Optimal Duration of Low Molecular Weight Heparin for the Treatment of Cancer-Related Deep Vein Thrombosis: The Cancer-DACUS Study.


PURPOSE: We evaluated the role of residual vein thrombosis (RVT) to assess the optimal duration of anticoagulants in patients with cancer who have deep vein thrombosis (DVT) of the lower limbs.
PATIENTS AND METHODS: Patients with active cancer and a first episode of DVT treated with low molecular weight heparin (LMWH) for 6 months were eligible. Patients were managed according to RVT findings: those with RVT were randomly assigned to continue LMWH for an additional 6 months (group A1) or to discontinue it (group A2), and patients without RVT stopped LMWH (group B). The primary end point was recurrent venous thromboembolism (VTE) during the 1 year after disconinuation of LMWH, and the secondary end point was major bleeding. Analyses are from the time of random assignment.
RESULTS: Between October 2005 and April 2010, 347 patients were enrolled. RVT was detected in 242 patients (69.7%); recurrence occurred in 22 of the 119 patients in group A1compared with 27 of 123 patients in group A2. The adjusted hazard ratio (HR) for group A2 versus A1 was 1.37 (95% CI, 0.7 to 2.5; P = .311). Three of the 105 patients in group B developed recurrent VTE; adjusted HR for group A1 versus B was 6.0 (95% CI, 1.7 to 21.2; P = .005). Three major bleeding events occurred in group A1, and two events each occurred in groups A2 and B. The HR for major bleeding in group A1 versus group A2 was 3.78 (95% CI, 0.77 to 18.58; P = .102). Overall, 42 patients (12.1%) died during follow-up as a result of cancer progression.
CONCLUSION: In patients with cancer with a first DVT, treated for 6 months with LMWH, absence of RVT identifies a population at low risk for recurrent thrombotic events. Continuation of LMWH in patients with RVT up to 1 year did not reduce recurrent VTE.

Advertisements

What Everyone Should Know About Blood Clots .


Just like a traffic jam on the highway, blood clots impede normal circulation in your body and can be dangerous. Here are some blood clot basics and information on steps you can take to help avoid the problem.

Signs of a serious blood clot

Thrombosis is a medical term for blood clot. Deep vein thrombosis (DVT) occurs in one of the large veins, usually in your legs. DVT can cause pain and swelling in the area where blood clots form. The area might also be reddened and feel warm to the touch.

The most common complication from DVT is pulmonary embolism (blockage), which occurs when a clot or part of a clot breaks off and lodges in the lungs. Symptoms of pulmonary embolism include shortness of breath and sudden pain in the chest that gets worse when you breathe deeply.

Risk factors and ways to avoid DVT

Anybody can get DVT, but surgery or injury increases your risk, as does increasing age and weight gain. Some people have clotting disorders that increase their risk for DVT.

Ways to avoid DVT include:

Quitting smoking, maintaining a healthy weight and exercising regularly.
If you are hospitalized, ask your healthcare providers about available DVT prevention, such as mechanical devices to aid circulation.
If you are on a long flight, or if you sit for hours, wear compression stockings and get up and move around or perform stretching exercises.
“As many as 60 percent of all people who suffer an episode of deep vein thrombosis will also develop post-thrombotic syndrome,” says vascular medicine specialist Natalie Evans, MD.

This syndrome can cause long-term pain, swelling and even ulcers.

Blood thinners and what not to eat

Physicians prescribe blood thinners to some DVT patients to prevent future clotting. Warfarin or Coumadin is a type of blood thinner that has been used for decades, but frequent blood tests are needed to monitor dosage.

Dr. Evans adds, “Patients should talk with their doctor or pharmacist…to learn about potential interactions with foods and drugs.”

The Vitamin K found in greens and other foods can interfere with Coumadin’s effects. There’s a long list of foods that you should eat only in moderation while you are on the drug.

Cranberries and cranberry products like cranberry juice can intensify Coumadin’s effect, so it’s best to avoid them while you are on the drug.

Pros and cons of new medications

Newer blood-thinner medications, including rivaroxaban (Xarelto), apixaban (Eliquis) and dabigatran (Pradaxa), can be used for DVT prevention and do not require frequent blood tests, making them more convenient.

These new-generation blood thinners also may have fewer negative interactions with foods and other drugs. However, they are also more expensive than warfarin, and a specific antidote, in cases of bleeding, is not available. Patients should talk to their physician about the risks and benefits of taking these medications.

Beware of high impact sports

If you’re taking blood thinners, participating in high-impact sports can lead to potentially dangerous bleeding. Dr. Evans says that during exercise, “people who’ve had DVT and PE in the past need to be aware of the symptoms of recurrent clots, that is, leg pain and swelling, shortness of breath, chest pain that’s worse with deep breathing.”

While you are on blood thinners, there’s always a danger from cuts or bruising, even in going about your everyday activities like shaving or gardening.

Keep a medical card in your wallet that says you are on blood thinners, and never take any prescription or non-prescription medications without talking with your doctor first.

 

Thrombolysis for acute deep vein thrombosis.


Standard treatment for deep vein thrombosis aims to reduce immediate complications. Use of thrombolysis or clot dissolving drugs could reduce the long-term complications of post-thrombotic syndrome (PTS) (pain, swelling, skin discolouration, or venous ulceration) in the affected leg. This is the second update of a review first published in 2004.
OBJECTIVES: To assess the effects of thrombolytic therapy and anticoagulation versus anticoagulation in the management of people with acute deep vein thrombosis (DVT) of the lower limb as determined by the effects on pulmonary embolism, recurrent venous thromboembolism, major bleeding, post-thrombotic complications, venous patency and venous function. SEARCH
METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2013) and CENTRAL (2013, Issue 4).
SELECTION CRITERIA: Randomised controlled trials (RCTs) examining thrombolysis and anticoagulation versus anticoagulation for acute DVT were considered.
DATA COLLECTION AND ANALYSIS: In the previous review of 2010, one review author (LW) selected trials, extracted data and assessed study quality, with checking at all stages by the other review author (MPA). If necessary, we sought additional information from trialists. For this update (2013), LW and CB selected trials, extracted data independently, and sought advice from MPA where necessary. All studies, existing and new, required full risk of bias assessment in line with current Cochrane procedures. Two of LW, CB and MA independently assessed risk of bias with discussion with the third author where necessary.
MAIN RESULTS: Seventeen studies with 1103 participants were included. Complete clot lysis occurred significantly more often in the treatment group in early follow up (risk ratio (RR) 4.91; 95% confidence interval (CI) 1.66 to 14.53, P = 0.004) and at intermediate follow up (RR 2.37; 95% CI 1.48 to 3.80, P = 0.0004). A similar effect was seen for any degree of improvement in venous patency. Significantly less PTS occurred in those receiving thrombolysis, (RR 0.64; 95% CI 0.52 to 0.79, P < 0.0001). Leg ulceration was reduced although the data were limited by small numbers (RR 0.48; 95% CI 0.12 to 1.88, P = 0.29). Those receiving thrombolysis had significantly more bleeding complications (RR 2.23; 95% CI 1.41 to 3.52, P = 0.0006). Three strokes occurred in the treatment group, all in trials conducted pre-1990, and none in the control group. There was no significant effect on mortality detected at either early or intermediate follow up. Data on the occurrence of pulmonary embolism (PE) and recurrent DVT were inconclusive. Systemic thrombolysis is now not commonly used and catheter-directed thrombolysis (CDT) is the more favoured means of administration. This has been studied in iliofemoral DVT, and results from two trials are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion.
AUTHORS’ CONCLUSIONS: Thrombolysis increases the patency of veins and reduces the incidence of PTS following proximal DVT by a third. Strict eligibility criteria are necessary to reduce the risk of bleeding complications and this limits the applicability of this treatment. In those who are treated there is a small increased risk of bleeding. In recent years CDT is the most studied route of administration, and results appear to be similar to systemic administration.

Oral Apixaban for the Treatment of Acute Venous Thromboembolism.


BACKGROUND

Apixaban, an oral factor Xa inhibitor administered in fixed doses, may simplify the treatment of venous thromboembolism.

METHODS

In this randomized, double-blind study, we compared apixaban (at a dose of 10 mg twice daily for 7 days, followed by 5 mg twice daily for 6 months) with conventional therapy (subcutaneous enoxaparin, followed by warfarin) in 5395 patients with acute venous thromboembolism. The primary efficacy outcome was recurrent symptomatic venous thromboembolism or death related to venous thromboembolism. The principal safety outcomes were major bleeding alone and major bleeding plus clinically relevant nonmajor bleeding.

RESULTS

The primary efficacy outcome occurred in 59 of 2609 patients (2.3%) in the apixaban group, as compared with 71 of 2635 (2.7%) in the conventional-therapy group (relative risk, 0.84; 95% confidence interval [CI], 0.60 to 1.18; difference in risk [apixaban minus conventional therapy], −0.4 percentage points; 95% CI, −1.3 to 0.4). Apixaban was noninferior to conventional therapy (P<0.001) for predefined upper limits of the 95% confidence intervals for both relative risk (<1.80) and difference in risk (<3.5 percentage points). Major bleeding occurred in 0.6% of patients who received apixaban and in 1.8% of those who received conventional therapy (relative risk, 0.31; 95% CI, 0.17 to 0.55; P<0.001 for superiority). The composite outcome of major bleeding and clinically relevant nonmajor bleeding occurred in 4.3% of the patients in the apixaban group, as compared with 9.7% of those in the conventional-therapy group (relative risk, 0.44; 95% CI, 0.36 to 0.55; P<0.001). Rates of other adverse events were similar in the two groups.

CONCLUSIONS

A fixed-dose regimen of apixaban alone was noninferior to conventional therapy for the treatment of acute venous thromboembolism and was associated with significantly less bleeding

Source: NEJM

For Acute Venous Thromboembolism, Apixaban Compares Favorably with Conventional Treatment.


Apixaban was as effective as enoxaparin plus warfarin and produced fewer bleeding complications.
Apixaban (Eliquis), a factor Xa inhibitor, is one of several new oral anticoagulation drugs that require no monitoring. In this industry-sponsored, placebo-controlled trial, 5400 patients with acute venous thromboembolism (VTE) received 6-month courses of either apixaban (given twice daily) or conventional treatment with enoxaparin followed by warfarin. The qualifying diagnosis was deep venous thrombosis (DVT) in 65% of patients and pulmonary embolism (with or without DVT) in 35%.

Apixaban was noninferior to conventional therapy at 6 months: The primary efficacy outcome (recurrent symptomatic or fatal VTE) occurred in 2.3% of apixaban recipients and in 2.7% of conventional-therapy recipients. Rates of major bleeding were significantly lower in the apixaban group than in the conventional-therapy group (0.6% vs. 1.8%).

COMMENT

In this study, oral therapy with apixaban was as effective as — and possibly safer than — enoxaparin plus warfarin for patients with acute venous thromboembolism. In another recent trial, apixaban lowered the incidence of recurrent VTE (compared with placebo) in patients who already had completed initial 6- to 12-month course of conventional anticoagulation (NEJM JW Gen Med Jan 3 2013). However, apixaban currently is FDA-approved only for stroke prevention in patients with atrial fibrillation; the only new drug that is FDA-approved for fully oral treatment of acute VTE is another factor Xa inhibitor, rivaroxaban (Xarelto).

Source: NEJM

Oral Apixaban for the Treatment of Acute Venous Thromboembolism.


BACKGROUND

Apixaban, an oral factor Xa inhibitor administered in fixed doses, may simplify the treatment of venous thromboembolism.

METHODS

In this randomized, double-blind study, we compared apixaban (at a dose of 10 mg twice daily for 7 days, followed by 5 mg twice daily for 6 months) with conventional therapy (subcutaneous enoxaparin, followed by warfarin) in 5395 patients with acute venous thromboembolism. The primary efficacy outcome was recurrent symptomatic venous thromboembolism or death related to venous thromboembolism. The principal safety outcomes were major bleeding alone and major bleeding plus clinically relevant nonmajor bleeding.

RESULTS

The primary efficacy outcome occurred in 59 of 2609 patients (2.3%) in the apixaban group, as compared with 71 of 2635 (2.7%) in the conventional-therapy group (relative risk, 0.84; 95% confidence interval [CI], 0.60 to 1.18; difference in risk [apixaban minus conventional therapy], −0.4 percentage points; 95% CI, −1.3 to 0.4). Apixaban was noninferior to conventional therapy (P<0.001) for predefined upper limits of the 95% confidence intervals for both relative risk (<1.80) and difference in risk (<3.5 percentage points). Major bleeding occurred in 0.6% of patients who received apixaban and in 1.8% of those who received conventional therapy (relative risk, 0.31; 95% CI, 0.17 to 0.55; P<0.001 for superiority). The composite outcome of major bleeding and clinically relevant nonmajor bleeding occurred in 4.3% of the patients in the apixaban group, as compared with 9.7% of those in the conventional-therapy group (relative risk, 0.44; 95% CI, 0.36 to 0.55; P<0.001). Rates of other adverse events were similar in the two groups.

.

CONCLUSIONS

A fixed-dose regimen of apixaban alone was noninferior to conventional therapy for the treatment of acute venous thromboembolism and was associated with significantly less bleeding

Source: NEJM

 

 

 

 

AMPLIFY: Apixaban in Acute VTE as Effective But Safer Than Standard Anticoagulation.


The oral factor Xa inhibitorapixaban (Eliquis, Pfizer/Bristol-Myers Squibb) was as effective as standard enoxaparin plus warfarin in treating acute venous thromboembolism (VTE) in a large randomized trial, one in which treatment with apixaban also led to a 69% drop in risk of major bleeding complications[1].

“The efficacy of apixaban in the patients with pulmonary embolism was similar to that in patients with deep vein thrombosis [DVT], and the relative effect was maintained in the approximately 40% of patients who presented with extensive disease,” write Dr Giancarlo Agnelli (University of Perugia, Italy) and associates, in the New England Journal of Medicine.

Their report on the Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-Line Therapy (AMPLIFY) trial, conducted at 358 centers in 28 countries, was slated for publication July 1, 2013 in conjunction with the study’s scheduled presentation here at the 2013 Congress of the International Society on Thrombosis and Haemostasis. The New England Journal of Medicine lifted its embargo on AMPLIFY coverage on June 30, following, it said, an embargo break by Reuters

“After 60 years of warfarin, it is an exciting time in thrombosis care,” writes Dr Mary Cushman(University of Vermont, Burlington) in an accompanying editorial [2]. However, “shifting with care to new treatments is essential to safe and effective practice.” She cautions that “new anticoagulants are not for every patient” and notes developments that have helped make warfarin management less burdensome, including the advent of prothrombin-time self-testing, anticoagulation clinics, and reduced monitoring frequency for some patients.

Also, she notes, a lot remains to be learned about the new oral agents, apixaban along with dabigatran(Pradaxa, Boehringer Ingelheim) and rivaroxaban (Xarelto, Bayer/Johnson & Johnson), including reversal strategies, monitoring (eg, in the presence of interacting drugs, extremes of patient weight, or bleeding or thrombosis complications), [and] approaches to treatment failure.”

The trial randomized 5395 patients with acute, symptomatic proximal VTE and/or pulmonary embolism (PE) to receive, with double blinding, either apixaban (n=2691) or subcutaneous enoxaparin followed by warfarin (n=2704). The factor Xa inhibitor was given as 10 mg twice daily for seven days followed by 5 mg twice daily for six months; enoxaparin was given for at least five days (median 6.5 days), with warfarin continued for six months.

The primary efficacy outcome was seen in 2.3% of patients taking apixaban and 2.7% of those on conventional therapy, which handily met the prespecified criteria for apixaban noninferiority (p<0.001). The results were nearly identical in each of the two VTE subgroups: those who entered with DVT and those who had PE.

Major bleeding occurred in 0.6% of the apixaban and 1.8% of the conventional-therapy groups, for a 69% drop in relative risk with the factor Xa inhibitor (p<0.001 for superiority). The composite of major bleeding or clinically relevant nonmajor bleeding fell by 56% (p<0.001 for superiority). VTE recurred within 30 days in 0.2% and 0.3%, respectively.

Relative Risk (95% CI) for Outcomes Apixaban vs Conventional Therapy

End points RR (95% CI)
First recurrent VTE or VTE-related death* 0.84 (0.60–1.18)
Major bleeding 0.31 (0.17–0.55)
Major or clinically relevant nonmajor bleeding 0.44 (0.36–0.55)
Death during treatment period 0.79 (0.53–1.19)
VTE or CV death 0.80 (0.57–1.11)
VTE, VTE-related death, or major bleeding 0.62 (0.47–0.83)

*Primary efficacy outcome

“The efficacy and safety of apixaban were consistent across a broad range of subgroups, including those based on clinically important features such as an age of more than 75 years, a body weight of more than 100 kg, use of parenteral anticoagulant treatment before randomization, and the duration of such treatment,” suggesting that the findings are likely generalizable across a broad spectrum of patients, according to the group. The findings at participating centers where warfarin-treated patients were more often maintained in a therapeutic INR range were also consistent with trial’s overall results, they write.

“On the basis of the results of this trial, together with those of the [AMPLIFY-EXT] trial, apixaban provided a simple, effective, and safe regimen for the initial and long-term treatment of venous thromboembolism.”

In AMPLIFY-EXT, as heartwire reported late last year, the risk of recurrent VTE or death was significantly reduced among patients who completed a full six-month course of anticoagulation for VTE and then stayed on apixaban another six to 12 months, so-called extended therapy for VTE, compared with anticoagulated patients who were then given placebo.

The trial was funded by Pfizer and Bristol-Myers Squibb. Agnelli discloses receiving personal fees from Pfizer in relation to the conduct of the trial, and other personal fees from Boehringer Ingelheim, Sanofi, Daiichi-Sankyo, and Bayer Healthcare. Disclosures for the coauthors are listed on the journal’s website. Cushman had no disclosures.

http://www.medscape.com

 

ti�ue�&� �t� effects. If you’re taking a supplement, it’s a good idea to check the FDA website periodically for updates.

 

Source: Mayo clinic

 

 

white�pn�t� X1� font-size:9.0pt;font-family:”Arial”,”sans-serif”;color:#666666′>And, I’ll tell you right now, after this last year, leaving Waiheke Island, going to Hawaii (as detailed in Going Out On A Limb), well… I feel freer, happier, more peaceful and more my true self than I ever have in 35 years and I categorically COULD NOT have done it if I had not reached out for support.

 

So, I implore you, if you are someone who is afraid to reach out for support, please… for the love of all things… swallow your fears, your negative self-talk, your pride or whatever is keeping you stuck and please, please put your freaking hand up! The Universe will deliver what you need if you will only step up to help yourself. People will materialise to support you. Information will find its way to you when you move forward to open your arms to receive it. You will find help in the most unlikely of places if you are willing to step outside your comfort zone. Do not judge how things may have gone before… perhaps once before you reached out and you didn’t get the response and support you needed. The past is gone and it has no bearing now. Life is short, don’t waste one second of it when the support you need lies all around you, beckoning you to call upon it.

 

Normalization of Vital Signs Does Not Reduce Risk for Acute Pulmonary Embolism.


Up to one third of patients whose abnormal triage vital signs reverted to normal values had PE.

In a prospective single-center study, researchers evaluated whether normalization of vital signs in patients who present with symptoms of pulmonary embolism (PE) reduces the probability of the disease. Patients at an urban academic emergency department (ED) in North Carolina were enrolled if they were older than 17 years and had at least one predefined sign or symptom and one risk factor for PE.

Of 192 patients, 35 (18%) were diagnosed with PE by computed tomography in the ED. In patients whose abnormal triage vital signs normalized at any time during their ED visit, incidence of PE was not lower than for patients whose vital signs did not normalize. The incidence of PE for patients with abnormal pulse rate, respiratory rate, shock index, or pulse oximetry at triage that subsequently normalized was 18%, 14%, 19%, and 33%, respectively.

Comment: Just as a normal blood gas value does not rule out acute pulmonary embolism, this study shows that normalization of initially abnormal vital signs also does not reduce the likelihood of PE. The best approach for patients presenting with signs and symptoms of PE is to note abnormal vital signs occurring at any time after symptom onset and use these vital sign numbers in the determination of pretest probability of PE, even if they subsequently normalized.

Source:Journal Watch Emergency Medicine

 

Extended Treatment After Unprovoked Venous Thromboembolism.


Apixaban, which is not yet FDA-approved for VTE, lowered recurrence by about 7 percentage points during 1 year.

In patients who have completed courses of initial anticoagulation for unprovoked venous thromboembolism (VTE), extended treatment with warfarin, the oral factor Xa inhibitor rivaroxaban (Xarelto), or (to a lesser extent) aspirin can lower the rate of recurrence. How does apixaban (Eliquis), another oral factor Xa inhibitor, fare in this regard? In an industry-sponsored randomized trial, 2500 patients who had just completed 6 to 12 months of standard anticoagulation for deep venous thrombosis or pulmonary embolism received twice-daily doses of 5-mg apixaban, 2.5-mg apixaban, or placebo. The qualifying VTE events were unprovoked in 92% of cases.

During 1 year of treatment, the incidence of symptomatic or fatal recurrent VTE was 9% in the placebo group and 2% in both apixaban groups — a significant difference. For several composite endpoints that also included all-cause mortality or arterial thrombotic events, apixaban consistently conferred a 7- to 8-percentage-point advantage over placebo. Rates of major bleeding were lower than 1% in all three groups.

Comment: Apixaban recently was FDA-approved for patients with atrial fibrillation. If it is approved eventually for extended treatment following VTE, it will become another option for patients with this condition. However, several caveats apply: This study lasted for only 12 months, most participants were relatively young (mean age, 57), most had normal renal function, and the drug will be expensive. Studies in which apixaban and alternative therapies are compared directly, and additional data on safety and efficacy in older and sicker patients, would

be valuable.

Source: Journal Watch General Medicine

Preventing Thrombosis During Chemotherapy.


Prophylactic anticoagulation with the low-molecular-weight heparin semuloparin reduced the incidence of thromboembolic events without increasing the risk for major bleeding.

Venous thromboembolism (VTE) often complicates cancer and is related to patient performance status, tumor stage, and treatment. Many chemotherapeutic agents increase the risk for VTE, even in ambulatory outpatients. However, whether prophylactic anticoagulation diminishes VTE risk during chemotherapy is unclear.

To address this issue, an international team of investigators conducted an industry-supported, randomized, double-blind, placebo-controlled trial involving 3212 patients who were beginning to receive chemotherapy for cancers typically associated with an increased risk for VTE; 36% of patients had lung cancer, and 28.9% had colorectal cancer. Most tumors (66%) were metastatic; the remaining tumors were locally advanced. Patients with adequate renal function (creatinine clearance >30 mL/minute) received either the hemisynthetic low-molecular-weight heparin (LMWH) semuloparin (20 mg/day subcutaneously) or placebo for a median 3.5 months.

The primary outcome — any symptomatic deep venous thrombosis (DVT), nonfatal pulmonary embolism (PE), or death related to VTE — occurred in fewer semuloparin recipients than placebo recipients (1.2% vs. 3.4%; hazard ratio, 0.36; P<0.001). Semuloparin was also associated with significantly lower risk for DVT (odds ratio, 0.32; 95% confidence interval, 0.15–0.62) and PE (OR, 0.41; 95% CI, 0.19–0.85). However, overall survival was similar in both groups. Rates of major bleeding and nonmajor clinically relevant bleeding were low (about 2%), and other adverse events were also similar in both groups.

Comment: The decision to administer anticoagulant prophylaxis to patients receiving chemotherapy is informed by several factors: the nature of the chemotherapy, patient characteristics, tumor type and stage, and the safety and efficacy of available antithrombotic agents. This trial demonstrates that in carefully selected patients with high-risk tumors, LMWH — which is simple to administer without monitoring — safely reduced the incidence of VTE when given concomitantly with chemotherapy.

Source: Journal Watch Oncology and Hematology