抗凝药物预防与治疗肿瘤患者静脉血栓栓塞症的研究进展

目的:综述抗凝药物预防和治疗肿瘤患者静脉血栓栓塞症(VTE)的研究进展,为VTE的临床防治提供参考。方法:以"肿瘤""静脉血栓栓塞症""抗凝药物""Tumour""Cancer""Venous thromboembolism""Anticoagulant drugs"等为关键词,在中国知网、万方数据、PubMed等数据库中组合查询2010年1月-2020年5月发表的相关文献,归纳抗凝药物预防和治疗肿瘤患者VTE的研究进展。结果与结论:目前临床常用的抗凝药物包括低分子肝素、Ⅹa因子抑制剂、华法林等。无论是预防还是治疗肿瘤患者VTE,低分子肝素都是首选药物,但其皮下注射的给药方式并不十分方便,且在严重肾功能衰竭的患者中不推荐使用。经典口服抗凝药物华法林由于影响因素(如其他药物、机体状态)较多并未在肿瘤患者VTE治疗中得到首选的推荐,且需检测国际标准化比值、起效慢、体内清除时间长。口服直接Xa因子抑制剂在肿瘤患者VTE预防和治疗方面显示出有利的风险效益,首选用于血栓风险高、出血风险低的人群。     

抗凝药物在妊娠期静脉血栓栓塞疾病中的应用

妊娠相关静脉血栓栓塞疾病是导致孕产妇死亡的主要原因之一,且近年来发病率有上升趋势。在适宜的时机合理使用抗凝药物对于妊娠相关静脉血栓栓塞疾病的防治、改善母婴结局尤为重要。本文介绍了妊娠期静脉血栓栓塞疾病高危因素的评估方法及妊娠期抗凝药物的使用原则,以期能够为相关问题的临床用药提供借鉴和参考。     

抗凝药物防治癌症患者静脉血栓栓塞症的药物经济学系统评价

目的:系统评价抗凝药物预防或治疗癌症患者静脉血栓栓塞症(VTE)的药物经济性.方法:计算机检索PubMed、Embase、Cochrane图书馆、中国知网、万方数据、维普网、中国生物医学文献服务系统以及The NHS Economic Evaluation Database、The Healthy Technology...     

430例住院肿瘤患者抗凝预防回顾性分析

目的回顾性分析住院肿瘤患者肿瘤相关静脉血栓的预防情况,探讨临床药学服务在肿瘤患者静脉血栓栓塞症(VTE)预防中应发挥的积极作用。方法查阅某三级甲等医院2017年1—10月住院的肿瘤患者病历430份,对患者静脉栓塞评分、预防用抗凝药物使用率、治疗用抗凝药物使用率进行回顾性调查统计。结果经评估Caprini风险评分≥3分的高危及极高危肿瘤患者共426例,占99.1%,其中14例给予抗凝预防,总体抗凝预防使用率为3.3%;化疗相关栓塞风险评估显示,212例接受化疗的肿瘤患者中,87.7%患者罹患VTE高风险的肿瘤,评分≥3分的高危患者有36例(17.0%,36/212),其中2例给予抗凝预防,总体抗凝预防率为5.6%(2/36)。430例患者中,共14例接收抗凝预防治疗,其中11例(78.6%,11/14)患者给予指南推荐的低分子肝素或活化的Xa因子抑制剂,抗凝药物选用总体较为合理。结论该院住院肿瘤患者静脉血栓的预防尚存在不足,提示临床药师应针对问题开展相应的学习及宣教,积极参与肿瘤患者静脉血栓的预防及管理,提高肿瘤患者生活质量,改善生存预后。     

胸部恶性肿瘤围手术期抗凝药物预防静脉血栓栓塞症的回顾性分析

目的:回顾性分析胸部恶性肿瘤围手术期使用抗凝药物预防静脉血栓栓塞症的现状及其合理性,探讨临床药学服务在肿瘤患者静脉血栓栓塞症预防中应发挥的积极作用.方法:查阅2019年6～12月某三甲综合医院胸部恶性肿瘤围术期住院患者195例的临床资料,对患者基本情况,Caprini风险评估量表、抗凝药物使用情况及其合理性等进行统计和...     

妇科肿瘤术后静脉血栓栓塞症延展性用药管理模式构建

目的构建临床药师主导的院外延展性抗凝预防妇科肿瘤患者术后静脉血栓栓塞症(VTE)的用药管理方法,探索一种抗凝专业临床药师深入临床开展药学服务的工作模式。方法2021年6-12月共纳入南通大学附属肿瘤医院妇瘤科卵巢癌、宫颈癌及子宫内膜癌患者182例,采用数字随机法分为对照组(91例)及干预组(91例)。对照组采用常规治疗,干预组在常规治疗的基础上给予临床药师干预。比较两组预防VTE疗效、延展性抗凝疗程完成率、不良事件发生率和用药依从性等。结果与对照组相比,临床药师干预可有效提高延展性抗凝疗程完成率(58.2%vs.79.1%),降低无症状深静脉血栓(DVT)发生率(11.0%vs.2.2%)及不良反应发生率(35.2%vs.12.1%),提高患者用药依从性(50.5%vs.69.2%)。结论抗凝药物管理是一个慢性长期的过程,本研究通过构建妇科肿瘤术后延展性抗凝用药模式,可以为临床药师找到临床工作新的切入点,为临床提供更为优质的药学服务。     

静脉血栓栓塞性疾病的抗凝与溶栓药物治疗进展

静脉血栓栓塞性疾病（venous thromboembolism，VTE）是比较常见的周围血管病变，主要临床类型包括下肢深静脉血栓形成（deep venous thrombosis，DVT）和肺血栓栓塞（pulmonary thromboembolism，PTE），后者约占肺栓塞（pulmonary embolism，PE）的90％以上^[1]。目前有效的治疗药物包括抗凝和溶栓药物，本文主要介绍目前临床常用的抗凝和溶栓药物以及这2类药物的新药研究方向与动态。     

妇科抗凝药物治疗深静脉血栓的合理性评价标准的构建与应用

目的探讨某三甲医院(以下简称"某院")妇科术后深静脉血栓形成患者抗凝药物应用的合理性评价,旨在为临床合理用药提供参考,同时探索一种妇产科临床药师深入临床开展药学服务的工作模式。方法回顾性分析2017年1月至2018年3月住院患者中有深静脉血栓形成诊断的19例患者的临床资料,统计患者基本情况、临床诊断、手术情况、常见危险因素、用药前后辅助检查情况以及用药情况,并通过用药合理性评价表来评价抗凝药物应用的合理性。结果根据合理性评价标准对19例病例进行评价,存在的不合理用药情况主要为药物选择不合理4例(21.05%)、用法用量不合理9例(47.37%)、监测指标不合理4例(21.05%)、用药疗程不合理13例(68.42%)、更换药物不合理5例(26.32%)。结论妇科抗凝药物的使用存在不合理现象,妇产科临床药师可以以此为切入点,通过开展知识宣教、用药建议、医嘱审核、处方点评等方式提高抗凝药物在临床的合理使用,也可通过对下肢深静脉血栓形成患者开展用药教育、定期随访等工作体现药师价值。     

肺癌患者静脉血栓栓塞症的危险因素分析及预防现状

目的：通过了解某院肺癌患者静脉血栓栓塞症（VTE）形成的相关危险因素和预防现状，以及抗凝药物的疗效分析和影响因素，以推动临床进行规范化的血栓预防。方法：收集该院2017年6月到2018年6月住院的肺癌患者的病历资料，回顾性分析与VTE相关的危险因素并进行评分，比较使用抗凝药物前后血细胞、凝血象以及肝肾功能的变化。采用SPSS 22.0软件进行数据处理。结果：患者的治疗方式、性别、吸烟史、饮酒史、病理分型、白细胞、中性粒细胞、血红蛋白与VTE的形成相关（P<0.05）。二元Logistic回归分析示：手术、有饮酒史、血红蛋白<100 g·L^-1是导致肺癌患者VTE的独立危险因素。部分患者在使用抗凝药物前后缺乏相应的检测指标。患者的饮酒史、病理分型、肝肾功能与抗凝药物的疗效有一定的相关性（P<0.05）。低分子肝素类抗凝药物的使用对患者的肝功能有一定的损害。结论：导致肺癌患者VTE的因素较多，临床对患者的凝血状态应提高重视。抗凝药物的使用应该更加规范，用药期间应监测患者肝功能。     

妇科肿瘤161例围手术期预防静脉血栓栓塞症的分析

目的：对妇科恶性肿瘤手术患者静脉血栓栓塞症（venous thromboembolism,VTE）的预防现状进行分析。方法：对2017年12月~2018年8月南京鼓楼医院收治的161例妇科恶性肿瘤手术患者的基本资料、VTE预防措施、抗凝药物使用情况等进行回顾性分析。结果：161例妇科恶性肿瘤手术患者的深静脉血栓发生率为1.9%;接受机械联合药物预防的患者有32例（19.9%）,接受机械预防的患者有129例（80.1%）。结论：静脉血栓栓塞症是妇产科围手术期严重的并发症,而合并恶性肿瘤者尤甚。围手术期对患者进行VTE风险评估、分级,采取措施预防是非常必要的,但是如何评估患者风险、如何采取预防措施仍待权威“指南”提供统一方案,以便参照落实。     

低分子肝素联合香丹注射液预防妇科恶性肿瘤腹腔镜手术后静脉血栓性疾病

目的探讨妇科恶性肿瘤腹腔镜手术后早期应用低分子肝素联合香丹注射液预防静脉血栓性疾病的临床疗效。方法采用前瞻性随机对照研究的方法,将2011年1月—2013年1月在解放军152医院住院期间106例妇科腹腔镜恶性肿瘤手术后患者随机分为2组,试验组(53例)和对照组(53例),试验组术后12 h常规采用低分子肝素2500 U,皮下注射及香丹注射液20 ml静脉滴注进行预防,对照组不采用预防性用药,比较两组患者静脉血栓性疾病的发生率及术后出血情况。结果所有患者均在腹腔镜下成功完成手术,无中转开腹患者。试验组和对照组患者术后静脉血栓性疾病的发生率分别为1.9%(1/53)和33.9%(20/53),两组比较,差异有统计学意义(P<0.05)。试验组和对照组患者术后出血发生率分别为3.8%(3/53)和1.9%(1/53),两者比较差异无统计学意义(P>0.05)。结论术后早期应用低分子肝素联合香丹注射液可明显降低妇科腹腔镜恶性肿瘤手术后患者静脉血栓性疾病的发生率,且安全有效,不会增加术后出血风险。     

低分子肝素联合参芎注射液治疗肿瘤静脉血栓栓塞分析

目的观察低分子肝素联合参芎注射液治疗肿瘤静脉血栓栓塞的临床疗效。方法选取2010-2011年我院收治的恶性肿瘤患者共24例,随机分为治疗组和对照组,每组12例。对照组仅予低分子肝素(速碧林)治疗,85 IU/kg皮下注射,治疗组在对照组的基础上给予参芎注射液200 mL静滴。两组患者的疗程均为15d。结果治疗组总有效率(100%)明显高于对照组(83.3%),两组比较差异有统计学意义(P<0.05)。两组患者在用药期间均未发生出血倾向及过敏反应。结论低分子肝素联合参芎注射液治疗肿瘤静脉血栓栓塞,效果显著,未见明显的不良反应。     

Use of heparin for the prevention of venous thromboembolism

The value of heparin in the prevention of venous thromboembolism has been shown effective and safe by controlled studies. However, how these studies have influenced physicians' decisions in thrombo-prophylaxis is not known. With the aim of evaluating the frequency and the appropriateness of prophylaxis for venous thromboembolism in our centre, we performed a cross-sectional study on a specific day. Among 667 patients who were admitted to hospital on this day, 134 (20 per cent) were receiving heparin. This had been prescribed for the prophylaxis of venous thromboembolism to 82 (12 per cent) patients. Immobilization was the risk factor most strongly associated with prophylaxis. Prophylaxis with heparin was only used in 79 out of 444 high-risk patients (21.6 per cent). One hundred and eighty-three patients had been subject to major surgery and heparin was being given only to 34 of them (18.6 per cent). A wide variability in the use of prophylaxis, depending on the hospital ward, was also recorded. We conclude that prophylaxis with heparin is underused in our milieu.     

Extended therapy for primary and secondary prevention of venous thromboembolism

Clinical practice guidelines currently suggest extended anticoagulation therapy for primary and secondary prevention of venous thromboembolism (VTE). The optimal duration of anticoagulation has been an active area of clinical investigation for patients undergoing orthopedic surgeries and those diagnosed with a first episode of unprovoked VTE. Practice guidelines, VTE incidence, clinical predictors/mediators, and clinical trial evidence is reviewed to help pharmacists and other health care providers make an informed, patient-specific decision on the optimal duration of anticoagulation therapy. Extended anticoagulation up to 5 weeks following orthopedic surgery for primary VTE prevention and indefinitely following a first episode of unprovoked VTE for secondary VTE prevention should be considered only if the risk of bleeding is not high and the cost and burden of anticoagulation is acceptable to the patient. The optimal duration of anticoagulation therapy for primary or secondary prevention of VTE should include the health care provider and patient making a decision based on evaluation of individual benefits, risks, and preferences.     

Fondaparinux versus enoxaparin for the prevention of venous thromboembolism

Venous thromboembolism is a frequent, life-threatening, postoperative complication of hip-fracture and total-knee-replacement surgery. Fondaparinux is a synthetic polysaccharide that selectively binds to antithrombin, the primary endogenous regulator of blood coagulation. Low molecular weight heparins, such as enoxaparin, are less specific inhibitors of coagulation. In patients undergoing hip-fracture surgery, fondaparinux is more effective than once-daily enoxaparin as prophylaxis for venous thromboembolism. Fondaparinux (25 mg/day sc.) was also more effective than enoxaparin (30 mg sc. b.i.d.) as prophylaxis for venous thromboembolism in elective knee surgery. These differences may be explained by the fact that there is less prophylaxis cover with enoxaparin, as it has a much shorter duration of action than fondaparinux. Thus, with the present dosing regimens, fondaparinux is probably preferable to enoxaparin for the prevention of venous thromboembolism.     

肺血栓栓塞症48例临床分析

目的 总结肺血栓栓塞症(PTE)的临床特点.方法 回顾性分析48例PTE患者的临床特点.结果 PTE患者常伴有深静脉血栓形成、创伤和(或)骨折、心血管疾病等危险因素;动脉血气分析、D-二聚体、心电图检查可提示PTE;超声心动图对PTE有诊断作用;螺旋CT肺动脉血管造影(CTPA)是确诊PTE的可靠方法.结论 PTE是心血管疾病中的常见病,对有症状的高危患者应及早行CTPA检查,以明确诊断.     

Fondaparinux versus enoxaparin for the prevention of venous thromboembolism

Venous thromboembolism is a frequent, life-threatening, postoperative complication of hip-fracture and total-knee-replacement surgery. Fondaparinux is a synthetic polysaccharide that selectively binds to antithrombin, the primary endogenous regulator of blood coagulation. Low molecular weight heparins, such as enoxaparin, are less specific inhibitors of coagulation. In patients undergoing hip-fracture surgery, fondaparinux is more effective than once-daily enoxaparin as prophylaxis for venous thromboembolism. Fondaparinux (25 mg/day s.c.) was also more effective than enoxaparin (30 mg s.c. b.i.d.) as prophylaxis for venous thromboembolism in elective knee surgery. These differences may be explained by the fact that there is less prophylaxis cover with enoxaparin, as it has a much shorter duration of action than fondaparinux. Thus, with the present dosing regimens, fondaparinux is probably preferable to enoxaparin for the prevention of venous thromboembolism.     

Economic evaluation of enoxaparin for the prevention of venous thromboembolism in acutely ill medical patients

OBJECTIVE: To conduct an economic evaluation of the prevention of venous thromboembolism in acutely ill medical patients. METHOD: We used a previously described economic model created in the context of the UK National Health Service and applied it to St. Thomas' Hospital, London. A clinical review to determine the number of medical admissions that would require thromboprophylaxis at St. Thomas' Hospital, based on the inclusion criteria of a medical thromboprophylaxis trial (MEDENOX), was conducted. Costs and effectiveness were determined, based on the provision of thromboprophylaxis to 2000 medical patients. RESULTS: Comparing treatment with low-molecular-weight heparin (enoxaparin, 40 mg once daily), unfractionated heparin (5000 IU twice daily), or no prophylaxis, the highest cost of thromboprophylaxis was associated with unfractionated heparin (199,000 pounds sterling = 4306,000 Euros), compared with enoxaparin (198,000 pounds sterling = 305,000 Euros) or no prophylaxis (176,000 pounds sterling = 271,000 Euros). The model suggested that enoxaparin thromboprophylaxis would result in fewer thromboembolic-related events. Using sensitivity analysis, incorporating certain St. Thomas'-specific costs showed enoxaparin compared with unfractionated heparin or no thromboprophylaxis was cost saving. The cost savings of 65,000 pounds sterling ( = 100,000 Euros) and 31,000 pounds sterling ( = 48,000 Euros) respectively are based on maximum uptake of thromboprophylaxis. CONCLUSIONS: The graded implementation of enoxaparin thromboprophylaxis over a four-year period would require funding redistribution. The funding Health Authority would save overall but St. Thomas' would require an increase in drug expenditure across the clinical directorates of 35,000 pounds sterling ( = 54,000 Euros) after 4 years.     

Treating patients with cancer and acute venous thromboembolism

Introduction: Cancer and venous thromboembolism (VTE) are closely related, with a high risk of VTE associated with cancer and a strong impact of VTE on cancer prognosis. The management and treatment of cancer-associated VTE are particularly challenging and, in many cases, are not guided by a high level of evidence.

Areas covered: In this review, we present the best therapeutic approach to acute deep vein thrombosis (DVT) and pulmonary embolism (PE) and to some controversial issues, such as home treatment, optimal duration of anticoagulation, management of VTE recurrence during anticoagulant treatment, and of unsuspected PE. Then, the available evidence on other cancer-related VTE manifestations is presented, such as catheter-related thrombosis and splanchnic vein thrombosis.

Expert opinion: While solid evidence exists on the advantage of low molecular weight heparin (LMWH) over vitamin K antagonists (VKAs) during the first 3 to 6 months after acute DVT and/or PE, several issues have not been sufficiently investigated yet. These include the role of LMWH beyond the first 3 to 6 months, whether it is still more effective than VKA and if its intensity could be safely reduced, the strategies to identifying accurate predictors of VTE recurrence and the role of direct oral anticoagulants.     

基于Caprini血栓风险评估模型对妇科恶性肿瘤相关静脉血栓形成的风险预测

目的 探究Caprini血栓风险评估模型以及新建立的模型对妇科恶性肿瘤相关静脉血栓(VTE)形成的风险预测价值。方法 选取2015年1月—2020年6月湖南省肿瘤医院妇科恶性肿瘤并发VTE的患者161例,依据1∶2的比例抽取同期322例妇科恶性肿瘤患者为对照组。收集两组患者的临床资料,分析影响妇科恶性肿瘤相关VTE发生的危险因素,构建新的Caprini血栓风险评估模型,绘制受试者工作特征(ROC)曲线,与原Caprini血栓风险评估模型进行比较。结果 对照组患者的Caprini评分低于VTE组(P<0.001)。两组患者年龄、肿瘤分期、高血压、高脂血症、糖尿病、输血史、绝经状态、化疗、血小板计数和D-2聚体水平比较,差异具有统计学意义(P<0.05)。多因素Logistic回归分析显示,合并高血压、高脂血症、糖尿病、有输血史、绝经、化疗、血小板计数≥300×109L^-1和D-2聚体≥0.55μm·mL^-1均为妇科恶性肿瘤患者发生VTE的独立危险因素(P<0.05)。与Caprini血栓风险评估模型相比较,新构建的Caprin...