness regarding the rational use of medicines. The data were obtained via the Material Resources Management System Module of the Ministry of Health. For the appropriateness of treatments, the Global Initiative for Asthma, the Global Initiative for Chronic Obstructive Lung Disease, and the guidelines for the rational use of medicines were used. We also investigated whether any de-escalation method or physical exercise was performed. Statistical analyses were performed using descriptive statistics to determine the mean, standard deviation, and frequency. The results showed that healthcare providers ignored potential drug reactions or adverse interactions, and reflecting the lack of adherence to the current treatment guides, 35.8% irrational use of medicines was recorded. Thus, de-escalation methods should be used to decrease costs or narrow the antibiotic spectrum, antibiotic selection should consider the resistance patterns, culturing methods should be analyzed, and monotherapy should be preferred over combination treatments.

Lovenox Induced Tissue Necrosis, a Case Report and Literature Review

Lovenox is a trade name for Enoxaparin. It is a low molecular weight heparin (LMWH) and has other trade names like Clexane and Xaparin. It is an anticoagulant used to prevent and treat venous thromboembolism events (VTE) like deep vein thrombosis or pulmonary embolism, and is given as a subcutaneous injection. General speaking, the most common skin reactions as a result of enoxaparin use are: urticarial, ecchymosis, and even skin necrosis due to vasculitis. These side effects are usually located at the injection site. New studies have pointed out the side effect that could occur a distance from the site of Lovenox injection. In our case extensive skin and subcutaneous tissue necrosis developed at the abdominal wall injection site.

Anticoagulation with the oral direct thrombin inhibitor dabigatran does not enlarge hematoma volume in experimental intracerebral hemorrhage

BACKGROUND

The direct thrombin inhibitor dabigatran etexilate (DE) may constitute a future replacement of vitamin K antagonists for long-term anticoagulation. Whereas warfarin pretreatment is associated with greater hematoma expansion after intracerebral hemorrhage (ICH), it remains unclear what effect direct thrombin inhibitors would have. Using different experimental models of ICH, this study compared hematoma volume among DE-treated mice, warfarin-treated mice, and controls.

METHODS AND RESULTS

CD-1 mice were fed with DE or warfarin. Sham-treated mice served as controls. At the time point of ICH induction, DE mice revealed an increased activated partial thromboplastin time compared with controls (mean±SD 46.1 ± 5.0 versus 18.0 ± 1.5 seconds; P=0.022), whereas warfarin pretreatment resulted in a prothrombin time prolongation (51.4 ± 17.9 versus 10.4 ± 0.3 seconds; P<0.001). Twenty-four hours after collagenase-induced ICH formation, hematoma volume was 3.8 ± 2.9 μL in controls, 4.8 ± 2.7 μL in DE mice, and 14.5 ± 11.8 μL in warfarin mice (n=16; Welch ANOVA between-group differences P=0.007; posthoc analysis with the Dunnett method: DE versus controls, P=0.899; warfarin versus controls, P<0.001; DE versus warfarin, P=0.001). In addition, a model of laser-induced cerebral microhemorrhage was applied, and the distances that red blood cells and blood plasma were pushed into the brain were quantified. Warfarin mice showed enlarged red blood cell and blood plasma diameters compared to controls, but no difference was found between DE mice and controls.

CONCLUSIONS

In contrast with warfarin, pretreatment with DE did not increase hematoma volume in 2 different experimental models of ICH. In terms of safety, this observation may represent a potential advantage of anticoagulation with DE over warfarin.

Severe bleeding secondary to misuse of fondaparinux: a case report

Venous thromboembolism (VTE) remains a great challenge because of its frequency and of its potential severity. However, VTE treatment can also lead to iatrogenic complications. We report a case of thigh haematoma by a 83-year-old woman under fondaparinux for a solear thrombosis. Then we discuss the indications of Unfractionated Heparin (UFH), Low-Molecular-Weight Heparins (LMWH) and Fondaparinux, which are the three classes of rapidly acting anticoagulant treatments nowadays available. As their efficacy is comparable, the choice between these classes relies on the risk of adverse effects, which depends on some patient's characteristics. LMWH and fondaparinux are contra-indicated by the patients with a renal clearance under 30 ml/min. Only UFH are authorized during the whole pregnancy even though LMWH are more and more used. Fondaparinux has proven its safety by patients over 100 kg. UFH requires a daily biological management whereas it is optional for LMWH and fondaparinux, as long as their contra-indications are taken into account. No Heparin-induced-thrombocytopenia Syndrome (HIT-Sd) has been proven yet under fondaparinux so that platelets management seems not necessary, contrary to UFH and LMWH which require a twice-weekly platelets count. The accuracy of the therapeutic indication should result in the best benefit/risk assessment.

The relationship between monoclonal gammopathy of undetermined significance and venous thromboembolic disease

INTRODUCTION

Monoclonal gammopathy of undetermined significance (MGUS) has been proposed to be a risk factor for venous thromboembolic disease (VTE). However, no series published to date has been population-based or included a control group with similar comorbidities to people with MGUS.

PATIENTS/METHODS

We reviewed the records of all the male veterans in a single VA healthcare system with MGUS between January 1, 1996 and December 31, 2005. We compared the rate of VTE in 166 patients with MGUS with the rate of VTE in an age-matched control group of 465 patients who had tested negative for monoclonal gammopathy by serum protein electrophoresis (SPEP).

RESULTS

The VTE rate in the MGUS group was 2.2 per 100 person-years, which was not significantly different from the rate in the control group, 1.4 per 100 person-years (HR 1.38, CI 0.63-3.01, p=0.42). Most VTE events occurred within 4 months of the diagnosis of MGUS. In univariate analysis, albumin level (HR 0.21, CI 0.1-0.41, p<0.001), abnormal leukocyte count (HR 2.53, CI 1.09-5.86, p=0.03), and history of prior VTE (HR 4.41, CI 1.69-11.54, p=0.003) were associated with increased risk of VTE. On multivariate analysis, albumin level and history of prior VTE remained significant, but presence of MGUS was still not significantly associated with VTE risk.

CONCLUSION

Our results suggest that the increased rate of VTE in people with MGUS may be primarily due to other underlying conditions that led to testing for a monoclonal gammopathy rather than to the monoclonal gammopathy itself.