Treatment and secondary prevention of venous thromboembolism in cancer patients. Current strategies and new therapeutic options

Cancer is a major and independent risk factor of venous thromboembolism (VTE). In clinical practice, a high number of VTE events occurs in patients with cancer, and treatment of cancer-associated VTE differs in several aspects from treatment of VTE in the general population. However, treatment in cancer patients remains a major challenge, as the risk of recurrence of VTE as well as the risk of major bleeding during anticoagulation is substantially higher in patients with cancer than in those without cancer. In several clinical trials, different anticoagulants and regimens have been investigated for treatment of acute VTE and secondary prophylaxis in cancer patients to prevent recurrence. Based on the results of these trials, anticoagulant therapy with low-molecular-weight heparins (LMWH) has become the treatment of choice in cancer patients with acute VTE in the initial period and for extended and long-term anticoagulation for 3-6 months. New oral anticoagulants directly inhibiting thrombin or factor Xa, have been developed in the past decade and studied in large phase III clinical trials. Results from currently completed trials are promising and indicate their potential use for treatment of VTE also in cancer patients. However, the role of the new oral thrombin and factor Xa inhibitors for VTE treatment in cancer patients still has to be clarified in further studies specifically focusing on cancer-associated VTE. This brief review will summarize the current strategies of initial and long-term VTE treatment in patients with cancer and discuss the potential use of the new oral anticoagulants.     

Diagnosis and management of venous thromboembolism

Venous thromboembolic disease is a common disease associated with significant morbidity and mortality. Accurate and timely diagnosis should be guided by the use of validated clinical prediction rules. The mainstay of therapy is anticoagulation, although alternative approaches, such as use of concurrent thrombolysis or placement of vena caval filters, may be appropriate in selected patients. Determination of duration of anticoagulation requires a detailed assessment of the risk factors associated with the event allowing estimation of recurrence risk, and careful assessment of bleeding risk. Although extremely effective, anticoagulants have a narrow therapeutic window; systems should be in place to reduce risk of adverse events associated with these agents.     

Recent advances in the management of venous thromboembolism

Deep venous thrombosis and pulmonary embolism are frequently diagnosed in patients encountered in a primary-care practice. In the past 10 years, many important advances have been made regarding the management of these disorders. Risk factors have been better defined than in the past. Several new prophylactic measures--such as external pneumatic compression of the lower extremities, dihydroergotamine in combination with heparin, adjusted-dose heparin, and two-step warfarin therapy--can be used to help prevent deep venous thrombosis in surgical patients. The use of serial impedance plethysmography has expanded options for noninvasive diagnosis of deep venous thrombosis. Correlations between pulmonary embolism and ventilation-perfusion lung scan patterns have been clarified. Although much has been learned about heparin and warfarin that affect common management decisions, the indications for thrombolytic therapy for venous thromboembolism remain controversial. Finally, studies have shown that calf vein thrombi that are not detectable by impedance plethysmography and that show no evidence of proximal propagation by serial impedance plethysmography do not require treatment.     

Current status of postoperative venous thromboembolism

Venous thromboembolism has been a common illness even in Japan and gets increased social as well as medical attention, especially during postoperative period. The most effective way of reducing unexpected death from postoperative venous thromboembolism is to institute a comprehensive institutional policy of primary prophylaxis in patients at risk. Since the clinical experience has shown that there are ethnic differences between Japanese and westerners in coagulability, it will be inappropriate to assume that the results of western studies are fully applicable to the clinical situation in Japan. Although it is difficult to prepare the guideline for prophylaxis of venous thromboembolism based on reliable evidence for Japanese currently, available epidemiologic information has been obtained in orthopedic or gynecologic fields.     

Understanding the new emerging oral anticoagulants for venous thromboembolism prophylaxis

Patients who have major orthopaedic surgery are at high risk for developing venous thromboembolism (VTE). Assessment of risk and treatment to prevent VTE are considered standard of care due to its significant morbidity, potential mortality, and clinical burden and cost. Guidelines are available aiding orthopaedic surgeons to choose the best methods of VTE prophylaxis. Optimal VTE prevention has not been achieved. Recent advances in the understanding of the coagulation cascade have evolved because of a novel understanding of the molecular influences on the coagulation pathway. Subsequently, new anticoagulants have been developed that target specific factors within the coagulation cascade that are contrasted to the currently used agents that have a broad effect on the coagulation pathway. Multiple clinical trials have tested the new anticoagulants within the orthopaedic total knee and total hip arthroplasty arena. In addition, research to find new ways to prevent VTE was driven by limitations of the currently available agents. The new oral anticoagulants extensively trialed in orthopaedics are dabigatran, rivaroxaban, and apixaban. Clinical trials indicate that the new oral agents have the potential to impact VTE prophylaxis in regard to efficacy, predicta bility and consistency, clinical monitoring, adherence as to use and duration, and convenience. Concerns persist regarding issues of bleeding complications, liver enzyme elevation, patients with renal disease, and drug-to-drug interactions. The new oral agents do not have an antidote to reverse bleeding effect and have no reliable assay to measure effect. Nurses need to be aware of these new VTE prophylactic choices and their implications in order to provide the best outcomes for their patients.     

Current and future perspectives in imaging of venous thromboembolism

Summary

Several thrombus imaging techniques for the diagnosis of venous thromboembolism (VTE) are available. The most prevalent forms of VTE are deep vein thrombosis of the lower extremities and pulmonary embolism. However, VTE may also occur at unusual sites such as deep veins of the upper extremity and the splanchnic and cerebral veins. Currently, the imaging techniques most widely used in clinical practice are compression ultrasonography and computed tomography (CT) pulmonary angiography. Moreover, single‐photon emission CT, CT venography, positron emission tomography, and different magnetic resonance imaging (MRI) techniques, including magnetic resonance direct thrombus imaging, have been evaluated in clinical studies. This review provides an overview of the technique, diagnostic accuracy and potential pitfalls of these established and emerging imaging modalities for the different sites of venous thromboembolism.     

The assessment and management of venous thromboembolism

This article examines venous thromboembolism (VTE) and offers guidance on its prevention. VTE is a potentially fatal condition, which can be prevented using both pharmacological and mechanical methods. Nursing staff should be aware of the risk factors that predispose patients to venous thromboembolism and ensure that high-risk patients receive the prophylaxis they require.     

Current strategies in prophylaxis and treatment of venous thromboembolism

During the past two decades well designed randomized controlled trials have addressed every important aspect of prophylaxis against venous thromboembolism (VTE) and treatment of established VTE. In addition, systematic reviews and meta-analyses have been performed in most of these areas. The most important advances are the widely accepted and effective VTE prophylaxis in major orthopedic surgery and the shift from in-hospital to outpatient treatment of a majority of patients with established VTE. The major hurdles at this point are efficient selection of the appropriate medically ill patients for prophylaxis and the inconvenience of long-term secondary prophylaxis with vitamin K antagonists. Although new, orally available anticoagulants without need for monitoring or dose adjustments have been in clinical trials for a decade, none is approved yet, and will not be discussed in this review.     

静脉血栓栓塞症的诊断现状

静脉血栓栓塞症(venous thromboembolism,VTE)包括深静脉血栓形成(deep vein thrombosis,DVT)和肺血栓栓塞症(pulmonary thromboembolism,PTE)。PTE是肺栓塞的一种类型,定义为来自静脉系统或右心的血栓阻塞肺动脉或其分支所导致,以肺循环和呼吸功能障碍为主要临床和病理特征的     

The management of venous thromboembolism in cancer patients

Venous thromboembolism (VTE), encompassing deep venous thrombosis and pulmonary embolism (PE), is a common complication of cancer and an important cause of preventable mortality in people with cancer. Because VTE can be clinically silent, fatal PE generally occurs without warning, and preventive measures are, therefore, necessary in high-risk patients. Clinical guidelines recommend the use of low-molecular-weight heparins in the treatment and prevention of VTE in patients with cancer, in addition to non-pharmacological interventions aimed at reducing thrombotic risk. Nurses have an important role in helping to identify patients at risk of developing VTE, and in the implementation of preventive or therapeutic regimens, and monitoring the development of complications. Furthermore, nurses are in an ideal position to educate patients on the importance of preventive measures and to help ensure compliance with thromboprophylactic interventions.     

Current options in the management of olanzapine-associated weight gain

OBJECTIVE: To evaluate options for the management of weight gain associated with olanzapine therapy. DATA SOURCES: MEDLINE (1966-May 2004), International Pharmaceutical Abstracts (1970-August 2003), The Cochrane Library, and EMBASE (1974-August 2003) databases were searched using the key words antipsychotics, atypical antipsychotics, olanzapine, and weight gain. Bibliographies of cited articles were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and all information deemed relevant was included for this review. DATA SYNTHESIS: Weight gain is a common adverse effect of olanzapine, a member of the atypical antipsychotic class. Data are limited supporting a specific therapeutic approach to the management of weight gain with olanzapine treatment. Reversal of weight gain with lifestyle modifications and adjunctive pharmacologic therapies such as nizatidine and amantadine has been modest. Experience with adjunctive pharmacologic treatment has been limited to small, observational studies and case reports. Although data are limited, weight reduction has been observed in select patients switching from olanzapine to an alternative atypical antipsychotic. CONCLUSIONS: At this time, targeting lifestyle modifications provides the most reasonable approach to minimize weight gain observed with olanzapine therapy. Preliminary evidence evaluating adjunctive pharmacologic treatment for this indication has demonstrated minimal clinical benefit. Switching to an alternative atypical antipsychotic agent associated with less significant weight gain may be appropriate in select patients. Further clinical trials are needed to support a specific therapeutic approach to managing weight gain with olanzapine.     

Current concepts in venous thromboembolism and major lower limb orthopaedic surgery

Venous thromboembolism remains a major cause of morbidity and mortality among patients undergoing major orthopaedic surgery. With improved surgical techniques, the use of heparin-based thromboprophylactic agents has allowed significant advances in the prevention of thrombosis during the past 30 years. With an aging population and the growing burden of degenerative joint disease, the management of this preventable disease remains at the forefront of surgical care. Despite the use of the supposedly most effective antithrombotic agents (low-molecular-weight heparins), recent studies have highlighted considerable prevalence of thrombosis, especially among hip fracture patients. New prevention strategies include a greater use of existing therapies, combining chemical and mechanical methods, extending the duration of prophylaxis and, most importantly, developing more effective agents with improved benefit to risk ratios.     

Subtrochanteric fractures: Current management options

Purpose: To review current management options for subtrochanteric fractures of the femur. These fractures behave differently from other proximal femoral fractures and have their own management pitfalls and problems.

Method: Articles were identified from Medline. Papers on the management of subtrochanteric fractures were assessed, and included if they contained relevant information. The articles were divided into groups depending on the type of management described. Conservative and operative management were considered separately. Operative management was classified according to the type of device used into extramedullary and intramedullary.

Conclusions: Conservative management gives satisfactory results in 56% of patients compared to 70?–?80% for operative methods. The studies on conservative methods are mostly dated, with less stringent outcome measures. Conservative management is safe, and has a low frequency of non-union. It is most applicable in regions where facilities are suboptimal, in patients unfit for surgery, and in children. When considering operative management, intramedullary devices appear to give better results than extramedullary devices, particularly when the medial buttress of the proximal femur is compromised. However, when operative treatment is undertaken, it should be by experienced surgeons using the technique with which they are most familiar.     

围术期静脉血栓栓塞症预防及管理的证据总结

目的 检索、获取国内外围术期患者静脉血栓栓塞症(Venous thromboembolism,VTE)预防及管理的相关证据并对最佳证据进行总结,为临床实践提供循证依据.方法 计算机检索UpToDate、乔安娜布里格斯研究所循证卫生保健中心数据库、国际指南图书馆、美国指南网、英国国家卫生与临床优化研究所、加拿大安大略注册...     

肿瘤患者输液港相关性血栓预防及管理的最佳证据总结

目的 检索、评价和整合肿瘤患者输液港相关性血栓预防及管理的相关证据,为临床实践提供参考。方法 使用计算机检索中国知网、BMJ Best Practice、UpToDate、Cochrane Library、乔安娜布里格斯研究所循证卫生保健中心数据库、CINAHL、Embase、PubMed、中国临床指南文库、苏格兰院际指南网、美国国立指南库、美国输液护士协会网站、美国国家综合癌症网、美国临床肿瘤学会网站、欧洲肿瘤内科学会网站、安大略省注册护士协会网站中关于肿瘤患者输液港相关性血栓预防及管理的证据,包括指南、系统评价、证据总结、推荐实践及专家共识,检索时限为建库至2021年3月10日。结果 共纳入12篇文献,包括指南4篇、系统评价5篇、证据总结1篇、专家共识2篇,从风险评估、导管置入与维护、血栓筛查与诊断、预防、管理与治疗、健康教育6个方面,共总结30条最佳证据。 结论 该研究总结了肿瘤患者输液港相关性血栓预防及管理的最佳证据。护士及护理管理者可结合临床情景及患者意愿选择并应用证据,以制订科学的肿瘤患者输液港相关性血栓预防及管理方案,提升护理质量。     

围手术期预防静脉血栓栓塞症的健康教育研究现状

静脉血栓栓塞症(VTE)是围手术期常见并发症,是医院内非预期死亡的重要危险因素之一,严重影响患者术后康复,但是采取合适的预防措施可有效降低围手术期VTE的发生率。健康教育作为必不可少的防治措施之一,可以作为基础干预手段,使医患双方了解VTE预防的必要性,产生改变现状的意愿。本文对围手术期VTE的健康教育研究现状进行综述,包括患者对预防VTE的健康教育的需求、内容、方式、评价体系及展望。     

住院患者静脉血栓栓塞症PDSA循环防治管理效果研究

目的 探讨PDSA循环在住院患者静脉血栓栓塞症(VTE)防治管理中的效果.方法 选取2019年1-12月住院患者61136例为对照组,2020年1-12月住院患者55118例为观察组.对照组采用常规管理办法,观察组采用PDSA循环管理模式.比较2组患者VTE预防措施落实率、中高危患者VTE预防措施落实率、VTE发生率.结果 落实PDSA循环管理模式后,VTE预防措施落实率由42.26％提高至76.32％,中高危患者物理预防措施落实率由38.24％提高至70.26％,VTE发生率由4.04‰降低至2.99‰,差异有统计学意义(P＜0.05).结论 PDSA循环管理规范了VTE防治的各环节流程,提高了预防措施落实率,深化了防治质量内涵,降低了VTE发生率,保证了患者安全.