1
|
Chen YT, Liu CH, Pan WY, Jheng PR, Hsieh YSY, Burnouf T, Fan YJ, Chiang CC, Chen TY, Chuang EY. Biomimetic Platelet Nanomotors for Site-Specific Thrombolysis and Ischemic Injury Alleviation. ACS APPLIED MATERIALS & INTERFACES 2023. [PMID: 37384742 DOI: 10.1021/acsami.3c06378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Due to the mortality associated with thrombosis and its high recurrence rate, there is a need to investigate antithrombotic approaches. Noninvasive site-specific thrombolysis is a current approach being used; however, its usage is characterized by the following limitations: low targeting efficiency, poor ability to penetrate clots, rapid half-life, lack of vascular restoration mechanisms, and risk of thrombus recurrence that is comparable to that of traditional pharmacological thrombolysis agents. Therefore, it is vital to develop an alternative technique that can overcome the aforementioned limitations. To this end, a cotton-ball-shaped platelet (PLT)-mimetic self-assembly framework engineered with a phototherapeutic poly(3,4-ethylenedioxythiophene) (PEDOT) platform has been developed. This platform is capable of delivering a synthetic peptide derived from hirudin P6 (P6) to thrombus lesions, forming P6@PEDOT@PLT nanomotors for noninvasive site-specific thrombolysis, effective anticoagulation, and vascular restoration. Regulated by P-selectin mediation, the P6@PEDOT@PLT nanomotors target the thrombus site and subsequently rupture under near-infrared (NIR) irradiation, achieving desirable sequential drug delivery. Furthermore, the movement ability of the P6@PEDOT@PLT nanomotors under NIR irradiation enables effective penetration deep into thrombus lesions, enhancing bioavailability. Biodistribution analyses have shown that the administered P6@PEDOT@PLT nanomotors exhibit extended circulation time and metabolic capabilities. In addition, the photothermal therapy/photoelectric therapy combination can significantly augment the effectiveness (ca. 72%) of thrombolysis. Consequently, the precisely delivered drug and the resultant phototherapeutic-driven heat-shock protein, immunomodulatory, anti-inflammatory, and inhibitory plasminogen activator inhibitor-1 (PAI-1) activities can restore vessels and effectively prevent rethrombosis. The described biomimetic P6@PEDOT@PLT nanomotors represent a promising option for improving the efficacy of antithrombotic therapy in thrombus-related illnesses.
Collapse
Affiliation(s)
- Yan-Ting Chen
- Graduate Institute of Nanomedicine and Medical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Chia-Hung Liu
- Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-Hsing Street, Taipei 11031, Taiwan
- TMU Research Center of Urology and Kidney, Taipei Medical University, No. 250, Wu-Hsing Street, Taipei 11031, Taiwan
- Department of Urology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City 23559, Taiwan
| | - Wen-Yu Pan
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
- Ph.D. Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
| | - Pei-Ru Jheng
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Yves S Y Hsieh
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
- Division of Glycoscience, Department of Chemistry, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, AlbaNova University Centre, Stockholm SE106 91, Sweden
| | - Thierry Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Yu-Jui Fan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Chia-Che Chiang
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Tzu-Yin Chen
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
| | - Er-Yuan Chuang
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
- Cell Physiology and Molecular Image Research Center, Taipei Medical University-Wan Fang Hospital, Taipei 11696, Taiwan
| |
Collapse
|
2
|
Fiorda Diaz J, Echeverria-Villalobos M, Esparza Gutierrez A, Dada O, Stoicea N, Ackermann W, Abdel-Rasoul M, Heard J, Uribe A, Bergese SD. Sugammadex versus neostigmine for neuromuscular blockade reversal in outpatient surgeries: A randomized controlled trial to evaluate efficacy and associated healthcare cost in an academic center. Front Med (Lausanne) 2022; 9:1072711. [PMID: 36569123 PMCID: PMC9772266 DOI: 10.3389/fmed.2022.1072711] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Neuromuscular blockade is an essential component of the general anesthesia as it allows for a better airway management and optimal surgical conditions. Despite significant reductions in extubation and OR readiness-for-discharge times have been associated with the use of sugammadex, the cost-effectiveness of this drug remains controversial. We aimed to compare the time to reach a train-of-four (TOF) response of ≥0.9 and operating room readiness for discharge in patients who received sugammadex for moderate neuromuscular blockade reversal when compared to neostigmine during outpatient surgeries under general anesthesia. Potential reduction in time for OR discharge readiness as a result of sugammadex use may compensate for the existing cost-gap between sugammadex and neostigmine. Methods We conducted a single-center, randomized, double arm, open-label, prospective clinical trial involving adult patients undergoing outpatient surgeries under general anesthesia. Eligible subjects were randomized (1:1 ratio) into two groups to receive either sugammadex (Groups S), or neostigmine/glycopyrrolate (Group N) at the time of neuromuscular blockade reversal. The primary outcome was the time to reverse moderate rocuronium-induced neuromuscular blockade (TOF ratio ≥0.9) in both groups. In addition, post-anesthesia care unit (PACU)/hospital length of stay (LOS) and perioperative costs were compared among groups as secondary outcomes. Results Thirty-seven subjects were included in our statistical analysis (Group S= 18 subjects and Group N= 19 subjects). The median time to reach a TOF ratio ≥0.9 was significantly reduced in Group S when compared to Group N (180 versus 540 seconds; p = 0.0052). PACU and hospital LOS were comparable among groups. Postoperative nausea and vomiting was the main adverse effect reported in Group S (22.2% versus 5.3% in Group N; p = 0.18), while urinary retention (10.5%) and shortness of breath (5.3%) were only experienced by some patients in Group N. Moreover, no statistical differences were found between groups regarding OR/anesthesia, PACU, and total admission costs. Discussion Sugammadex use was associated with a significantly faster moderate neuromuscular blockade reversal. We found no evidence of increased perioperative costs associated with the use of sugammadex in patients undergoing outpatient surgeries in our academic institution. Clinical trial registration [https://clinicaltrials.gov/] identifier number [NCT03579589].
Collapse
Affiliation(s)
- Juan Fiorda Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States,*Correspondence: Juan Fiorda Diaz,
| | | | - Alan Esparza Gutierrez
- College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Olufunke Dada
- Department of Anesthesiology, University of Toledo, Toledo, OH, United States
| | - Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Wiebke Ackermann
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Mahmoud Abdel-Rasoul
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jarrett Heard
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alberto Uribe
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Sergio D. Bergese
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, United States
| |
Collapse
|
3
|
Salvi A, Nitti C, Fabbri A, Groff P, Ruggiero EG, Agnelli G. Diagnosis and Treatment of Deep Vein Thrombosis in the Emergency Department: Results of an Italian Nominal Group Technique Study. Clin Appl Thromb Hemost 2021; 26:1076029620959720. [PMID: 33112649 PMCID: PMC7791439 DOI: 10.1177/1076029620959720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Early diagnosis and treatment of deep vein thrombosis (DVT) is a main issue in
the Emergency setting. With the aim of assisting clinicians in the diagnosis and
the subsequent management of DVT in the Emergency Departments, a Nominal Group
Technique (NGT) study was conducted. A panel of 5 Italian experts developed 21
consensus statements based on available evidence and their clinical experience.
The agreed consensus statements may assist clinicians in applying the results of
clinical studies and clinical experience to routine care settings, providing
guidance on all aspects of the risk assessment, prophylaxis, early diagnosis and
appropriate treatment of DVT in the EDs.
Collapse
Affiliation(s)
- Aldo Salvi
- Emergency Department, 18494"Ospedali Riuniti Ancona", Ancona, Italy
| | - Cinzia Nitti
- Emergency Department, 18494"Ospedali Riuniti Ancona", Ancona, Italy
| | - Andrea Fabbri
- Emergency Department, "Presidio ospedaliero Morgagni-Pierantoni", Forlì, Italy
| | - Paolo Groff
- Emergency Department, 18633"Azienda ospedaliera di Perugia", Perugia, Italy
| | | | - Giancarlo Agnelli
- Internal and Vascular Medicine-Stroke Unit, 9309University of Perugia, Perugia, Italy
| |
Collapse
|
4
|
Stubblefield WB, Kline JA. Outpatient treatment of emergency department patients diagnosed with venous thromboembolism. Postgrad Med 2021; 133:11-19. [PMID: 33840338 DOI: 10.1080/00325481.2021.1916299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious, patient-centered, and cost-effective care. From a patient perspective, outpatient treatment of VTE can been simplified by the use of direct oral anticoagulant (DOACs) medications, and is supported by clinical trial evidence, and clinical practice guidelines from international societies. Outpatient treatment of patients with DVT has been more widely accepted as a best practice, while adoption of outpatient treatment of low-risk patients with acute PE has lagged. Many acute care clinicians remain wary of discharging patients with PE, concerned about drug access, adherence, and follow-up. Patients with VTE should be risk stratified identically as emerging evidence has demonstrated efficacy and safety in the interdependence of acute care protocols for the outpatient treatment of low-risk DVT and PE. Clinicians who practice in the acute care setting should be comfortable with risk stratification, anticoagulation, and discharge of low-risk VTE.
Collapse
Affiliation(s)
- William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center Nashville United States
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, USA
| |
Collapse
|
5
|
Zhang X, Huang J, Peng Z, Lu X, Yang X, Ye K. Comparing Safety and Efficacy of Rivaroxaban with Warfarin for Patients after Successful Stent Placement for Chronic Iliofemoral Occlusion: A Retrospective Single Institution Study. Eur J Vasc Endovasc Surg 2020; 61:484-489. [PMID: 33388238 DOI: 10.1016/j.ejvs.2020.11.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 11/05/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim was to compare the safety and effectiveness of rivaroxaban and warfarin as anticoagulants for treating patients with post-thrombotic syndrome (PTS) with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting. METHODS This single institution retrospective study analysed patients with PTS with chronic iliofemoral venous occlusion who were prescribed rivaroxaban or warfarin for one year after successfully undergoing iliofemoral venous stenting. The primary safety and efficacy endpoints were bleeding complication rate and primary patency rate at one year. Secondary outcomes included Villalta score, symptom recurrence rate, ulcer healing rate, and clinically driven target lesion revascularisation (CD-TLR) rate during follow up. RESULTS From January 2016 to December 2017, 154 legs from 154 patients were included in this study (69 in rivaroxaban group and 85 in warfarin group). The groups were well matched for patient demographics, clinical characteristics, and procedural details. There was no significant difference between the rivaroxaban group and warfarin group in bleeding complication rate (10% vs. 16%, p = .23, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.25 - 1.37) at one year, as well as major bleeding complication rate (0% vs. 2%, p = .20, HR 0.16, 95% CI 0.01 - 2.61) and minor bleeding complication rate (10% vs. 14%, p = .40, HR 0.67, 95% CI 0.27 - 1.66). The primary patency rate was higher in the rivaroxaban group at one year (84% vs. 71%, p = .049, HR 0.50, 95% CI 0.26 - 0.96) and at two years (79% vs. 63%, p = .037, HR 0.52, 95% CI 0.29 - 0.93). At a mean follow up of 24 months (range 1 - 42 months), the rivaroxaban group had a significantly lower post-operative Villalta score (4.87 ± 3.51 vs. 6.88 ± 5.85, p = .010, t = 2.64, 95% CI 0.50 - 3.52), lower rate of symptom recurrence (4% vs. 32%, p < .001), lower CD-TLR rates (3% vs. 13%, p = .039), and higher ulcer healing rate (90% vs. 59%, p = .004) than the warfarin group. CONCLUSION For PTS patients with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting, rivaroxaban probably exhibited similar safety but superior efficacy to warfarin. However, further prospective control studies with large sample size are necessary to confirm the results.
Collapse
Affiliation(s)
- Xing Zhang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Jiaqi Huang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Zhiyou Peng
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Xinrui Yang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China.
| |
Collapse
|
6
|
Kline J, Adler D, Alanis N, Bledsoe J, Courtney D, D'Etienne J, B Diercks D, Garrett J, Jones AE, MacKenzie D, Madsen T, Matuskowitz A, Mumma B, Nordenholz K, Pagenhardt J, Runyon M, Stubblefield W, Willoughby C. Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department. BMJ Open 2020; 10:e038078. [PMID: 33004396 PMCID: PMC7534683 DOI: 10.1136/bmjopen-2020-038078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION In the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED. METHODS AND ANALYSIS This protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016-2017. ETHICS AND DISSEMINATION All sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.
Collapse
Affiliation(s)
- Jeffrey Kline
- Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David Adler
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Naomi Alanis
- Emergency Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Joseph Bledsoe
- Emergency Medicine, Intermountain Health Care Inc, Salt Lake City, Utah, USA
| | - Daniel Courtney
- Emergency Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - James D'Etienne
- Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - Deborah B Diercks
- Emergency Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - John Garrett
- Emergency Medicine, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Alan E Jones
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - David MacKenzie
- Emergency Medicine, Maine Medical Center, Portland, Maine, USA
| | - Troy Madsen
- Emergency Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Andrew Matuskowitz
- Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bryn Mumma
- Emergency Medicine, University of California Davis, Davis, California, USA
| | - Kristen Nordenholz
- Emergency Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - Justine Pagenhardt
- Emergency Medicine, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Michael Runyon
- Emergency Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - William Stubblefield
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | |
Collapse
|
7
|
Adedeji A, Chukwura O, Obafemi T, McNulty SB, Reinert JP. Anticoagulation Strategies in the Management of Lemierre Syndrome: A Systematic Review of the Literature. Ann Pharmacother 2020; 55:658-665. [PMID: 32909436 DOI: 10.1177/1060028020957620] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To determine the optimal anticoagulation strategy in patients diagnosed with Lemierre Syndrome (LS). DATA SOURCES A systematic review in accordance with PRISMA guidelines was conducted using PubMed, MEDLINE, Scopus, ProQuest, and CINAHL from January to April 2020. Search terms included "Lemierre Syndrome" AND "anticoagulation" NOT "prophylaxis" OR "atrial fibrillation," in addition to a list of parenteral and oral anticoagulants. Adult patients who developed a clot and required systemic anticoagulation as a result of LS were included in this review. STUDY SELECTION AND DATA EXTRACTION A total of 4180 records were initially identified, though following the removal of duplicates and nonrelevant entries, 216 full-text articles were reviewed for inclusion; 13 articles were ultimately included. DATA SYNTHESIS The majority (11/14) of patients developed thromboses of the internal jugular veins, which corresponds to the pathophysiology of LS. Anticoagulation strategies were varied in the included literature, though 12/14 patients initially received a parenteral product. Two patients received a direct-acting oral anticoagulant (DOAC) following either intravenous heparin or subcutaneous enoxaparin and had outcomes similar to patients transitioned to warfarin. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Anticoagulation in LS is a clinical controversy because the thromboembolic events have rarely led to significant complications; thrombi typically resolve independently, and concerns for bleeding risks are well founded; however, this review indicates both the efficacy and safety of anticoagulation. CONCLUSIONS Anticoagulation is both efficacious and safe in LS, including treatment using a DOAC. Although further studies are needed, clinicians should consider a duration of anticoagulation of 6 to 12 weeks.
Collapse
|
8
|
Khatib R, Ross S, Kennedy SA, Florez ID, Ortel TL, Nieuwlaat R, Neumann I, Witt DM, Schulman S, Manja V, Beyth R, Clark NP, Wiercioch W, Schünemann HJ, Zhang Y. Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis. Blood Adv 2020; 4:500-513. [PMID: 32040553 PMCID: PMC7013254 DOI: 10.1182/bloodadvances.2019001223] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 12/20/2019] [Indexed: 12/22/2022] Open
Abstract
Increasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. We performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital. Medline, Embase, and Cochrane databases were searched up to July 2019 for relevant randomized clinical trials (RCTs), and prospective cohort studies. Two investigators independently screened titles and abstracts of identified citations and extracted data from relevant full-text papers. Risk ratios (RRs) were calculated, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Seven RCTs (1922 patients) were included in meta-analyses on managing patients with DVT. Pooled estimates indicated decreased risk of PE (RR = 0.64; 95% confidence interval [CI], 0.44-0.93) and recurrent DVT (RR = 0.61; 95% CI, 0.42-0.90) for home management, both with moderate certainty of the evidence. Reductions in mortality and major bleeding were not significant, both with low certainty of the evidence. Two RCTs (445 patients) were included in meta-analyses on home management of low-risk patients with PE. Pooled estimates indicated no significant difference in all-cause mortality, recurrent PE, and major bleeding, all with low certainty of the evidence. Results of pooled estimates from 3 prospective cohort studies (234 patients) on home management of PE showed similar results. Our findings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment.
Collapse
Affiliation(s)
- Rasha Khatib
- Advocate Research Institute, Advocate Health Care, Downers Grove, IL
| | - Stephanie Ross
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sean Alexander Kennedy
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ivan D Florez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
| | - Thomas L Ortel
- Division of Hematology, Medicine and Pathology, Duke University Medical Center, Durham, NC
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, The First I. M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Veena Manja
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente Colorado, Aurora, CO; and
| | - 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, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Guang' anmen Hospital, China Academy of Chinese Medical Science, Xicheng District, Beijing, China
| |
Collapse
|
9
|
Home treatment of patients with cancer-associated venous thromboembolism - An evaluation of daily practice. Thromb Res 2019; 184:122-128. [PMID: 31731069 DOI: 10.1016/j.thromres.2019.10.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Home treatment of cancer-associated venous thromboembolism (VTE) is challenging due to the high risk of adverse events. While home treatment is quite agreeable to cancer patients, studies evaluating the safety of VTE home treatment in this setting are largely unavailable. METHODS This was an observational study in patients with cancer-associated VTE. The main outcomes were the proportion of patients treated at home (hospital discharge <24 h after diagnosis) and the 3-month incidence of VTE-related adverse events (major bleeding, recurrent VTE and/or suspected VTE-related mortality) in patients managed in hospital versus at home. RESULTS A total of 183 outpatients were diagnosed with cancer-associated VTE: 69 had deep vein thrombosis (DVT) and 114 had pulmonary embolism (PE ± DVT). Of those, 120 (66%) were treated at home; this was 83% for patients with DVT and 55% for patients with PE (±DVT). The 3-month incidence of any VTE-related adverse event was 13% in those treated at home versus 19% in the hospitalized patients (HR 0.48; 95%CI 0.22-1.1), independent of initial presentation as PE or DVT. All-cause 3-month mortality occurred in 33 patients treated as inpatient (54%) compared to 29 patients treated at home (24%; crude HR 3.1 95%CI 1.9-5.0). CONCLUSIONS Two-third of patients with cancer-associated VTE - including PE - were selected to start anticoagulant treatment at home. Cancer-associated VTE is associated with high rates of VTE-related adverse events independent of initial in hospital or home treatment. However, home treatment may be a good option for selected patients with cancer-associated DVT or PE.
Collapse
|
10
|
Musco SE, Smallwood SM, Gossard J. Development and Evaluation of a Pharmacist-Driven Screening Tool to Identify Patients Presenting to the Emergency Department Who Are Eligible for Outpatient Treatment of Deep Vein Thrombosis. J Pharm Pract 2019; 34:378-385. [PMID: 33969771 DOI: 10.1177/0897190019872582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a critical and costly health issue. Treatment in the outpatient setting is preferred compared to the inpatient setting. However, there is a lack of evidence regarding how best to identify patients who are ideal for outpatient DVT treatment. OBJECTIVE To design and evaluate a pharmacist-driven screening tool for the identification of patients presenting to the emergency department (ED) at a community hospital with DVT who are appropriate for outpatient treatment. METHODS This study was conducted in sequential phases: compilation and vetting of screening criteria, descriptive evaluation of criteria through retrospective chart review, and quantification of potential cost savings by avoiding admissions. Criteria were collected via literature search and assembled into a screening tool, which was applied retroactively to a cohort of ED patients admitted with DVT diagnosis. RESULTS A screening tool was developed with multidisciplinary input and consisted of 5 categories with individual patient and disease state criteria. The majority (91%) of patients reviewed would not have qualified for outpatient DVT treatment based on the retrospective application of the screening tool. The most common disqualification criteria category was high risk of bleeding/clotting (n = 81), and the most frequently represented parameter within that category was antithrombotic therapy prior to admission (n = 53). CONCLUSION A screening tool may not be the most efficient method for health-care practitioners such as pharmacists to identify ED patients appropriate for outpatient management of DVT. Other avenues should be explored for improving the cost-effective management of these patients.
Collapse
Affiliation(s)
- Shaina E Musco
- 465018High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC, USA
| | | | - Jill Gossard
- Pharmacy Department, Community Howard Regional Hospital, Kokomo, IN, USA
| |
Collapse
|
11
|
Harder EM, Desai O, Marshall PS. Clinical Probability Tools for Deep Venous Thrombosis, Pulmonary Embolism, and Bleeding. Clin Chest Med 2019; 39:473-482. [PMID: 30122172 DOI: 10.1016/j.ccm.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Overdiagnosis of venous thromboembolism is associated with increasing numbers of patient complications and health care burden. Multiple clinical tools exist to estimate the probability of pulmonary embolism and deep venous thrombosis. When used with d-dimer testing, these can further stratify venous thromboembolism risk to help inform the use of additional diagnostic testing. Although there are similar tools to estimate bleeding risk, these are not as well-validated and lack reliability.
Collapse
Affiliation(s)
- Eileen M Harder
- Department of Internal Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA
| | - Omkar Desai
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA
| | - Peter S Marshall
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA.
| |
Collapse
|
12
|
Porath AD, Clodfelter S, Slaton T, Bookhart BK, Kozma CM, Rand ML, Bloch MJ. Policy Change for Deep Vein Thrombosis: Effects on Length of Stay and Hospitalization Costs of Moving From Warfarin to Direct Oral Anticoagulants. Clin Ther 2019; 41:269-279. [PMID: 30642614 DOI: 10.1016/j.clinthera.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/27/2018] [Accepted: 12/07/2018] [Indexed: 01/27/2023]
Abstract
PURPOSE Renown Health (Reno, Nevada), a large, locally owned, not-for-profit integrated health care network, has developed an institution-wide policy to shift the treatment of deep vein thrombosis (DVT) from a short-acting anticoagulant and vitamin K antagonist to the direct oral anticoagulant rivaroxaban combined with pharmacy-directed follow-up at an outpatient anticoagulation clinic. We examined data on hospitalizations and costs pre-/post-policy change. METHODS Data were obtained from the electronic health records of adults with newly diagnosed DVT treated at Renown Health. A quasi-experimental design was used to evaluate patients who received a DVT diagnosis before versus after the policy change. Primary outcomes were number of all-cause inpatient nights at 30 and 60 days post-DVT index date. Secondary outcomes were costs of all-cause overnight stays at 30 and 60 days post-DVT index. Outcomes were evaluated in propensity-weighted logistic regression and generalized linear models. FINDINGS There were 343 patients pre-policy change and 266 post-policy change. In the first 30 days postindex, the mean (95% CI) numbers of propensity-weighted all-cause inpatient nights were 1.27 (0.83-1.95) prechange and 0.66 (0.42-1.02) postchange (P = 0.038). Mean propensity-weighted estimated all-cause hospital costs in patients diagnosed as outpatients were $7848 ($4990-$12,344) prechange and $2466 ($1553-$3915) postchange (P <0.001). Mean costs of all-cause overnight stays in inpatient-diagnosed DVT patients were $8907 prechange and $7449 postchange (P = 0.600). In the first 60 days postindex, the mean number of all-cause inpatient nights (P = 0.219) and mean costs of all-cause overnight stays (P = 0.275) were not significantly different before and after the policy change. IMPLICATIONS Changing institutional policy to increase the utilization of a direct oral anticoagulant and pharmacist-led outpatient anticoagulation clinics may reduce length of hospital stay and decrease health care expenditures in the treatment of DVT.
Collapse
Affiliation(s)
- Adam D Porath
- Renown Health Anticoagulation Program, Reno, NV, USA.
| | | | - Terra Slaton
- CK Consulting Associates, LLC, St. Helena Island, SC, USA
| | | | - Chris M Kozma
- CK Consulting Associates, LLC, St. Helena Island, SC, USA
| | | | - Michael J Bloch
- Renown Institute for Heart and Vascular Health, Reno, NV, USA
| |
Collapse
|
13
|
Trocio J, Rosen VM, Gupta A, Dina O, Vo L, Hlavacek P, Rosenblatt L. Systematic literature review of treatment patterns for venous thromboembolism patients during transitions from inpatient to post-discharge settings. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 11:23-49. [PMID: 30588051 PMCID: PMC6305128 DOI: 10.2147/ceor.s179080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Direct oral anticoagulants (DOACs) have emerged as viable alternatives to traditional treatments such as vitamin K antagonists (VKAs) for venous thromboembolism (VTE). The objective of this review was to summarize evidence on the use of DOACs and VKAs to treat VTE in the US for patients transitioning from inpatient to post-discharge settings. Materials and methods A systematic review of the VTE literature identified studies published in English (January 1, 2011–December 31, 2016) that reported inpatient and post-discharge treatments and discharge location. Two reviewers screened abstracts, abstracted information from included studies, and assessed the quality of the study methodology and reporting. Results Forty-nine studies were included (24 clinical and 25 economic). A limited number of studies (eight clinical and three economic) examined VTE treatment patterns during transitions of care from inpatient to post-discharge settings, irrespective of anticoagulant (eg, DOAC, warfarin, heparin), and < 25% of all studies reported a post-discharge location. Three clinical studies that reported inpatient and outpatient treatment found better patient outcomes with DOAC vs warfarin. Fourteen economic studies reported that DOACs were associated with shorter hospital length of stay (LOS) and lower direct costs vs warfarin. No studies reported indirect costs. Discussion Although DOACs are associated with shorter LOS, lower costs, and better patient outcomes vs VKAs, it appears in one study that only a small percentage of patients with stable VTE who are discharged to home may be receiving DOACs. Conclusion These findings identified the potential areas of opportunity to improve the management of VTE through coordination of care from the inpatient to the outpatient settings.
Collapse
Affiliation(s)
- Jeffrey Trocio
- US Health Economics and Outcomes Research Pfizer Inc., New York, NY, USA,
| | - Virginia M Rosen
- Health Economics and Outcomes Research, Optum Inc., Eden Prairie, MN, USA
| | - Anu Gupta
- US Medical Affairs, Pfizer Inc., New York, NY, USA
| | - Oluwaseyi Dina
- US Health Economics and Outcomes Research Pfizer Inc., New York, NY, USA,
| | - Lien Vo
- US Health Economics and Outcomes Research, Bristol-Myers Squibb, Lawrenceville, NJ, USA
| | - Patrick Hlavacek
- US Health Economics and Outcomes Research Pfizer Inc., New York, NY, USA,
| | - Lisa Rosenblatt
- US Medical Affairs, Bristol-Myers Squibb, Lawrenceville, NJ, USA
| |
Collapse
|
14
|
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71:e59-e109. [PMID: 29681319 DOI: 10.1016/j.annemergmed.2018.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
15
|
Weeda ER, Butt S. Systematic Review of Real-World Studies Evaluating Characteristics Associated With or Programs Designed to Facilitate Outpatient Management of Deep Vein Thrombosis. Clin Appl Thromb Hemost 2018; 24:301S-313S. [PMID: 30428693 PMCID: PMC6714833 DOI: 10.1177/1076029618811082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Select patients with acute deep vein thrombosis (DVT) can be managed as outpatients. We sought to conduct a systematic review of real-world studies describing either (1) the clinical characteristics associated with outpatient DVT treatment in all-comers or (2) emergency department (ED) programs designed to facilitate outpatient DVT treatment. MEDLINE and SCOPUS were searched (January 1, 2012, to May 1, 2018) to identify citations meeting the aforementioned criteria. Twenty-one real-world studies were included. The proportion of all-comer patients with DVT managed as outpatients was ≤50% in 11 of 15 studies. With the exception of younger age, no characteristics were consistently associated with outpatient treatment across the 13 studies reporting these characteristics. We identified 8 studies describing ED programs aimed at facilitating DVT outpatient treatment, all of which provided education and included measures to encourage early outpatient follow-up after ED discharge. In conclusion, the proportion of patients with DVT managed as outpatients across real-world studies was low. Several ED programs aimed at facilitating this treatment have been described. It is possible that programs similar to these will increase the proportion of patients with DVT that can be safely managed as outpatients.
Collapse
Affiliation(s)
- Erin R Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Sofia Butt
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| |
Collapse
|
16
|
|
17
|
DiRenzo BM, Beam DM, Kline JA, Deodhar KS, Weber ZA, Davis CM, Walroth TA. Implementation and Preliminary Clinical Outcomes of a Pharmacist-managed Venous Thromboembolism Clinic for Patients Treated With Rivaroxaban Post Emergency Department Discharge. Acad Emerg Med 2018; 25:634-640. [PMID: 28921763 DOI: 10.1111/acem.13311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 07/10/2017] [Accepted: 09/12/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The objective was to describe the implementation, work flow, and differences in outcomes between a pharmacist-managed clinic for the outpatient treatment of venous thromboembolism (VTE) using a non-vitamin K oral anticoagulant versus care by a primary care provider (PCP). METHODS Patients in the studied health system that are diagnosed with low-risk VTE in the emergency department are often discharged without hospital admission. These patients are treated with a non-vitamin K oral anticoagulant and follow-up either in a pharmacist-managed VTE clinic or with their PCP. Pharmacists in the VTE clinic work independently under a collaborative practice agreement (CPA). An evaluation of 34 patients, 17 in each treatment arm, was conducted to compare the differences in treatment-related outcomes of rivaroxaban when managed by a pharmacist versus a PCP. RESULTS The primary endpoint was a 6-month composite of anticoagulation treatment-related complications that included a diagnosis of major bleeding, recurrent thromboembolism, or fatality due to either major bleeding or recurrent thromboembolism. Secondary endpoints included number of hospitalizations, adverse events, and medication adherence. There was no difference in the primary endpoint between groups with one occurrence of the composite endpoint in each treatment arm (p = 1.000), both of which were recurrent thromboembolic events. Medication adherence assessment was formally performed in eight patients in the pharmacist group versus no patients in the control group. No differences were seen among other secondary endpoints. CONCLUSIONS The pharmacist-managed clinic is a novel expansion of clinical pharmacy services that treats patients with low-risk VTEs with rivaroxaban in the outpatient setting. The evaluation of outcomes provides support that pharmacist-managed care utilizing standardized protocols under a CPA may be as safe as care by a PCP.
Collapse
Affiliation(s)
| | - Daren M. Beam
- Department of Emergency Medicine Indiana University School of Medicine IndianapolisIN
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine IndianapolisIN
| | | | | | | | | |
Collapse
|
18
|
Wells PS, Lensing AWA, Haskell L, Levitan B, Laliberté F, Durkin M, Ashton V, Xiao Y, Crivera C, Lejeune D, Schein J, Lefebvre P. Cost comparison of continued anticoagulation with rivaroxaban versus placebo based on the 1-year EINSTEIN-Extension trial efficacy and safety results. J Med Econ 2018; 21:587-594. [PMID: 29469638 DOI: 10.1080/13696998.2018.1444615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS The EINSTEIN-Extension trial (EINSTEIN-EXT) found that continued treatment with rivaroxaban for an additional 6 or 12 months (vs placebo) after 6-12 months of initial anticoagulation significantly reduced the risk of recurrent venous thromboembolism (VTE) with a small non-significant increased risk of major bleeding (none fatal or in critical site). This study aimed to compare total healthcare cost between rivaroxaban and placebo, based on the EINSTEIN-EXT event rates. METHODS Total healthcare cost was calculated as the sum of treatment and clinical event costs from a US managed care perspective. Treatment duration and event rates were obtained from the EINSTEIN-EXT study. Adjustment on treatment duration was made by assuming a 10% non-adherence rate. Drug costs were based on wholesale acquisition costs. Cost estimates for clinical events (i.e. recurrent deep vein thrombosis [DVT], recurrent pulmonary embolism, major bleeding, clinically relevant non-major bleeding) were determined from the literature. Results were examined over a ±20% range of each cost component and over 95% confidence intervals (CIs) of event rate differences in deterministic (one-way) and probabilistic sensitivity analyses (PSA). RESULTS Total healthcare cost was $1,454 lower for rivaroxaban-treated (vs placebo-treated) patients in the base-case, with a lower clinical event cost fully offsetting drug cost. The cost savings of recurrent DVT alone (-$3,102) was greater than drug cost ($2,723). Total healthcare cost remained lower for rivaroxaban in the majority (73%) of PSA (cost difference [95% CI] = -$1,454 [-$2,396, $1,231]). LIMITATIONS This study was conducted over the 1-year observation period of the EINSTEIN-EXT trial, which limited "real-world" applicability and examination of long-term economic impact. Assumptions on drug and clinical event costs were US-based and, thus, not applicable to other healthcare systems. CONCLUSIONS Total healthcare costs were estimated to be lower for patients continuing rivaroxaban therapy compared to those receiving placebo in VTE patients who had completed 6-12 months of VTE treatment.
Collapse
Affiliation(s)
- Philip S Wells
- a Department of Medicine , University of Ottawa, Ottawa Hospital Research Institute , Ottawa , ON , Canada
| | | | - Lloyd Haskell
- c Janssen Research & Development, LLC , Raritan , NJ , USA
| | - Bennett Levitan
- d Janssen Research & Development, LLC , Titusville , NJ , USA
| | | | | | | | | | | | | | - Jeff Schein
- f Janssen Scientific Affairs, LLC , Raritan , NJ , USA
| | | |
Collapse
|
19
|
Howard LS. Non-vitamin K antagonist oral anticoagulants for pulmonary embolism: who, where and for how long? Expert Rev Respir Med 2018. [PMID: 29542359 DOI: 10.1080/17476348.2018.1452614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a relatively common cardiopulmonary emergency that is a major cause of hospitalization and morbidity and is the primary cause of mortality associated with venous thromboembolism (VTE). During the last decade, one of the biggest changes in the management of PE has been the approval of four non-vitamin K antagonist oral anticoagulants (NOACs; apixaban, dabigatran, edoxaban and rivaroxaban) for the treatment of PE and deep vein thrombosis and secondary prevention of VTE. Areas covered: This article reviews the evolving management of PE in the NOAC era and addresses three fundamental questions: who should receive NOACs over conventional heparin/vitamin K antagonist regimens for the treatment of acute PE; should patients be treated as inpatients or outpatients; and how long should patients be treated to reduce the risk of recurrence? Expert commentary: The management of PE is changing. NOACs provide new anticoagulant treatment options for patients with PE, based on Phase III clinical study results. The consistent efficacy and safety profile of NOACs across many PE patient subgroups, including the elderly, fragile patients, those with active cancer and high-risk (right ventricular dysfunction) patients, suggests NOAC use will increase among these patients.
Collapse
Affiliation(s)
- Luke S Howard
- a Imperial College Healthcare NHS Trust , Hammersmith Hospital , London , UK
| |
Collapse
|
20
|
Zhang C, Xu B, Liang G, Zeng X, Yang C, Zhang F, Wan Z, Yu W, Chen D, Ge Z, Zhang X. Rivaroxaban versus nadroparin for preventing deep venous thrombosis after total hip arthroplasty following femoral neck fractures: A retrospective comparative study. J Int Med Res 2018; 46:1936-1946. [PMID: 29560772 PMCID: PMC5991221 DOI: 10.1177/0300060518762281] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objective This study was performed to evaluate the efficacy of rivaroxaban versus nadroparin for preventing deep venous thrombosis (DVT) in elderly patients with osteoporosis undergoing initial total hip arthroplasty (THA) for femoral neck fractures. Methods Prospectively maintained databases were reviewed to retrospectively compare elderly patients with osteoporosis who underwent initial THA for femoral neck fractures from 2007 to 2015. The patients received peroral rivaroxaban at 10 mg/day for 2 weeks or subcutaneous injections of nadroparin at 0.3 mL/day for 2 weeks until the primary analysis cut-off date. The time to first on-study DVT was the primary endpoint. Results In total, 399 patients were included (rivaroxaban group: n=200; mean age, 70.20 ± 9.16 years and nadroparin group: n = 199; mean age, 69.90 ± 8.87 years), with a mean 3-year follow-up. The time to first on-study DVT was significantly longer in the rivaroxaban than nadroparin group (12 and 5 days, respectively). The incidence of DVT within the 2-week follow-up was significantly higher in the nadroparin than rivaroxaban group (6.8% and 19.7%, respectively), but this difference was no longer present at the final follow-up. Conclusion Rivaroxaban was associated with a significant reduction in the occurrence of first on-study DVT compared with nadroparin.
Collapse
Affiliation(s)
- Chi Zhang
- 1 Department of Joint Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Liwan District, Guangzhou, Guangdong, China
| | - Bo Xu
- 2 Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Yuexiu District, Guangzhou, Guangdong, People's Republic of China
| | - Guanzhao Liang
- 3 Emergency Department, The First Affiliated Hospital of Sun Yat-sen University, Yuexiu District, Guangzhou, Guangdong, People's Republic of China
| | - Xianshang Zeng
- 4 Department of Orthopaedics, The First Affiliated Hospital of Sun Yat-sen University, Yuexiu District, Guangzhou, Guangdong, People's Republic of China
| | - Chen Yang
- 5 Department of Physical Examination, The First Affiliated Hospital of Sun Yat-sen University, Yuexiu District, Guangzhou, Guangdong, People's Republic of China
| | - Fan Zhang
- 6 Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Yuexiu District, Guangzhou, Guangdong, People's Republic of China
| | - Zi Wan
- 7 Department of Urology, The First Affiliated Hospital of Sun Yat-sen University, Yuexiu District, Guangzhou, Guangdong, People's Republic of China
| | - Weiguang Yu
- 4 Department of Orthopaedics, The First Affiliated Hospital of Sun Yat-sen University, Yuexiu District, Guangzhou, Guangdong, People's Republic of China
| | - Deng Chen
- 8 Department of Joint Surgery, The First People's Hospital of Jingmen, Hubei, Dongbao District, Jingmen, Hubei, People's Republic of China
| | - Zhe Ge
- 9 Department of Orthopaedics, Jinshan Hospital, Fudan University, Jinshan District, Shanghai, People's Republic of China
| | - Xinchao Zhang
- 9 Department of Orthopaedics, Jinshan Hospital, Fudan University, Jinshan District, Shanghai, People's Republic of China
| |
Collapse
|
21
|
Coombs M, Fox B. Outpatient Treatment of Pulmonary Embolism: a Practical Guide. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0144-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
22
|
Chu A, Limberg J. Rivaroxaban program for acute venous thromboembolism upon ED discharge, with focus on utility of commercially available dose pack. Am J Emerg Med 2017; 35:1910-1914. [DOI: 10.1016/j.ajem.2017.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/29/2022] Open
|
23
|
Roy PM, Moumneh T, Penaloza A, Sanchez O. Outpatient management of pulmonary embolism. Thromb Res 2017; 155:92-100. [DOI: 10.1016/j.thromres.2017.05.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/21/2017] [Accepted: 05/01/2017] [Indexed: 01/17/2023]
|
24
|
Singer AJ, Xiang J, Kabrhel C, Merli GJ, Pollack C, Tapson VF, Wildgoose P, Peacock WF. Multicenter Trial of Rivaroxaban for Early Discharge of Pulmonary Embolism From the Emergency Department (MERCURY PE): Rationale and Design. Acad Emerg Med 2016; 23:1280-1286. [PMID: 27537530 DOI: 10.1111/acem.13072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/12/2016] [Accepted: 08/15/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Traditionally, patients with pulmonary embolism (PE) are admitted from the emergency department and treated with low-molecular-weight heparin followed by warfarin. Several studies now demonstrate that it is possible to identify low-risk PE patients that can safely be treated as outpatients. The advent of the direct-acting oral anticoagulants such as rivaroxaban has made it easier than ever to manage patients outside of the hospital. This article describes the design of a randomized controlled trial aimed at testing the hypothesis that low-risk PE patients can be safely and effectively managed at home using rivaroxaban, resulting in fewer days of hospitalization than standard-of-care treatment. METHODS We have initiated a multicenter, open-label, randomized clinical trial in which low-risk adult PE patients (identified by the Hestia criteria) are randomized to outpatient management with oral rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily for 90 days versus standard care, determined by the treating physician and based on local practices. The primary clinical endpoint will be the total number of inpatient hospital days (including the index admission) for venous thromboembolic or bleeding-related events during the first 30 days after randomization. A total of 150 subjects per group will provide 82% power to detect a difference of 1 day or greater in the primary outcome. RESULTS Patient enrollment is ongoing at present in 45 of 60 planned sites. No interim analysis is planned and the study is being monitored by a data safety management board. CONCLUSIONS The MERCURY PE study is designed to test the hypothesis that outpatient management of low-risk PE patients with rivaroxaban reduces the number of hospitalization days from venous thromboembolism and bleeding compared with standard care. This article describes the rationale and methodology for this study.
Collapse
Affiliation(s)
- Adam J. Singer
- Department of Emergency Medicine; Stony Brook Medicine; Stony Brook NY
| | | | | | - Gino J. Merli
- Department of Medicine; Jefferson Medical College; Philadelphia PA
| | - Charles Pollack
- Department of Emergency Medicine; Jefferson Medical College; Philadelphia PA
| | - Victor F. Tapson
- Department of Medicine; Cedars-Sinai Medical Center (VFT); Los Angeles CA
| | | | - W. Frank Peacock
- Department of Emergency Medicine; Baylor College of Medicine; Houston TX
| |
Collapse
|
25
|
Margolis JM, Deitelzweig S, Kline J, Tran O, Smith DM, Bookhart B, Crivera C, Schein J. Shorter Hospital Stays and Lower Costs for Rivaroxaban Compared With Warfarin for Venous Thrombosis Admissions. J Am Heart Assoc 2016; 5:JAHA.116.003788. [PMID: 27792638 PMCID: PMC5121479 DOI: 10.1161/jaha.116.003788] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Venous thromboembolism, including deep vein thrombosis and pulmonary embolism, results in a substantial healthcare system burden. This retrospective observational study compared hospital length of stay (LOS) and hospitalization costs for patients with venous thromboembolism treated with rivaroxaban versus those treated with warfarin. Methods and Results Hospitalizations for adult patients with a primary diagnosis of deep vein thrombosis or pulmonary embolism who were initiated on rivaroxaban or warfarin were selected from MarketScan's Hospital Drug Database between November 1, 2012, and December 31, 2013. Patients treated with warfarin were matched 1:1 to patients treated with rivaroxaban using exact and propensity score matching. Hospital LOS, time from first dose to discharge, and hospitalization costs were reported descriptively and with generalized linear models (GLMs). The final study cohorts each included 1223 patients (751 with pulmonary embolism and 472 with deep vein thrombosis). Cohorts were well matched for demographic and clinical characteristics. Mean (±SD) LOS was 3.7±3.1 days for patients taking rivaroxaban and 5.2±3.7 days for patients taking warfarin, confirmed by GLM‐adjusted results (rivaroxaban 3.7 days, warfarin 5.3 days, P<0.001). Patients with provoked venous thromboembolism admissions showed longer LOSs (rivaroxaban 5.1±4.5 days, warfarin 6.5±5.6 days, P<0.001) than those with unprovoked venous thromboembolism (rivaroxaban 3.3±2.4 days, warfarin 4.8±2.8 days, P<0.001). Days from first dose to discharge were 2.4±1.7 for patients treated with rivaroxaban and 3.9±3.7 for patients treated with warfarin when initiated with parenteral anticoagulants (P<0.001), and 2.7±1.7 and 3.7±2.1, respectively, when initiated without parenteral anticoagulants (P<0.001). Patients initiated on rivaroxaban incurred significantly lower mean total hospitalization costs ($8688±$9927 versus $9823±$9319, P=0.004), confirmed by modeling (rivaroxaban $8387 [95% confidence interval, $8035–$8739]; warfarin $10 275 [95% confidence interval, $9842–$10 708]). Conclusions Rivaroxaban was associated with significantly shorter hospital LOS and lower hospitalization costs compared with warfarin.
Collapse
Affiliation(s)
| | - Steven Deitelzweig
- Ochsner Health System and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | | | - Oth Tran
- Truven Health Analytics, Bethesda, MD
| | | | | | | | | |
Collapse
|
26
|
Deitelzweig S, Laliberté F, Crivera C, Germain G, Bookhart BK, Olson WH, Schein J, Lefebvre P. Hospitalizations and Other Health Care Resource Utilization Among Patients with Deep Vein Thrombosis Treated with Rivaroxaban Versus Low-molecular-weight Heparin and Warfarin in the Outpatient Setting. Clin Ther 2016; 38:1803-1816.e3. [DOI: 10.1016/j.clinthera.2016.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/28/2016] [Accepted: 07/01/2016] [Indexed: 11/17/2022]
|
27
|
Hunt TD, Guglielminotti J, Li G. Costs Associated with Anesthesia-Related Adverse Events During Labor and Delivery in New York State, 2010. Anesth Analg 2016; 122:2007-16. [DOI: 10.1213/ane.0000000000001291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
28
|
Stein PD, Matta F, Hughes MJ. Home Treatment of Deep Venous Thrombosis According to Comorbid Conditions. Am J Med 2016; 129:392-7. [PMID: 26551984 DOI: 10.1016/j.amjmed.2015.10.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/26/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cautious exploration of the safety of home treatment of deep venous thrombosis has been recommended by many. Our goal was to identify categories of patients with deep venous thrombosis who typically are hospitalized, and categories frequently treated at home. METHODS The Nationwide Emergency Department Sample and the Nationwide Inpatient Sample, 2007-2012, were used to determine the number of patients seen in emergency departments throughout the US with deep venous thrombosis and no diagnosis of pulmonary embolism, the proportion of such patients hospitalized according to comorbid conditions and age, the proportion discharged early (≤2 days), and charges for hospitalization and emergency department visits. RESULTS From 2007-2012, home treatment was selected for 905,152 of 2,671,452 (33.9%) patients with deep venous thrombosis. Home treatment was more frequent in those with no comorbid conditions than with comorbid conditions, 58.0% compared with 15.5% (P <.0001). Early discharge (≤2 days) was in 23.9% with no comorbid conditions, compared with 12.8% with comorbid conditions. Among patients aged 18-50 years, home treatment was selected in 62.9% with no comorbid conditions, compared with 24.2% with comorbid conditions (P <.0001). Among hospitalized patients with no comorbid conditions, 40.7% were aged 18-50 years. Their charges for hospitalization in 2012 were $494 million. CONCLUSION Patients aged 50 years or younger with deep venous thrombosis and no comorbid conditions appear to be a group that can be targeted for more frequent home treatment, which would save millions of dollars.
Collapse
Affiliation(s)
- Paul D Stein
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.
| | - Fadi Matta
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing
| | - Mary J Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing
| |
Collapse
|
29
|
Beam DM, Kahler ZP, Kline JA. Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. Acad Emerg Med 2015; 22:788-95. [PMID: 26113241 PMCID: PMC5034796 DOI: 10.1111/acem.12711] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/12/2015] [Accepted: 01/23/2015] [Indexed: 12/14/2022]
Abstract
Objectives The study hypothesis was that a target‐specific anticoagulant would allow successful home treatment of selected patients with deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosed in two urban emergency departments (EDs). Methods A protocol was established for treating low‐risk DVT or PE patients with rivaroxaban and clinic, follow‐up at both 2 to 5 weeks, and 3 to 6 months. Patients were determined to be low‐risk by using a modified version of the Hestia criteria, supplemented by additional criteria for patients with active cancer. Acceptable outcome rates were defined as venous thromboembolism (VTE) recurrence ≤ 2.1% or bleeding ≤ 9.4% during treatment. VTE recurrence required positive imaging of any VTE. The International Society of Thrombosis and Hemostasis definition of major or clinically relevant nonmajor bleeding was used. Results From March 2013 through April 2014, a total of 106 patients were treated. Seventy‐one (68%) had DVT, 30 (28%) had PE, and five (3%) had both, representing 51% of all DVTs and 27% of all PEs diagnosed in both EDs during the period of study. The 106 patients have been followed for a mean (±SD) of 389 (±111) days (range = 213 to 594 days). No patient had VTE recurrence, and no patient had a major or clinically relevant bleeding event while on therapy (none of the 106, 0%, 95% confidence interval [CI] = 0% to 3.4%). However, three patients 2.8% (95% CI = 1% to 8%) had recurrent DVT after cessation of therapy. Conclusions Patients diagnosed with VTE and immediately discharged from the ED while treated with rivaroxaban had a low rate of VTE recurrence and bleeding.
Collapse
Affiliation(s)
- Daren M. Beam
- The Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
- The Department of Cellular and Integrative Physiology Indiana University School of Medicine Indianapolis IN
| | - Zachary P. Kahler
- The Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Jeffrey A. Kline
- The Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
- The Department of Cellular and Integrative Physiology Indiana University School of Medicine Indianapolis IN
| |
Collapse
|