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Macki M, Haddad Y, Suryadevara R, Dabaja AL, Chedid M, Chang V. Prophylactic Low-Molecular-Weight Heparin Versus Unfractionated Heparin in Spine Surgery (PLUSS): A Pilot Matched Cohort Study. Neurosurgery 2021; 89:1097-1103. [PMID: 34634115 DOI: 10.1093/neuros/nyab363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite a proven superior efficacy of prophylactic low-molecular-weight heparin (LMWH) over unfractionated heparin (UFH) in the majority of surgical specialties, chemoprophylactic techniques after spine surgery have not been established because of the fear of epidural hematomas with LMWH. OBJECTIVE To determine the efficacy of LMWH vs UFH in the prevention of venous thromboembolism (VTE) events, balanced against the risk of epidural hematoma. METHODS This is the first matched cohort design that directly compares prophylactic LMWH to UFH after spine surgery for degenerative/deformity pathologies at a tertiary academic center. Prospectively collected patients receiving prophylactic LMWH and a historical cohort of patients receiving prophylactic UFH (prior to 2017) were matched in 1:1 ratio based on age ±5 yr, American Society of Anesthesiologists classification, location in the spinal column, and type of surgery. RESULTS Of 562 patients, VTE events equaled 1.4% (n = 8): 1.4% (n = 4) with LMWH was exactly equal to 1.4% (n = 4) with UFH. Epidural hematomas reached 0.8% (n = 5): 1.4% (n = 4) with UFH vs 0.3% (n = 1) with the LMWH (P = .178). Utilizing adjusted odds ratio (ORadj), the type of chemoprophylaxis after spine surgery failed to predict VTE events. Similarly, the chemoprophylactic technique failed to predict epidural hematoma in the multivariable regression analysis, although UFH trended toward a higher complication rate (ORadj = 3.15 [0.48-20.35], P = .227). CONCLUSION Chemoprophylactic patterns failed to predict VTE. Although no differences in epidural hematoma rates were detected, our analysis does highlight a trend toward a safer profile with LMWH vs UFH. LMWH may be a safe alternative to UFH in spine surgery.
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Affiliation(s)
- Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Yazeed Haddad
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | | | - Abed Latif Dabaja
- Department of Internal Medicine, Garden City Hospital, Garden City, Michigan, USA
| | - Mokbel Chedid
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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Nair P, Trivedi R, Hu P, Zhang Y, Merchant AM. Low-molecular weight vs. unfractionated heparin for prevention of venous thromboembolism in general surgery: a meta-analysis. Updates Surg 2020; 73:75-83. [PMID: 32880870 DOI: 10.1007/s13304-020-00872-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/23/2020] [Indexed: 11/24/2022]
Abstract
To assess the association between low-molecular weight heparin (LMWH) and unfractionated heparin (UFH) in the prevention of venous thromboembolism (VTE) among participants undergoing general surgery. LMWH and UFH are the standard of practice in the prevention of VTE in surgery. However, in the context of general surgery, studies comparing the effectiveness of these treatments are limited. A systematic search was conducted to find studies which examined the comparative effectiveness between LMWH and UFH in the prophylaxis of VTE in the context of general surgery. The number of events of VTE in groups receiving LMWH or UFH was the primary outcome of interest, and was used to calculate odds-ratios. Amongst 33,068 participants pooled from twelve studies, the rate of VTE was 1.3% in those treated with LMWH, and 3.1% in those treated with UFH. Although there was a wide difference in rates due to clinical heterogeneity, there was no statistically significant difference between treatment effects [OR 0.77; 95% CI 0.58-1.03; p value = 0.0783; I2= 62.3%; 12 studies]. In terms of the sensitivity analysis, sources overly contributing to heterogeneity were removed. The random-effects model continued to show insignificance between LMWH and UFH in the prevention of VTE in participants undergoing general surgery [OR 0.86; 95% CI 0.69-1.08; p value = 0.2005; I2= 0%; 9 studies]. Results show an equal effectiveness in the prevention of VTE between participants undergoing general surgery in those allocated to receive LMWH to those allocated to receive UFH.
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Affiliation(s)
- Prachi Nair
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Radhika Trivedi
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Patrick Hu
- Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA
| | - Yingting Zhang
- Robert Wood Johnson Library of the Health Sciences, New Brunswick, NJ, USA
| | - Aziz M Merchant
- Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA.
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3
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Macki M, Haider SA, Anand SK, Fakih M, Elmenini J, Suryadevara R, Chang V. A Survey of Chemoprophylaxis Techniques in Spine Surgery Among American Neurosurgery Training Programs. World Neurosurg 2020; 133:e428-e433. [DOI: 10.1016/j.wneu.2019.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/06/2019] [Accepted: 09/07/2019] [Indexed: 10/26/2022]
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Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). CONCLUSIONS For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.
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Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
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Trivedi NN, Fitzgerald SJ, Schmaier AH, Wera GD. Venous Thromboembolism Chemoprophylaxis in Total Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2019; 7:e2. [PMID: 30601202 DOI: 10.2106/jbjs.rvw.18.00010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nikunj N Trivedi
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Steven J Fitzgerald
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alvin H Schmaier
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Glenn D Wera
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Matar CF, Kahale LA, Hakoum MB, Tsolakian IG, Etxeandia‐Ikobaltzeta I, Yosuico VED, Terrenato I, Sperati F, Barba M, Schünemann H, Akl EA. Anticoagulation for perioperative thromboprophylaxis in people with cancer. Cochrane Database Syst Rev 2018; 7:CD009447. [PMID: 29993117 PMCID: PMC6389341 DOI: 10.1002/14651858.cd009447.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The choice of the appropriate perioperative thromboprophylaxis for people with cancer depends on the relative benefits and harms of different anticoagulants. OBJECTIVES To systematically review the evidence for the relative efficacy and safety of anticoagulants for perioperative thromboprophylaxis in people with cancer. SEARCH METHODS This update of the systematic review was based on the findings of a comprehensive literature search conducted on 14 June 2018 that included a major electronic search of Cochrane Central Register of Controlled Trials (CENTRAL, 2018, Issue 6), MEDLINE (Ovid), and Embase (Ovid); handsearching of conference proceedings; checking of references of included studies; searching for ongoing studies; and using the 'related citation' feature in PubMed. SELECTION CRITERIA Randomized controlled trials (RCTs) that enrolled people with cancer undergoing a surgical intervention and assessed the effects of low-molecular weight heparin (LMWH) to unfractionated heparin (UFH) or to fondaparinux on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, and thrombocytopenia. DATA COLLECTION AND ANALYSIS Using a standardized form, we extracted data in duplicate on study design, participants, interventions outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, PE, symptomatic venous thromboembolism (VTE), asymptomatic DVT, major bleeding, minor bleeding, postphlebitic syndrome, health related quality of life, and thrombocytopenia. We assessed the certainty of evidence for each outcome using the GRADE approach (GRADE Handbook). MAIN RESULTS Of 7670 identified unique citations, we included 20 RCTs with 9771 randomized people with cancer receiving preoperative prophylactic anticoagulation. We identified seven reports for seven new RCTs for this update.The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.63 to 1.07; risk difference (RD) 9 fewer per 1000, 95% CI 19 fewer to 4 more; moderate-certainty evidence), PE (RR 0.49, 95% CI 0.17 to 1.47; RD 3 fewer per 1000, 95% CI 5 fewer to 3 more; moderate-certainty evidence), symptomatic DVT (RR 0.67, 95% CI 0.27 to 1.69; RD 3 fewer per 1000, 95% CI 7 fewer to 7 more; moderate-certainty evidence), asymptomatic DVT (RR 0.86, 95% CI 0.71 to 1.05; RD 11 fewer per 1000, 95% CI 23 fewer to 4 more; low-certainty evidence), major bleeding (RR 1.01, 95% CI 0.69 to 1.48; RD 0 fewer per 1000, 95% CI 10 fewer to 15 more; moderate-certainty evidence), minor bleeding (RR 1.01, 95% CI 0.76 to 1.33; RD 1 more per 1000, 95% CI 34 fewer to 47 more; moderate-certainty evidence), reoperation for bleeding (RR 0.93, 95% CI 0.57 to 1.50; RD 4 fewer per 1000, 95% CI 22 fewer to 26 more; moderate-certainty evidence), intraoperative transfusion (mean difference (MD) -35.36 mL, 95% CI -253.19 to 182.47; low-certainty evidence), postoperative transfusion (MD 190.03 mL, 95% CI -23.65 to 403.72; low-certainty evidence), and thrombocytopenia (RR 3.07, 95% CI 0.32 to 29.33; RD 6 more per 1000, 95% CI 2 fewer to 82 more; moderate-certainty evidence). LMWH was associated with lower incidence of wound hematoma (RR 0.70, 95% CI 0.54 to 0.92; RD 26 fewer per 1000, 95% CI 39 fewer to 7 fewer; moderate-certainty evidence). The meta-analyses found the following additional results: outcomes intraoperative blood loss (MD -6.75 mL, 95% CI -85.49 to 71.99; moderate-certainty evidence); and postoperative drain volume (MD 30.18 mL, 95% CI -36.26 to 96.62; moderate-certainty evidence).In addition, the meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with Fondaparinux for the following outcomes: any VTE (DVT or PE, or both; RR 2.51, 95% CI 0.89 to 7.03; RD 57 more per 1000, 95% CI 4 fewer to 228 more; low-certainty evidence), major bleeding (RR 0.74, 95% CI 0.45 to 1.23; RD 8 fewer per 1000, 95% CI 16 fewer to 7 more; low-certainty evidence), minor bleeding (RR 0.83, 95% CI 0.34 to 2.05; RD 8fewer per 1000, 95% CI 33 fewer to 52 more; low-certainty evidence), thrombocytopenia (RR 0.35, 95% CI 0.04 to 3.30; RD 14 fewer per 1000, 95% CI 20 fewer to 48 more; low-certainty evidence), any PE (RR 3.13, 95% CI 0.13 to 74.64; RD 2 more per 1000, 95% CI 1 fewer to 78 more; low-certainty evidence) and postoperative drain volume (MD -20.00 mL, 95% CI -114.34 to 74.34; low-certainty evidence) AUTHORS' CONCLUSIONS: We found no difference between perioperative thromboprophylaxis with LMWH versus UFH and LMWH compared with fondaparinux in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in people with cancer. There was a lower incidence of wound hematoma with LMWH compared to UFH.
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Affiliation(s)
- Charbel F Matar
- American University of Beirut Medical CenterDepartment of Internal MedicineRiad El SolhBeirutLebanon1107 2020
| | - Lara A Kahale
- American University of BeirutFaculty of MedicineBeirutLebanon
| | - Maram B Hakoum
- American University of BeirutFamily MedicineBeirutLebanon1107 2020
| | | | - Itziar Etxeandia‐Ikobaltzeta
- McMaster UniversityDepartments of Health Research Methods, Evidence, and Impact and of Medicine1280 Main Street WestHamiltonONCanadaL8S 4K1
| | | | - Irene Terrenato
- Regina Elena National Cancer InstituteBiostatistics‐Scientific DirectionVia Elio Chianesi 53RomeItaly00144
| | - Francesca Sperati
- Regina Elena National Cancer InstituteBiostatistics‐Scientific DirectionVia Elio Chianesi 53RomeItaly00144
| | - Maddalena Barba
- IRCCS Regina Elena National Cancer InstituteDivision of Medical Oncology 2 ‐ Scientific DirectionVia Elio Chianesi 53RomeItaly00144
| | - Holger Schünemann
- McMaster UniversityDepartments of Health Research Methods, Evidence, and Impact and of Medicine1280 Main Street WestHamiltonONCanadaL8S 4K1
| | - Elie A Akl
- American University of Beirut Medical CenterDepartment of Internal MedicineRiad El SolhBeirutLebanon1107 2020
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The long path to NOAC. PHLEBOLOGIE 2016. [DOI: 10.12687/phleb2319-4-2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryThe discovery of anticoagulant drugs occurred at a time when the process of blood coagulation only had been roughly described and their mode of action was unknown. Nevertheless, heparin – which was discovered 100 years ago – and warfarin – which was developed in the 1920s – had taken off on a triumphal course which is unique in medical history. The synthesis of anticoagulants with targeted mode of action was only achieved at the end of the last century, e. g. the inhibitor of factor Xa fondaparinux or the recombinant production of the direct thrombin inhibitor hirudin, closely followed by the synthesis of the direct oral inhibitors of factor Xa and thrombin. These compounds had been clinically developed in the early 21st century and meanwhile, they have become available for several indications. Dabigatran is the only thrombin inhibitor and rivaroxaban, apixaban and edoxaban are the three factor Xa inhibitors which entered the market and have started replacing the conventional anticoagulants for treatment of venous thromboembolic complications and for prevention of stroke in patients with atrial fibrillation. They have several characteristics in common such as a reproducible bioavailability, much shorter halflives than vitamin K antagonists, low interaction with other drugs, fixed dosing regimens without the necessity for routine coagulation controls and a better risk-/benefit profile than conventional anticoagulants. However, there are differences between the various compounds with regard to metabolism, renal elimination and the various dosing regimens which definitely need to be considered when prescribed to various patient populations.
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8
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McGuire M, Dobesh PP. Therapeutic Update on the Prevention and Treatment of Venous Thromboembolism. J Pharm Pract 2016. [DOI: 10.1177/0897190004271779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Venous thromboembolism (VTE) is a common condition that increases in incidence with age and risk factors. Therapies for VTE are aimed at either preventing the disease in high-risk individuals or treating patients who have developed VTE. Assessing risk and aggressively using the recommended therapies is primacy in preventing VTE in surgical and medical patients. Risk of VTE in medical patients has become more defined in recent years, and prophylaxis in this group can prevent scores of iatrogenic VTE. Treatment of VTE has evolved in the past decade from a condition that required hospitalization for 5 to 7 days to a disease state that can be conveniently and safely treated on an outpatient basis, largely due to the advent of low-molecular-weight heparins and patient self-directed treatment.
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Affiliation(s)
- Mike McGuire
- Kos Pharmaceuticals, 125 West Third Avenue, Conshohocken, Pennsylvania 19428
| | - Paul P. Dobesh
- Division of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, Missouri, St. Luke's Hospital, Chesterfield, Missouri
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9
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Abstract
Objective: To review the published clinical data on prophylaxis for thromboembolism in order to develop general guidelines to encourage the establishment of local protocols for management. Data sources: Published papers on thromboembolism over the period 1991–1997 were identified by Medline search and/or from the authors' personal literature collections and reviewed. Study selection: A total of 981 studies were identified. Only those papers reporting randomized studies with clearly defined diagnostic methods and clear end-points were included in this review. Data extraction: The available evidence for each specialty was summarized and reviewed by the authors responsible for each specialty, prior to presentation and discussion of their findings within the group. Where a consensus opinion was achieved in a speciality, general guidelines for thromboprophylaxis were summarized. Where a consensus could not be agreed, recommendations for further work were made. Data synthesis: There is evidence to support the preferred use of low-molecular-weight heparins (LMWHs) over unfractionated heparin (UFH) in orthopaedic surgery, major trauma and general surgery. However, the ideal duration of thromboprophylaxis has yet to be defined. The use of once daily subcutaneous administration of LMWH offers major practical advantages and may have significant cost saving implications. Further work is required to investigate the use of thromboprophylaxis in minimal access surgery, trauma, elective lower limb surgery, hip fracture and pregnancy; to compare the efficacy of LMWH and mechanical prophylaxis; and to investigate extended prophylaxis after discharge. Conclusions: There is overwhelming evidence that thromboembolic prophylaxis reduces the incidence of postoperative deep vein thrombosis and pulmonary embolism. Recommendations concerning the management of these patients when stratified into low, moderate and high risk are made with the suggestion that hospitals develop their own guidelines for the treatment of these patients.
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Akl EA, Kahale L, Sperati F, Neumann I, Labedi N, Terrenato I, Barba M, Sempos EV, Muti P, Cook D, Schünemann H. Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Cochrane Database Syst Rev 2014:CD009447. [PMID: 24966161 DOI: 10.1002/14651858.cd009447.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The choice of the appropriate perioperative thromboprophylaxis in patients with cancer depends on the relative benefits and harms of low molecular weight heparin (LMWH) and unfractionated heparin (UFH). OBJECTIVES To update a systematic review of the evidence for the relative efficacy and safety of LMWH and UFH for perioperative thromboprophylaxis in patients with cancer. SEARCH METHODS We performed a comprehensive search for trials of anticoagulation in patients with cancer including a February 2013 electronic search of: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. We also handsearched conference proceedings, reviewed reference list of included studies, used the 'related citations' feature in PubMed, and searched clinicaltrials.gov for ongoing studies. SELECTION CRITERIA Randomized controlled trials (RCTs) that enrolled patients with cancer undergoing a surgical intervention and compared the effects of LMWH to UFH on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, or thrombocytopenia. DATA COLLECTION AND ANALYSIS Two review authors independently used a standardized form to extract in duplicate data on participants, interventions, outcomes of interest, and risk of bias. Where possible, we conducted meta-analyses using the random-effects model. MAIN RESULTS Of 9559 identified unique citations, we included 16 RCTs with 12,890 patients with cancer, all using preoperative prophylactic anticoagulation. We identified no new study with this update. The overall quality of evidence was moderate. The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.74 to 1.08), PE (RR 0.73; 95% CI 0.34 to 1.54), symptomatic DVT (RR 0.50; 95% CI 0.20 to 1.28), asymptomatic DVT (RR 0.81; 95% CI 0.66 to 1.01),major bleeding (RR 0.85; 95% CI 0.52 to 1.37), and minor bleeding (RR 0.92; 95% CI 0.47 to 1.79). LMWH was associated with lower incidence of wound hematoma (RR 0.68; 95% CI 0.52 to 0.88) but higher volume of intraoperative transfusion (mean difference (MD) 74 mL; 95% CI 47 to 102). The meta-analyses found no statistically significant differences for any of the following outcomes: reoperation for bleeding (RR 0.72; 95% CI 0.06 to 8.48) , intraoperative blood loss (MD= -6mL; 95% CI -87 to 74), postoperative transfusion (MD= 79mL; 95% CI -54 to 211), postoperative drain volume (MD= 27mL; 95% CI -44 to 98), and thrombocytopenia (RR 1.33; 95% CI 0.59 to 3.00). AUTHORS' CONCLUSIONS We found no difference between perioperative thromboprophylaxis with LMWH versus UFH in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in patients with cancer. Further trials are needed to evaluate the benefits and harms of different heparin thromboprophylaxis strategies in this population more thoroughly.
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Affiliation(s)
- Elie A Akl
- Department of Internal Medicine, American University of Beirut, Riad El Solh St, Beirut, Lebanon
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11
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Abstract
Low-molecular-weight heparins have several important advantages over unfractionated heparin (UFH). Due to a longer plasma half life together with high bioavailability and a linear dose-response relationship, the drugs can be safely and effectively administered in the hospital or ambulatory settings without the need to monitor the anticoagulant effect. Enoxaparin (Lovenox), Aventis Pharma) is a low-molecular-weight heparin which has been studied in a variety of clinical situations. In general surgery the efficacy of enoxaparin to prevent venous thromboembolism is similar to UFH but the tolerability is better. In patients undergoing cancer, orthopedic or vascular surgery the efficacy of enoxaparin is significantly higher with similar rates of bleeding complications. The database for enoxaparin in nonsurgical patients is smaller compared with surgical groups. There is evidence that the efficacy of enoxaparin may be superior to UFH in patients with severe cardiac disease. Efficacy and safety of UFH and enoxaparin are similar for the treatment of deep vein thrombosis. However, enoxaparin can be safely administered by the patients at home which is not possible with UFH. In patients with acute coronary syndromes, enoxaparin has been shown to reduce the rate of deaths and serious cardiac events in comparison with UFH. Furthermore, exonaparin treatment has been shown to be cost-effective, and therefore is the therapy of choice in this setting. In addition, enoxaparin has been shown to be a safe and effective alternative to the combination of UFH and phenprocoumone therapy in patients undergoing electrical cardioversion for atrial fibrillation.
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Affiliation(s)
- Thomas Hofmann
- Universitätsklinikum Hamburg-Eppendorf, Herzzentrum, Medizinische Klinik III, Martinistr. 52, 20246 Hamburg, Germany.
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12
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Choi SH, Shim JH, Park CH, Song KY. Low molecular-weight heparin for thromboprophylaxis in patients undergoing gastric cancer surgery: an experience from one Korean institute. Ann Surg Treat Res 2014; 86:22-7. [PMID: 24761403 PMCID: PMC3994607 DOI: 10.4174/astr.2014.86.1.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/13/2013] [Accepted: 10/24/2013] [Indexed: 02/02/2023] Open
Abstract
Purpose This study evaluated the efficacy for preventing venous thromboembolism (VTE) and adverse effects of low-molecular-weight heparin (LMWH) in order to launch a prospective clinical trial in Korea. Methods We reviewed the medical records of 108 consecutive patients who underwent gastric cancer surgery. These patients were divided into 2 groups according to the type of thromboprophylaxis: group A, LMWH combined with intermittent pneumatic compression (IPC); group B, IPC alone. The postoperative outcomes of the two groups were compared. Results Symptomatic VTE was observed in only 1 patient (0.9%) from group B. Postoperative bleeding was more common in group A than in group B (10.9% vs. 7.5%), although the difference was not significant (P = 0.055). Most bleeding episodes were minor and managed conservatively without intervention. Only a high body mass index was associated with a significantly increased risk of postoperative bleeding (odds ratio, 1.45; 95% confidence interval, 1.12-2.43; P = 0.051). Conclusion A 40 mg of enoxaparin sodium is a safe and feasible dose for prevention of VTE. With the results of this study, we are planning a prospective randomized clinical trial to investigate the clinical efficacy of LMWH thromboprophylaxis in gastric cancer patients in Korea.
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Affiliation(s)
- Sung Ho Choi
- Division of Gastrointestinal Surgery, Department of Surgery, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Jung Ho Shim
- Division of Gastrointestinal Surgery, Department of Surgery, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Cho Hyun Park
- Division of Gastrointestinal Surgery, Department of Surgery, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, The Catholic University of Korea School of Medicine, Seoul, Korea
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Malafaia O, Montagnini AL, Luchese A, Accetta AC, Zilberstein B, Malheiros CA, Jacob CE, Quireze-Junior C, Bresciani CJC, Kruel CDP, Cecconello I, Sad EF, Ohana JAL, Aguilar-Nascimento JED, Manso JEF, Ribas-Filho JM, Santo MA, Andreollo NA, Torres OJM, Herman P, Cuenca RM, Sallum RAA, Bernardo WM. Thromboembolism prevention in surgery of digestive cancer. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 25:216-23. [PMID: 23411918 DOI: 10.1590/s0102-67202012000400002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 11/10/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND The venous thromboembolism is a common complication after surgical treatment in general and, in particular, on the therapeutic management on cancer. Surgery of the digestive tract has been reported to induce this complication. Patients with digestive cancer have substantial increased risk of initial or recurrent thromboembolism. AIM To provide to surgeons working in digestive surgery and general surgery guidance on how to make safe thromboprophylaxis for patients requiring operations in the treatment of their gastrointestinal malignancies. METHODS The guideline was based on 15 relevant clinical issues and related to the risk factors, treatment and prognosis of the patient undergoing surgical treatment of cancer on digestive tract. They focused thromboembolic events associated with operations and thromboprophylaxis. The questions were structured using the PICO (Patient, Intervention or Indicator, Comparison and Outcome), allowing strategies to generate evidence on the main primary bases of scientific information (Medline / Pubmed, Embase, Lilacs / Scielo, Cochrane Library, PreMedline via OVID). Evidence manual search was also conducted (BDTD and IBICT). The evidence was recovered from the selected critical evaluation using discriminatory instruments (scores) according to the category of the question: risk, prognosis and therapy (JADAD Randomized Clinical Trials and New Castle Ottawa Scale for studies not randomized). After defining potential studies to support the recommendations, they were selected by the strength of evidence and grade of recommendation according to the classification of Oxford, including the available evidence of greater strength. RESULTS A total of 53,555 papers by title and / or abstract related to issue were found. Of this total were selected (1st selection) 478 studies that were evaluated as full-text. From them to support the recommendations were included in the consensus 132 papers. The 15 questions could be answered with evidence grade of articles with 31 A, 130 B, 1 C and 0 D. CONCLUSION It was possible to prepare safe recommendations as guidance for thromboembolism prophylaxis in operations on the digestive tract malignancies, addressing the most frequent topics of everyday work of digestive and general surgeons.
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Affiliation(s)
- Osvaldo Malafaia
- Colégio Brasileiro de Cirurgia Digestiva, São Paulo, SP, Brazil.
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Chandra R, Melino G, Thomas M, Lawrence MJ, Hunter RA, Moore J. Is extended thromboprophylaxis necessary in elective colorectal cancer surgery? ANZ J Surg 2013; 83:968-72. [DOI: 10.1111/ans.12244] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Raaj Chandra
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Giovanni Melino
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Michelle Thomas
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Matthew J. Lawrence
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - R. Andrew Hunter
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - James Moore
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
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Nicolaides A, Hull RD, Fareed J. General, vascular, bariatric, and plastic surgical patients. Clin Appl Thromb Hemost 2013; 19:122-33. [PMID: 23529479 DOI: 10.1177/1076029612474840c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Schellong SM, Encke A, Weber AA, Bramlage P, Paar WD, Haas S. Benefits and Risks of Preventing Thromboembolism With Enoxaparin in Patients With General Surgery in Real World—The CLEVER Study. Clin Appl Thromb Hemost 2012; 19:282-8. [DOI: 10.1177/1076029612461067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: We aimed to document enoxaparin use in real world and identify the risk factors for bleeding complications. Methods: Postauthorization study in 448 surgical patients receiving enoxaparin prophylaxis. Complete compression ultrasound (CCUS) was performed at day 10 ± 3. Results: During treatment, 11 of 448 patients had suspected deep venous thrombosis (DVT) but none confirmed. One patient had symptoms of pulmonary embolism ([PE] 0.22%; 95% confidence interval [CI] −0.21-0.66). There were no asymptomatic cases detected upon CCUS. At the 90-day follow-up, 4 (0.9%) of the 440 patients had DVT symptoms (95% CI 0.02-1.80) and none had PE; 5.4% had major and 11.6% any type of bleeding complications. Major bleeding was more frequent in those with kidney disease (odds ratio [OR] 5.53), those who are bedridden (OR 5.49), those with peridural indwelling catheters (OR 4.01), and those on nonsteroidal anti-inflammatory drugs (OR 3.33). Conclusions: Enoxaparin is effective and safe in surgical patients to prevent venous thromboembolism.
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Affiliation(s)
| | - Albrecht Encke
- Chirurgische Universitätsklinik Frankfurt/Main, Frankfurt, Germany
| | - Artur-Aaron Weber
- Universitätsklinikum Düsseldorf, Klinik für Allgemeine Pädiatrie und Neonatologie, Düsseldorf, Germany
| | - Peter Bramlage
- Institut für Pharmakologie und präventive Medizin, Mahlow, Germany
| | | | - Sylvia Haas
- Institut für Experimentelle Onkologie und Therapieforschung, Technische Universität München, Germany
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Dar TI, Wani KA, Ashraf M, Malik A, Ahmad S, Gojwari TA, Iqbal A. Low molecular weight heparin in prophylaxis of deep vein thrombosis in Asian general surgical patients: A Kashmir experience. Indian J Crit Care Med 2012; 16:71-4. [PMID: 22988360 PMCID: PMC3439781 DOI: 10.4103/0972-5229.99107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Deep vein thrombosis (DVT) occurs at a lower rate in Asia than in the rest of the world. We wanted to study the significance and efficacy of low molecular weight heparin (LMWH) in prophylaxis of DVT in major general surgical patients in the Kashmir Valley (India, Asia) so as to make it a routine in our patients. PATIENTS AND METHODS This was a prospective study in which the effect of LMWH was compared with no prophylaxis. RESULTS LMWHs are more effective than no prophylaxis in the prevention of DVT and pulmonary thromboembolism in highest-risk general surgical patients (odds ratio = 16.64; 95% confidence interval = 3.63-1130.03; P-value = 0.014). CONCLUSION LMWHs have a significant prophylactic effect on DVT in general surgical patients, with a higher benefit to risk ratio, and, in spite of the low incidence of DVT in Asia, its prophylaxis should routinely be considered in this part of the world as well, preferably in the form of LMWHs.
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Affiliation(s)
- Tanveer Iqbal Dar
- Department of General Surgery, SKIMS Soura, and SKIMS Medical College, Srinagar, J and K, India
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Bhagya Rao B, Kalayarasan R, Kate V, Ananthakrishnan N. Venous Thromboembolism in Cancer Patients Undergoing Major Abdominal Surgery: Prevention and Management. ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/783214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cancer is an important risk factor for venous thrombosis. Venous thromboembolism is one of the most common complications of cancer and the second leading cause of death in these patients. Recent research has given insight into mechanism and various risk factors in cancer patients which predispose to thromboembolism. The purpose of this review is to summarize the current knowledge on the prophylaxis, diagnosis, and management of venous thromboembolism in these patients.
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Affiliation(s)
- Bhavana Bhagya Rao
- Department of Gastroenterology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - R. Kalayarasan
- Department of Surgical Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Vikram Kate
- Department of General and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - N. Ananthakrishnan
- Department of Surgery, Mahatma Gandhi Medical College & Research Institute, Pondicherry 607402, India
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Spannagl M, Melzer N, Bramlage P, Englert C, Eisele R. Prospective, Non-interventional Study on the Real-World Use of Certoparin in Daily Practice—The PROMEMBER Study. Clin Appl Thromb Hemost 2012; 19:86-91. [DOI: 10.1177/1076029612449899] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Michael Spannagl
- LMU München, Klinikum Innenstadt, Medizinische Klinik Hämostaseologie/Angiologie, München, Germany
| | | | - Peter Bramlage
- Institut für Pharmakologie und präventive Medizin, Mahlow, Germany
| | | | - Ralf Eisele
- Stiftungsklinik Weißenhorn, Weißenhorn; Germany
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Antoniewicz AA, Zapała L, Poletajew S, Borówka A. Macroscopic hematuria-a leading urological problem in patients on anticoagulant therapy: is the common diagnostic standard still advisable? ISRN UROLOGY 2012; 2012:710734. [PMID: 22567422 PMCID: PMC3329860 DOI: 10.5402/2012/710734] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 01/18/2012] [Indexed: 12/01/2022]
Abstract
All urological standards of care are based on the past definition of the clinical importance of macroscopic hematuria. The aim of the study was to assess the phenomenon of iatrogenic hematuria in current clinical practice and analyze its origins in patients receiving anticoagulant drugs. Retrospective analysis of clinical documentation of 238 patients that were consulted for hematuria in 2007–2009 by 5 consultant urologists was performed. In the group of 238 patients with hematuria, 155 (65%) received anticoagulants. Abnormalities of urinary tract were found in 45 (19%) patients. Estimated cost of a single neoplasm detection reached the value of 3252 Euro (mean 3-day hospitalization). The strong correlation between the presence of hematuria and anticoagulant treatment was observed. Authors suggest to redefine the present and future role of hematuria from a standard manifestation of serious urological disease to a common result of a long-term anticoagulant therapy.
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Affiliation(s)
- Artur A Antoniewicz
- Department of Urology, Medical Centre of Postgraduate Education, Miedzylesie Hospital, 04-749 Warsaw, Poland
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21
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Dranitsaris G, Jelincic V, Choe Y. Meta-regression analysis to indirectly compare prophylaxis with dalteparin or enoxaparin in patients at high risk for venous thromboembolic events. Clin Appl Thromb Hemost 2012; 18:233-42. [PMID: 22387576 DOI: 10.1177/1076029611426869] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Dalteparin and enoxaparin are recommended as thromboprophylaxis for at least 10 days in patients undergoing abdominal surgery (AS) or hospitalized patients with acute medical illnesses. Even though both agents have proven clinical effectiveness through randomized trials, there have been no head-to-head studies. In this evaluation, indirect statistical techniques were used to compare safety and efficacy between dalteparin and enoxaparin in these 2 high-risk patient populations. METHODS A literature search was conducted from January 1980 to November 2010 for randomized trials evaluating dalteparin or enoxaparin prophylaxis following AS or in hospitalized patients. Binary outcomes for safety and efficacy were statistically pooled using fixed or random effects models in cases of significant heterogeneity. In trials where a common control was used (eg, unfractionated heparin [UH]), indirect statistical comparisons between dalteparin and enoxaparin were performed using meta-regression analysis with active drug as the primary independent variable. RESULTS The meta-analysis in AS patients showed that enoxaparin or dalteparin had comparable efficacy to UH in terms of venous thromboembolic events (VTEs; relative risk reduction [RR] = 0.87, P = .46). The indirect statistical comparison was unable to find significant differences between enoxaparin and dalteparin in terms of risk for VTE (P = .84), major bleeding (P = .38), heparin-induced thrombocytopenia ([HIT]; P = .084), or death (P = .97). In acutely ill medical patients, treatment with enoxaparin or dalteparin had a 52% VTE risk reduction compared to placebo (RR = 0.48, P < .001). The indirect comparison was also unable to find significant differences between enoxaparin and dalteparin in terms of VTEs (P = .15), major bleeds (P = .39), HIT (P = .48), and death (P = .41). CONCLUSIONS The findings suggest comparable safety and efficacy between dalteparin and enoxaparin in AS and in acutely ill medical patients.
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22
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Yavelov IS. Enoxaparin in cardiovascular disease: how to improve effectiveness and safety? КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2011. [DOI: 10.15829/1728-8800-2011-6-112-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The review analyses the specifics of enoxaparin therapy in the most prevalent cardiovascular diseases, such as acute coronary syndrome, venous thromboembolism, and atrial fibrillation. The decision strategy is presented for difficult and non-standard clinical situations (renal dysfunction, elderly age, heparin medication change, or abnormal body weight), when the optimal balance between effectiveness and safety requires modifying the standard treatment protocols.
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23
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Meguid C. Best Practice for Deep Vein Thrombosis Prophylaxis. J Nurse Pract 2011. [DOI: 10.1016/j.nurpra.2011.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
INTRODUCTION Both arterial and venous thromboembolism constitute a significant disease burden worldwide, leading to major use of healthcare resources. As anticoagulants play a pivotal role in the treatment of these disorders, it is vital for healthcare providers to have sufficient knowledge of their biochemical and clinical attributes. AREAS COVERED Enoxaparin is one of the most commonly used low-molecular-weight heparins in a wide variety of thromboembolic disorders and has several advantages over unfractionated heparin. An analysis of its biophysical profile, with special emphasis on pharmacokinetic and pharmacodynamic properties, is undertaken in this article. In addition, most recent major clinical studies elucidating its role in common thromboembolic conditions are discussed, while keeping the historical perspective at hand. Readers will be able to understand the pharmacologic properties of enoxaparin with their clinical relevance for day-to-day use and critically analyze the amount and weight of scientific evidence behind its use in various disorders. EXPERT OPINION In summary, enoxaparin has been shown, by a vast amount of scientific data, to be a safe and effective agent in the treatment of a whole spectrum of acute coronary syndromes, with similar efficacy and safety in the prevention and treatment of venous thromboembolism.
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Affiliation(s)
- Zafar Iqbal
- Newark Beth Israel Medical Center, Newark, NJ 07112, USA
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Abstract
Venous thromboembolic disease, which includes deep vein thromboses as well as pulmonary emboli, can be a significant complication in the postoperative patient. In particular, colorectal patients often carry a higher risk for venous thromboembolism when compared with patients undergoing other operative procedures. Features unique to colorectal patients are the high incidence of inflammatory bowel disease or malignancy. Typically, these patients will undergo lengthy pelvic procedures, which also contribute to a cumulative risk of venous thrombosis. It is critical that all patients and the proposed operative procedure are appropriately risk stratified. Risk stratification allows for easier implementation of an appropriate prophylactic strategy. There are a wide range of safe and effective mechanical and pharmacologic measures available. The authors provide very specific recommendations, but note that clinical judgment plays a significant role.
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Affiliation(s)
- Michael P McNally
- Department of Surgery, Division of Colon and Rectal Surgery, National Naval Medical Center, Bethesda, MD 20889, USA.
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Standard Prophylactic Enoxaparin Dosing Leads to Inadequate Anti-Xa Levels and Increased Deep Venous Thrombosis Rates in Critically Ill Trauma and Surgical Patients. ACTA ACUST UNITED AC 2010; 68:874-80. [DOI: 10.1097/ta.0b013e3181d32271] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jeong O, Ryu SY, Park YK, Kim YJ. The effect of low molecular weight heparin thromboprophylaxis on bleeding complications after gastric cancer surgery. Ann Surg Oncol 2010; 17:2363-9. [PMID: 20358302 DOI: 10.1245/s10434-010-1032-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Low molecular weight heparin (LMWH) has been widely used to prevent venous thromboembolism in cancer surgical patients. However, relatively few studies have examined the safety aspects related to the use of LMWH after abdominal cancer surgery. This study was designed to investigate the relationship between bleeding complications and LMWH thromboprophylaxis after gastric cancer surgery. METHODS From March to July in 2009, 179 consecutive patients who underwent gastric cancer surgery at our institution were administered LMWH (3200 U once daily from 2 to 6 h before surgery until discharge) perioperatively. A total of 182 patients consecutively treated before the introduction of LMWH prophylaxis were selected as controls. RESULTS There were 234 men and 127 women (mean age, 60 +/- 12 years). No significant intergroup differences were observed with respect to clinicopathological features and operative procedures. No patient in the LMWH or control group developed symptomatic venous thromboembolism postoperatively. However, the LMWH group had a significantly higher surgical complication rate (27.4 versus 15.4%, P = 0.005). Among the surgical complications, postoperative bleeding and wound complications were significantly higher in the LMWH group, whereas other complications were similar in the two study groups. Multivariate analysis showed that LMWH administration was an independent risk factor (odds ratio, 2.83; 95% confidence interval, 1.28-6.23, P = 0.009) of postoperative bleeding. CONCLUSIONS LMWH thromboprophylaxis was found to increase significantly the risk of bleeding complications after gastric cancer surgery. Optimal LMWH prophylaxis regimens, including the dosage and timing of treatment commencement, for gastric cancer surgery should be determined in further clinical trials.
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Affiliation(s)
- Oh Jeong
- Division of Gastrointestinal Surgery, Department of Surgery, Chonnam National University Hwasun Hospital, Jeollanam-do, Korea.
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Stein PD, Hull RD, Matta F, Yaekoub AY, Liang J. Incidence of thrombocytopenia in hospitalized patients with venous thromboembolism. Am J Med 2009; 122:919-30. [PMID: 19682670 DOI: 10.1016/j.amjmed.2009.03.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 03/16/2009] [Accepted: 03/18/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine the incidence of heparin-associated thrombocytopenia in patients receiving prophylaxis or treatment for venous thromboembolism. METHODS We assessed the database of the National Hospital Discharge Survey from 1979 through 2005 and complemented this with a meta-analysis of published literature. RESULT Among 10,554,000 patients discharged from short-stay hospitals throughout the US with venous thromboembolism during the 27 years of study, secondary thrombocytopenia was coded in 38,000 patients (0.36%). From 1979 through 1992, secondary thrombocytopenia was coded in only 0.15% of hospitalized patients with venous thromboembolism. The frequency increased sharply to 0.54% from 1993 through 2005. Secondary thrombocytopenia was rarely diagnosed among 1,446,000 patients aged <40 years and among 77,000 women who had venous thromboembolism with deliveries. Meta-analysis of published literature showed a higher incidence among patients who received unfractionated heparin (UFH) for prophylaxis than those who received low-molecular-weight heparin (LMWH) for prophylaxis. Treatment resulted in smaller differences of the incidence between UFH and LMWH. CONCLUSION Heparin-associated thrombocytopenia is rare among patients aged <40 years and women following delivery. The risk of heparin-associated thrombocytopenia is more duration-related than dose-related, and higher with UFH when used for an extended duration. Our findings and those of the literature suggest that although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of LMWH, particularly if extended prophylaxis or extended treatment is required.
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Affiliation(s)
- Paul D Stein
- Research and Advanced Studies Program, Michigan State University, College of Osteopathic Medicine, Detroit Medical Center Campus, Detroit, MI, USA.
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Thrombelastography versus AntiFactor Xa levels in the assessment of prophylactic-dose enoxaparin in critically ill patients. ACTA ACUST UNITED AC 2009; 66:1509-15; discussion 1515-7. [PMID: 19509608 DOI: 10.1097/ta.0b013e3181a51e33] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A standard dose of enoxaparin is frequently used for deep venous thrombosis (DVT) prophylaxis. Evidence suggests inconsistent bioavailability in intensive care unit (ICU) patients. Antifactor Xa activity (anti-Xa) has been used to monitor enoxaparin dosing but its accuracy and availability are problematic. Thrombelastography (TEG) is used to evaluate coagulation in diverse settings. The purpose of this study was to analyze whether TEG could be used to predict which enoxaparin-treated patients would develop DVT. METHODS Two hundred sixty-one simultaneous enoxaparin-active (active) and enoxaparin-neutralized (neutral) TEGs were performed in 61 surgical ICU patients over four consecutive days. Patient characteristics and anti-Xa were collected. DVT screening was per ICU protocol. RESULTS Mean (+/-SEM) age was 54 (+/-2.3) years and Acute Physiology and Chronic Health Evaluation II score was 17 (+/-0.7). There were 30 trauma and 31 general surgery patients (69% men). The DVT rate was 28%. Time to clot formation (R) and percent lysis at 30 minutes were different between active versus neutralized blood (p < 0.001). R time was 1.5 minutes shorter in patients with DVT versus those without (p < 0.001) indicating hypercoagulability in DVT patients. Anti-Xa levels were similar in patients with (0.135 +/- 0.012) and without (0.135 +/- 0.007) DVT (p = 0.97). There were no differences in age, body mass index, injury severity score, Acute Physiology and Chronic Health Evaluation II score, or trauma status between DVT and non-DVT groups. CONCLUSIONS TEG demonstrates differences between enoxaparin-neutralized and enoxaparin-active blood in ICU patients that may be used to guide dosing. TEG differentiates enoxaparin-treated patients who subsequently develop DVT while anti-Xa levels do not. TEG demonstrates an enoxaparin-related increase in fibrinolysis.
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Spyropoulos AC. The Prevention of Venous Thromboembolism After Surgery for Cancer. Cancer Invest 2009. [DOI: 10.1080/07357900802656541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Safety and efficacy of lower-dose unfractionated heparin for prophylaxis of deep vein thrombosis and pulmonary embolism in an Asian population. Blood Coagul Fibrinolysis 2008; 19:585-9. [PMID: 18685443 DOI: 10.1097/mbc.0b013e32830708ad] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study is to analyze the tolerance and efficacy of the subcutaneous administration of a reduced 2,500-unit low-dose unfractionated heparin given for an efficacious, yet Asian population-sensitive, prophylaxis for deep vein thrombosis and fatal pulmonary embolism. Eighty-seven Japanese patients were operated on either for abdominal or pelvic complications or both, as well as for gynecologic conditions including ovarian, cervical, and corpus cancers. Thirty-two of the patients were administered the experimental low dose of unfractionated calcium heparin for prophylaxis. The 2,500 units of low-dose unfractionated heparin were given subcutaneously 2 h preoperatively and again 12 h postoperatively. Other standard methods of mechanical prophylaxis, including graduated compression stockings and intermittent pneumatic compression, were performed. Fifty-five of the patients were not administered heparin, but did receive the same standard mechanical graduated compression stockings and intermittent pneumatic compression prophylaxis. We compared the surgical and postsurgical complications noted for low-dose unfractionated heparin patients with the results of those who received no heparin prophylaxis and analyzed this data using the Mann-Whitney U-test. There was no significant difference in the mean of the blood loss volumes. There were also no significant differences found in the perioperative bleeding complications between the two groups. However, three (3/55; 6%) of the patients in the no-heparin group suffered a symptomatic pulmonary embolism, although none were fatal. There were no pulmonary embolism onsets in the heparin prophylaxis group. We feel that we have provided evidence that several serious complications, such as perisurgical hemorrhage, deep vein thrombosis, fatal pulmonary embolism, and increased postoperative recovery times, can be prevented by prophylaxis with 2,500-unit low-dose unfractionated heparin.
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Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of Venous Thromboembolism. Chest 2008; 133:381S-453S. [PMID: 18574271 DOI: 10.1378/chest.08-0656] [Citation(s) in RCA: 2862] [Impact Index Per Article: 178.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- William H Geerts
- From Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Graham F Pineo
- Foothills Hospital, University of Calgary, Calgary, AB, Canada
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Hardy RG, Williams L, Dixon JM. Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin. Br J Surg 2008; 95:834-6. [DOI: 10.1002/bjs.6203] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Low molecular weight heparin (LMWH) is used in preference to unfractionated heparin (UFH) for the prevention of postoperative thromboembolism in many UK surgical units. There are, however, conflicting reports on the relative risk of significant bleeding in surgical patients, and no data exist in the literature for patients undergoing breast surgery.
Methods
Data for patients in the Edinburgh Breast Unit with postoperative breast haematoma that needed surgical intervention were analysed for two 12-month intervals in which either UFH (2001) or LMWH (2005–2006) was used for thromboprophylaxis. Haematoma rates in the 6 months after UFH was reintroduced in 2006–2007 were also determined.
Results
The rate of haematoma requiring surgical intervention was 0·4 per cent (six of 1452 wounds) in patients who had UFH, compared with 1·8 per cent (32 of 1780 wounds) for LMWH. The rate fell to 0·5 per cent (four of 773 wounds) on reinstituting UFH. The relative risk of haematoma was significantly higher with LMWH than with UFH (4·00 (95 per cent confidence interval 1·97 to 8·11); P < 0·001). No significant postoperative thromboembolic complications were recorded.
Conclusion
LMWH thromboprophylaxis was associated with a significant increase in haemorrhagic complications after breast surgery compared with UFH.
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Affiliation(s)
- R G Hardy
- Edinburgh Breast Unit, Western General Hospital, Edinburgh, UK
| | - L Williams
- Public Health Sciences, University of Edinburgh, Medical School, Edinburgh, UK
| | - J M Dixon
- Edinburgh Breast Unit, Western General Hospital, Edinburgh, UK
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Prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Surg Obes Relat Dis 2008; 3:494-5. [PMID: 17903767 DOI: 10.1016/j.soard.2007.06.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2007] [Accepted: 06/26/2007] [Indexed: 11/19/2022]
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Venous Disease and Pulmonary Embolism. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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36
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Richardson WS, Apelgren K, Fanelli RD, Earle D. Deep venous thrombosis prophylaxis in laparoscopy: An evidence-based review. Surg Endosc 2007; 21:2335-8. [DOI: 10.1007/s00464-007-9544-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Accepted: 07/09/2007] [Indexed: 10/22/2022]
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Richardson W, Apelgren K, Earle D, Fanelli R. Guidelines for deep venous thrombosis prophlaxis during laparoscopic surgery. Surg Endosc 2007; 21:2331-4. [PMID: 17712591 DOI: 10.1007/s00464-007-9543-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Accepted: 07/09/2007] [Indexed: 11/29/2022]
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Roche-Nagle G, Curran J, Bouchier-Hayes DJ, Tierney S. Risk-based evaluation of thromboprophylaxis among surgical inpatients: are low risk patients treated unnecessarily? Ir J Med Sci 2007; 176:169-73. [PMID: 17554579 DOI: 10.1007/s11845-007-0049-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 05/15/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Venous thromboembolism is a common source of morbidity and mortality but a variety of preventative measures are available. AIMS To audit the current practice of thromboprophylaxis and compare against published protocols. METHODS Three-hundred and seventy-six (376) surgical patients were surveyed prospectively. A Performa was completed recording the presence of up to 11 risk factors. A risk score was calculated and the use of specific thromboprophylatic measures identified. RESULTS Heparin thromboprophylaxis was widely used, eight patients (who were on aspirin therapy) failed to receive any prophylaxis (risk factors 4-6). In addition there were 60 patients at low risk (risk score <2) received LMWH from which they were unlikely to benefit. CONCLUSIONS Thromboembolic prophylaxis is widely but unselectively applied. Adoption of a risk: benefit ratio approach should ensure those who would benefit from thromboprophylaxis are adequately treated while those in whom thromboprophylaxis is not indicated are spared unnecessary therapy.
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Affiliation(s)
- G Roche-Nagle
- Department of Surgery, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin 9, Ireland.
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39
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Guidelines for deep venous thrombosis prophylaxis during laparoscopic surgery. Surg Endosc 2007; 21:1007-9. [PMID: 17410400 DOI: 10.1007/s00464-007-9340-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 02/08/2007] [Indexed: 10/23/2022]
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40
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Agnelli G, Caprini JA. The prophylaxis of venous thrombosis in patients with cancer undergoing major abdominal surgery: emerging options. J Surg Oncol 2007; 96:265-72. [PMID: 17474075 DOI: 10.1002/jso.20808] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cancer is a risk factor for venous thromboembolism (VTE). This risk is amplified by treatment with chemotherapy, radiation, or surgery. Thus, patients with cancer undergoing major surgery should receive appropriate prophylaxis. Available agents include low-dose unfractionated heparin (LDUH), low-molecular-weight heparin (LMWH), and Factor Xa inhibitors. Recent data suggest that Factor Xa inhibitors are safe and effective for VTE prevention in patients with cancer undergoing abdominal surgery. Further study in this patient population is warranted.
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Affiliation(s)
- Giancarlo Agnelli
- Stroke Unit and Cardiovascular Medicine, University of Perugia, Perugia, Italy.
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41
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Leonardi MJ, McGory ML, Ko CY. A systematic review of deep venous thrombosis prophylaxis in cancer patients: implications for improving quality. Ann Surg Oncol 2006; 14:929-36. [PMID: 17103259 DOI: 10.1245/s10434-006-9183-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 06/09/2006] [Accepted: 06/14/2006] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Deep venous thrombosis (DVT) prophylaxis is particularly important for surgical oncologists given the high rate of DVT in patients with malignancy. Additionally, DVT prophylaxis may soon be implemented by some payers as a "pay for performance" quality measure. This is a systematic review of randomized controlled trial (RCT) evidence for DVT prophylaxis in cancer patients undergoing surgery. We examine overall rates of DVT, the efficacy of high versus low-dose heparin prophylaxis, and the rate of bleeding complications. METHODS The Medline database was searched for English language RCTs using key words DVT, venous thromboembolism, prophylaxis, and general surgery. Inclusion criteria were RCTs evaluating surgical oncology patients. RESULTS Fifty-five RCTs studied DVT prophylaxis in surgery (nonorthopedic) patients. Twenty-six RCTs evaluated 7,639 cancer patients. The overall DVT rate was 12.7% for pharmacologic prophylaxis and 35.2% for controls. High-dose low-molecular weight heparin (LMWH) was more effective than low dose, lowering the DVT rate from 14.5% to 7.9% (P < 0.01). Heparin decreased the rate of proximal DVTs. Bleeding complications requiring discontinuation of prophylaxis occurred in 3% of the patients. There was no difference between LMWH and unfractionated heparin in efficacy, DVT location, or bleeding complications. CONCLUSION Using RCT data, this study demonstrates a greatly reduced DVT rate with pharmacologic prophylaxis in cancer patients, and higher doses appear more effective. Complication rates are low and should not prevent the use of prophylaxis in most patients. Finally, we found no difference between LMWH and unfractionated heparin in these RCTs. These results highlight the importance of routine pharmacologic prophylaxis in surgical patients with malignancy.
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Affiliation(s)
- Michael J Leonardi
- UCLA Department of Surgery, David Geffen School of Medicine at University of California, 10833 Le Conte Avenue, 72-215 CHS, Box 956904, Los Angeles, CA 90095-6904, USA.
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Simonneau G, Laporte S, Mismetti P, Derlon A, Samii K, Samama CM, Bergman JF. A randomized study comparing the efficacy and safety of nadroparin 2850 IU (0.3 mL) vs. enoxaparin 4000 IU (40 mg) in the prevention of venous thromboembolism after colorectal surgery for cancer. J Thromb Haemost 2006; 4:1693-700. [PMID: 16796710 DOI: 10.1111/j.1538-7836.2006.02083.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The optimal thromboprophylactic dosage regimen of low-molecular-weight heparins in high-risk general surgery remains debatable. OBJECTIVES We performed a randomized, double-blind study to compare the efficacy and safety of nadroparin 2850 IU (0.3 mL) and enoxaparin 4000 IU (40 mg) in the prevention of venous thromboembolism (VTE) after colorectal surgery for cancer. PATIENTS AND METHODS Patients undergoing resection of colorectal adenocarcinoma were randomized to receive once daily either 2850 IU nadroparin or 4000 IU enoxaparin s.c. for 9 +/- 2 days. The primary efficacy outcome was the composite of deep vein thrombosis (DVT) detected by bilateral venography or documented symptomatic DVT or pulmonary embolism up to day 12. The main safety outcome was major bleeding. A blinded independent committee adjudicated all outcomes. RESULTS Out of 1288 patients analyzed, efficacy was evaluable in 950 (73.8%) patients. The VTE rate was 15.9% (74/464) in nadroparin-treated patients and 12.6% (61/486) in enoxaparin-treated patients, a relative risk of 1.27 (95% confidence interval; CI: 0.93-1.74) that did not met the criterion for non-inferiority of nadroparin. The rate of proximal DVT was comparable in the two groups (3.2% vs. 2.9%, respectively), but that of symptomatic VTE was lower in nadroparin-treated patients (0.2% vs. 1.4%). There was significantly (P = 0.012) less major bleeding in nadroparin- than in enoxaparin-treated patients (7.3% vs. 11.5%, respectively). CONCLUSION Compared with those receiving enoxaparin 4000 IU, patients treated with nadroparin 2850 IU showed a higher incidence of asymptomatic distal DVT, but a lower incidence of symptomatic VTE. Nadroparin treatment was safer in terms of bleeding risk.
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Affiliation(s)
- G Simonneau
- Department of Pulmonary and Critical Medicine, Antoine Beclere University Hospital, Clamart, France.
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Negus JJ, Gardner JJ, Tann O, Lewis S, Cohen AT. Thromboprophylaxis in major abdominal surgery for cancer. Eur J Surg Oncol 2006; 32:911-6. [PMID: 16626920 DOI: 10.1016/j.ejso.2006.03.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 03/10/2006] [Indexed: 11/20/2022] Open
Abstract
AIMS To review the epidemiology and pathogenesis of venous thromboembolism (VTE) in surgical cancer patients, in addition to the use of thromboprophylaxis in major abdominal surgery, such as low-molecular-weight heparin (LMWH) and fondaparinux. METHODS Systematic review of the literature, focussing on risk factors for VTE, parenteral methods of thromboprophylaxis, approaches to prolonged prophylaxis, and effects on patient survival. FINDINGS Patients with cancer undergoing abdominal surgery are at substantially higher risk for VTE than patients without cancer. Furthermore, prolonged thromboprophylaxis for up to 4 weeks is more effective than short-term administration in these high-risk patients. The concurrent use of graduated compression stockings has a synergistic effect on the reduction in VTE risk. CONCLUSIONS Thromboprophylaxis with LMWH has been shown to minimise the incidence of thromboembolic events, and is a well-established therapy worldwide. The American College of Chest Physicians recommends the routine use of thromboprophylaxis, with LMWH or unfractionated heparin, in patients with cancer who are undergoing surgical procedures, and the appropriate use of these thromboprophylactic agents has significant implications for the clinical care and quality of life of surgical patients with cancer.
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Affiliation(s)
- J J Negus
- Vascular Diseases Research Group, Guy's, King's and St Thomas' School of Medicine, London SE5 9PJ, UK
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Abstract
The risk of cancer-associated thrombosis can be substantial, depending on tumor type, extent of cancer, and type of treatment. Unfractionated heparin and warfarin have been used in the prevention of cancer-associated thrombosis, but low-molecular-weight heparin (LMWH) is widely used for the prevention of venous thromboembolism in high-risk patients. Long-term management with warfarin is associated with close monitoring, an increased risk of drug interactions, and bleeding. LMWHs may offer an alternative outpatient treatment strategy for prophylactic treatment because of their simpler dosing, more predictable anticoagulant activity, and improved safety profile. Clinical trials examining the treatment of venous thromboembolism with LMWH in patients with cancer suggest a survival advantage for the treated groups. Subtle differences in the pharmacokinetics of available LMWHs exist, and each LMWH should be regarded as a distinct drug. Pharmacists should be aware of the US Food and Drug Administration-approved uses for each LMWH, dosing options, and the advantages and disadvantages of available delivery systems for various patient populations. Pharmacists can play a major role in educating patients and other health care professionals on risk factor recognition, patient risk stratification, and proper agent selection for prevention and treatment of cancer-associated thrombosis.
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Affiliation(s)
- Jane Pruemer
- Department of Clinical Pharmacy Practice, University of Cincinnati College of Pharmacy, Cincinnati, OH 45267, USA.
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Lederle FA, Sacks JM, Fiore L, Landefeld CS, Steinberg N, Peters RW, Eid AA, Sebastian J, Stasek JE, Fye CL. The prophylaxis of medical patients for thromboembolism pilot study. Am J Med 2006; 119:54-9. [PMID: 16431185 DOI: 10.1016/j.amjmed.2005.03.049] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Revised: 03/17/2005] [Accepted: 03/17/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE We assessed the feasibility of a large randomized trial intended to determine whether low-dose heparin prophylaxis given throughout hospitalization reduces mortality and morbidity in general medical patients. SUBJECTS AND METHODS Hospitalized general medical patients aged more than 60 years at 5 Department of Veterans Affairs (VA) medical centers were randomized to receive enoxaparin 40 mg or identical placebo, given daily by subcutaneous injection until hospital discharge. Outcomes included total mortality at 90 days (the primary outcome) and 1 year, and occurrence in the VA hospital within 90 days of symptomatic deep venous thrombosis, pulmonary embolism, and major bleeding. RESULTS Only 7.6% of hospitalized patients aged more than 60 years were eligible for the study, although a chart review had predicted 25%. The principal exclusions were prior indication for anticoagulation, anticipated need for anticoagulation, contraindication to heparin, expected hospitalization less than 3 days, and "supportive/palliative care only" status. We randomized 140 patients into each group, 28% of target recruitment. The groups were well matched by age and comorbidities. Death occurred in 13 patients receiving enoxaparin and 14 patients receiving placebo at 90 days (relative risk 0.93, 95% confidence interval 0.26-1.59), and in 36 and 32 patients, respectively, at 1 year (relative risk 1.13, 95% confidence interval 0.66-1.60). Clinical thromboembolic events occurred in 5 patients receiving enoxaparin and 8 patients receiving placebo, and major bleeding occurred in 2 and 5 patients, respectively. CONCLUSIONS The pilot study indicated that the full study was not feasible. The decision to use prophylaxis pertains to only a small proportion of general medical patients hospitalized at VA medical centers, and this proportion is overestimated by chart review. The effect of low-dose heparin prophylaxis on clinical outcomes in hospitalized general medical patients remains uncertain.
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Affiliation(s)
- Frank A Lederle
- Department of Medicine, Minneapolis Center for Epidemiological and Clinical Research, Veterans Affairs Medical Center, Minneapolis, Minn 55417, USA.
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Koch A, Bouges S, Ziegler S, Dinkel H, Daures JP, Victor N. Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention: Update of previous meta-analyses. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02802.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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48
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Efficacy and safety of enoxaparin versus
unfractionated heparin for prevention of deep vein thrombosis in elective cancer surgery: A double-blind randomized multicentre trial with venographic assessment. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.d01-3882.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005; 106:2710-5. [PMID: 15985543 DOI: 10.1182/blood-2005-04-1546] [Citation(s) in RCA: 516] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an uncommon but potentially devastating complication of anticoagulation with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Our objective was to determine and compare the incidences of HIT in surgical and medical patients receiving thromboprophylaxis with either UFH or LMWH. All relevant studies identified in the MEDLINE database (1984-2004), not limited by language, and from reference lists of key articles were evaluated. Randomized and nonrandomized controlled trials comparing prophylaxis with UFH and LMWH and measuring HIT or thrombocytopenia as outcomes were included. Two reviewers independently extracted data on thromboprophylaxis (type, dose, frequency, and duration), definition of thrombocytopenia, HIT assay, and rates of the following outcomes: HIT, thrombocytopenia, and thromboembolic events. HIT was defined as a decrease in platelets to less than 50% or to less than 100 x 10(9)/L and positive laboratory HIT assay. Fifteen studies (7287 patients) were eligible: 2 randomized controlled trials (RCTs) measuring HIT (1014 patients), 3 prospective studies (1464 patients) with nonrandomized comparison groups in which HIT was appropriately measured in both groups, and 10 RCTs (4809 patients) measuring thrombocytopenia but not HIT. Three analyses were performed using a random effects model and favored the use of LMWH: (1) RCTs measuring HIT showed an odds ratio (OR) of 0.10 (95% confidence interval [CI], 0.01-0.2; P = .03); (2) prospective studies measuring HIT showed an OR of 0.10 (95% CI, 0.03-0.33; P < .001); (3) all 15 studies measured thrombocytopenia. The OR was 0.47 (95% CI, 0.22-1.02; P = .06). The inverse variance-weighted average that determined the absolute risk for HIT with LMWH was 0.2%, and with UFH the risk was 2.6%. Most studies were of patients after orthopedic surgery.
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Affiliation(s)
- Nadine Martel
- Ottawa Health Research Institute, Ottawa Hospital Civic Campus, Ste F649, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
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50
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Chi L, Rogers KL, Uprichard AC, Gallagher KP. The therapeutic potential of novel anticoagulants. Expert Opin Investig Drugs 2005; 6:1591-605. [PMID: 15989566 DOI: 10.1517/13543784.6.11.1591] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Conventional anticoagulant therapy has been based on indirect inhibition of coagulation factors with heparin and warfarin. These agents display liabilities prompting the development of new anticoagulants over the last two decades. The first to be developed was a series of low molecular weight heparins(LMWHs). Their favourable pharmacokinetic profiles and risk/benefit ratios led to widespread use in Europe and, more recently, approval for their use in the USA. Paralleling the development of LMWHs has been the pursuit of a different strategy focused on direct rather than indirect inhibition of enzymes in the coagulation cascade. In contrast to heparin, LMWHs, or other glycosaminoglycans, direct inhibitors exert their effects independent of either antithrombin III (ATIII) or heparin cofactor II (HCII) and more effectively inhibit clot-bound thrombin or FXa. Highly potent, selective (versus other serine proteases)direct thrombin and FXa inhibitors have been identified and isolated from natural sources, such as leeches, ticks and hookworms. The recombinant forms and analogues of the senatural proteins have been produced using molecular biology techniques, i.e., rHirudin, Hirulogs, recombinant tick anticoagulant peptide (rTAP), recombinant antistasin (rATS) and recombinant nematode anticoagulant peptide-5 (rNAP-5). The design of novel structures or the modification of existing chemicals has led to the synthesis of many non-peptide, low molecular weight inhibitors of thrombin and FXa. Some of them are orally active and may be suitable for long-term clinical use. In addition, considerable progress has been made in developing specific TF/VIIa complex inhibitors. The anticoagulation properties of the new agents are being characterised in experimental studies. Some of them have been advanced to large scale clinical trials and their effectiveness, and sometimes relative ineffectiveness,in arterial and venous thromboembolic disorders has been demonstrated. They are being tested for their potential as new antithrombotic agents that act via direct enzyme inhibition. Thus,the clinician should in future be able to target different thrombotic conditions with proven, specific anticoagulant interventions.
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Affiliation(s)
- L Chi
- Vascular and Cardiac Diseases and Drug Development, Parke-Davis Pharmaceutical Research Division, Warner-Lambert Company, 2800 Plymouth Road, Ann Arbor, Michigan 48105, USA
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