Become familiar with the treatment of VTE and the management of anticoagulation
CHEST’s most recent publication, the 10th edition of the Antithrombotic Guideline, contains updated recommendations on 12 topics that were in the 9th edition and addresses 3 new topics.1.2 These new guidelines also contain 4 new guidance statements that did not appear in the ninth edition (2012) or the first update (2016), and 8 statements have been significantly changed in recent years due to new evidence.1-3
Presentation of the VTE
VTE is a common condition in which a blood clot forms in a vein, dislodges, and then travels through the blood.4.5 It is the third vascular diagnosis after heart attack and stroke, affecting more than 900,000 Americans each year, and is associated with considerable morbidity and mortality.6 There are 2 types.4.6.7
Deep vein thrombosis (DVT) is the result of the formation of a thrombus in a deep vein, most often in the lower extremities. Pulmonary embolism (PE) occurs when a thrombus dislodges from a vein and travels to the heart and then to a lung, completely or partially obstructing the pulmonary artery or its branches.
The most common triggers for VTE are cancer, hip or leg fracture, hospitalization, immobilization, and surgery. In women, pregnancy and the use of hormones such as estrogen or birth control pills for menopausal symptoms may also play a role.4.7
Some groups have a higher risk of clotting, including people over 40, with the risk doubling with each subsequent decade; people with antiphospholipid antibody syndrome, cancer, polycythemia vera or autoimmune disorders such as lupus; and those who are obese or overweight.7 The genetic causes of excessive blood clotting are also important. Hereditary traits such as a deficiency in antithrombin, factor V Leiden, or protein C or S may contribute to a state of hypercoagulability.7
The basic treatment for VTE is anticoagulation, provided there is no contraindication. After the initial anticoagulation, patients with DVT or PE typically continue anticoagulation for a period of time to prevent embolism, future recurrence, and death from thrombosis.5.6
In the CHEST guidelines, treatment recommendations are categorized as strong (grade 1) and low (grade 2) depending on the level of high quality (grade A), medium quality (grade B) or low quality (grade B). C) proof.
The 13 strong recommendations of the 10th edition are as follows:
- In patients with acute DVT of the leg, the guidelines advise against the use of an inferior vena cava (IVC) filter in addition to anticoagulants.
- In patients with acute distal DVT isolated from the leg treated with anticoagulation, it is recommended to use the same anticoagulant regimen as for patients with acute proximal DVT.
- In patients with cerebral venous sinus thrombosis, it is recommended to use anticoagulant therapy for at least the treatment phase (the first 3 months) rather than no anticoagulant therapy.
- In patients with thrombosis and antiphospholipid syndrome treated with anticoagulant therapy, dose-adjusted vitamin K antagonists are recommended over direct oral anticoagulant therapy.
Recommendations which are unchanged but now supported by better evidence include discouraging the use of the IVC filter in anticoagulated patients, discouraging thrombolytic therapy in patients with PE who are not hypotensive or are not worsening under anticoagulation, and the encouragement of indefinite anticoagulant therapy after a first unprovoked PE.2.3
New evidence has also led to several changes, including the use of newer oral anticoagulants (NOACs). NOACs are recommended over vitamin K antagonists (VKA) for the treatment of VTE in patients without cancer. Low molecular weight heparin remains the preferred long-term treatment for cancer and VTE, but it is no longer suggested to use VKA rather than NOAC in these patients.2.3
Clinicians often ask which NOAC is preferred, and these guidelines indicate that individual patients may favor the selection of one NOAC over another in cancer-free or cancer patients or may favor the selection of a NOAC or of a VKA in cancer patients. The guidelines did not express an overall preference for one NOAC over another or for NOAC or VKA in cancer patients, as indirect comparisons did not show convincingly varying results with different NOACs. . NOACs have not been compared to VKA in a wide range of patients with VTE and cancer, and there are no direct comparison trials of different NOACs.2.3.8
Another notable change in the 10th edition is that, based on a new low risk of bias study, graduated compression stockings are not routinely used to prevent post-thrombotic syndrome.3
Treatment of VTE and management of anticoagulation are common in clinical practice. Pharmacists should be aware of the recommendations and evidence for therapy and be aware of the most recent evidence related to the management of VTE. While there is still uncertainty related to the limited disease and particular patient populations, the most recent recommendations serve as a guide for treatment.
Joanna Lewis, PharmD, MBA, is the 340B Compliance Coordinator at Baptist Health in Jacksonville, Florida.
1. CHEST publishes new guidelines for the antithrombotic treatment of VTE. Press release. American College of Thoracic Physicians. August 3, 2021. Accessed August 13, 2021. https://www.chestnet.org/Newsroom/Press-Releases/2021/08/CHEST-releases-new-guidelines-for-antithrombotic-therapy-for-VTE-disease
2. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016; 149 (2): 315-352. doi: 10.1016 / j.chest.2015.11.02
3. Stevens SM, Woller SC, Baumann Kreuzinger L, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert group report – summary. Chest. Published online July 31, 2021. doi: 10.1016 / j.chest.2021.07.056
4. Data and statistics on venous thromboembolism. CDC. Updated February 7, 2020. Updated February 7, 2020. Accessed August 23, 2021. https://www.cdc.gov/ncbddd/dvt/data.html
5. Kearon C. Natural history of venous thromboembolism. Circulation. 2003; 107 (suppl 1): I22-130. doi: 10.1161 / 01.CIR.0000078464.82671.78
6. Philippe HM. Presentation of venous thromboembolism. Am J Manag Care. 2017; 23 (suppl 20): S376-S382.
7. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003; 107 (suppl 1): I9-I16. doi: 10.1161 / 01.CIR.0000078469.07362.E6
8. Schulman S, Kearon C, Kakkar AK, et al; Investigators of the RE-MEDY trial; Investigators of the RE-SONATE trial. Prolonged use of dabigatran, warfarin or placebo in venous thromboembolism. N Engl J Med. 2013; 368 (8): 709-718. doi: 10.1056 / NEJMoa1113697