-
BMJ Clinical Evidence Mar 2011Deep venous thrombosis (DVT) or pulmonary embolism may occur in almost 2 in 1000 people each year, with up to 25% of those having a recurrence. Around 5% to 15% of... (Review)
Review
INTRODUCTION
Deep venous thrombosis (DVT) or pulmonary embolism may occur in almost 2 in 1000 people each year, with up to 25% of those having a recurrence. Around 5% to 15% of people with untreated DVT may die from pulmonary embolism. Risk factors for DVT include immobility, surgery (particularly orthopaedic), malignancy, pregnancy, older age, and inherited or acquired prothrombotic clotting disorders.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for proximal DVT? What are the effects of treatments for isolated calf DVT? What are the effects of treatments for pulmonary embolism? What are the effects of interventions on oral anticoagulation management in people with thromboembolism? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 45 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: anticoagulation; compression stockings; low molecular weight heparin (short and long term, once or twice daily, and home treatment); oral anticoagulants (short and long term, high intensity, abrupt discontinuation, and computerised decision support); prolonged duration of anticoagulation; thrombolysis; vena cava filters; and warfarin.
Topics: Administration, Oral; Animals; Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Pulmonary Embolism; Thromboembolism; Venous Thrombosis; Warfarin
PubMed: 21385473
DOI: No ID Found -
Human Reproduction Update 2013BACKGROUND Poor fertility outcomes in women with recurrent implantation failure (≥ RIF) present significant challenges in assisted reproduction, and various adjuncts,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND Poor fertility outcomes in women with recurrent implantation failure (≥ RIF) present significant challenges in assisted reproduction, and various adjuncts, including heparin, are used for potential improvement in pregnancy rates. We performed this systematic review and meta-analysis to evaluate the effect of low-molecular-weight heparin (LMWH) on live birth rates (LBRs) and implantation rates (IRs) in women with RIF and undergoing IVF. METHODS Studies comparing LMWH versus control/placebo in women with RIF were searched for on MEDLINE, EMBASE, Cochrane Library, conference proceedings and databases for registered and ongoing trials (1980-2012). Statistical analysis was performed using Review Manager 5.1. The main outcome measure was LBR per woman. RESULTS Two randomized controlled trials (RCTs) and one quasi-randomized trial met the inclusion criteria. One study included women with at least one thrombophilia ( Qublan et al., 2008) and two studies included women with unexplained RIF ( Urman et al., 2009; Berker et al., 2011). Pooled risk ratios in women with ≥ 3 RIF (N = 245) showed a significant improvement in the LBR (risk ratio (RR) = 1.79, 95% confidence interval (CI) = 1.10-2.90, P = 0.02) and a reduction in the miscarriage rate (RR = 0.22, 95% CI = 0.06-0.78, P = 0.02) with LMWH compared with controls. The IR for ≥ 3 RIF (N = 674) showed a non-significant trend toward improvement (RR = 1.73, 95% CI 0.98-3.03, P = 0.06) with LMWH. However, the beneficial effect of LMWH was not significant when only studies with unexplained RIF were pooled. The summary analysis for the numbers needed to be treated with LMWH showed that approximately eight women would require treatment to achieve one extra live birth. CONCLUSIONS In women with ≥3 RIF, the use of adjunct LMWH significantly improves LBR by 79% compared with the control group; however, this is to be considered with caution, since the overall number of participants in the studies was small. Further evidence from adequately powered multi-centered RCTs is required prior to recommending LMWH for routine clinical use. This review highlights the need for future basic science and clinical research in this important field.
Topics: Abortion, Habitual; Anticoagulants; Birth Rate; Embryo Implantation; Female; Heparin, Low-Molecular-Weight; Humans; Live Birth; Pregnancy; Randomized Controlled Trials as Topic; Thrombophilia
PubMed: 23912476
DOI: 10.1093/humupd/dmt032 -
Haematologica Sep 2010Retinal vein occlusion is a frequent cause of visual loss for which few effective therapies are available. Anticoagulation with low molecular weight heparin might be of... (Meta-Analysis)
Meta-Analysis Review
Retinal vein occlusion is a frequent cause of visual loss for which few effective therapies are available. Anticoagulation with low molecular weight heparin might be of value in its treatment. We conducted a systematic review and meta analysis of randomized trials evaluating the effect of low molecular weight heparin in patients with retinal vein occlusion. Data sources included MEDLINE, EMBASE, HealthSTAR, the Cochrane Library, Lilacs, the Investigative Ophthalmology and Visual Science database and gray literature. Main outcome was the mean difference between the visual acuity measured at baseline and at six months expressed in the logMAR scale. Secondary outcome was a composite of any adverse ocular outcome including: worsening of visual acuity, visual fields or fluorescein angiography, or development of iris neovascularization, any neovascularization or neovascular glaucoma. Subgroup analyses for branch versus central retinal vein occlusion were conducted. We identified 1,084 references of which 3 studies comparing low molecular weight heparin with aspirin (229 evaluable patients) were included. Overall, the pooled mean visual acuity difference was -0.23 logMAR (95% CI -0.38, -0.09; P=0.002) in favor of low molecular weight heparin. Low molecular weight heparin was associated with a 78% risk reduction for developing any adverse ocular outcome (pooled RR 0.22; 95% CI 0.10, 0.46; P<0.001). In subgroup analyses benefits seemed lower in branch retinal vein occlusion. No increased vitreous hemorrhages were observed. In patients with retinal vein occlusion treatment with low molecular weight heparin seems to be associated with improvement in the visual acuity and less adverse ocular outcomes. These benefits might differ in patients with central as opposed to branch retinal vein occlusion. Further studies are required to confirm these findings and clarify its benefits in specific subgroups of patients before definitive recommendations can be made.
Topics: Aspirin; Heparin, Low-Molecular-Weight; Humans; Randomized Controlled Trials as Topic; Retinal Vein Occlusion; Treatment Outcome; Visual Acuity
PubMed: 20305141
DOI: 10.3324/haematol.2010.023614 -
Journal of Ayub Medical College,... 2021Osteoarthritis is the most common degenerative disease of the synovial joints in the elderly population with hip osteoarthritis as the second most commonly affected... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Osteoarthritis is the most common degenerative disease of the synovial joints in the elderly population with hip osteoarthritis as the second most commonly affected joint. A multitude of conservative treatments is used for pain relief and functional improvement including acetaminophen, NSAID, intra-articular corticosteroid, and viscosupplementation (VS). Different preparations of VS based on different molecular weights are commercially available. No systematic review or meta-analysis regarding the use of intra-articular high molecular weight hyaluronic acid (HMWHA) injection for the hip joint was published before. This review analyzes the efficacy of intra-articular HMWHA for hip osteoarthritis.
METHODS
PubMed, Google Scholar, Cochrane Library for randomized trials describing the efficacy of HMWHA for hip osteoarthritis was searched. The search terms were osteoarthritis, hip joint, outcomes, viscosupplementation, and high molecular weight hyaluronic acid in different combinations. Standardized mean difference (SMD) in VAS for pain relief and Lequesne index for functional outcomes while risk ratio (RR) for complications was used for data pooling.
RESULTS
Four studies comprising 185 and 189 patients in HMWHA and control groups were included, respectively. SMD for VAS and Lequesne index was -0.056 and -0.114, respectively while RR for complication was 0.879.
CONCLUSIONS
Intra-articular HMWHA injection provided pain relief, functional improvement, and no severe complications on immediate short term basis. However, the results do not favor treatment with HMWHA over other treatment methods. Randomized trials are further necessary to provide data regarding comparisons between HMWHA for hip osteoarthritis concerning clinicians' convenience, compliance, duration of relief, and cost-effectiveness.
Topics: Aged; Humans; Hyaluronic Acid; Injections, Intra-Articular; Molecular Weight; Osteoarthritis, Hip; Randomized Controlled Trials as Topic; Treatment Outcome; Viscosupplements; Visual Analog Scale
PubMed: 34137552
DOI: No ID Found -
Thrombosis Journal Jul 2022The association between gastrointestinal (GI) cancer and a high incidence of venous thromboembolism (VTE) is well known. Previous randomized controlled studies...
Direct oral anticoagulants versus low-molecular-weight heparins for the treatment of acute venous thromboembolism in patients with gastrointestinal cancer: a systematic review and meta-analysis.
BACKGROUND
The association between gastrointestinal (GI) cancer and a high incidence of venous thromboembolism (VTE) is well known. Previous randomized controlled studies demonstrated that direct oral anticoagulants (DOACs) effectively treat cancer-associated thrombosis (CAT). However, some DOACs appeared to increase the risk of bleeding, particularly in patients with GI malignancies. Therefore, the current systematic review and meta-analysis were conducted to evaluate the safety and efficacy of DOACs in GI cancer-associated thrombosis.
METHODS
Two investigators individually reviewed all studies that compared DOACs and low-molecular-weight heparins (LMWHs) in GI cancer-associated thrombosis and were published in MEDLINE and EMBASE before February 2022. The effect estimates and 95% confidence intervals (CIs) from each eligible study were combined using the Mantel-Haenszel method.
RESULTS
A total of 2226 patients were included in the meta-analysis. The rates of major bleeding in the DOAC and LMWH groups were not significantly different (relative risk [RR]: 1.31; 95% CI: 0.84-2.04; P = 0.23; I = 41%). However, the rate of clinically relevant nonmajor bleeding (CRNMB) was significantly higher in the DOAC group (RR: 1.76; 95% CI: 1.24-2.52; P = 0.002; I = 8%). The risks of recurrent VTE in the groups did not significantly differ (RR: 0.72; 95% CI: 0.49-1.04; P = 0.08; I = 0%).
CONCLUSIONS
The current data suggest that treatment of GI cancer-associated thrombosis with DOACs significantly increases the risk of CRNMB. However, the risk of major bleeding was not significantly different. The efficacy of DOACs for preventing recurrent VTE in GI cancer was comparable to that of LMWHs.
TRIAL REGISTRATION
INPLASY202180113 .
PubMed: 35902879
DOI: 10.1186/s12959-022-00399-7 -
Seminars in Thrombosis and Hemostasis Oct 2011Within the last two decades low molecular weight heparins (LMWH) have gained increasing widespread use as anticoagulants in children. The use of LMWH has been... (Meta-Analysis)
Meta-Analysis Review
Within the last two decades low molecular weight heparins (LMWH) have gained increasing widespread use as anticoagulants in children. The use of LMWH has been implemented into clinical care even though there is a lack of firm evidence on the efficacy and safety of LMWH in this population due to the absence of sufficiently powered randomized controlled trials. In the absence of clinical trials, we performed a meta-analysis of available single-arm studies using LMWH in children. A systematic search of electronic databases (Medline, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1980 to 2010 was conducted using keywords in combination both as MeSH terms and text words. Two authors independently screened citations and those meeting a priori defined inclusion criteria were retained. Data on year of publication, study design, country of origin, number of patients, ethnicity, venous thromboembolic events type, and frequency of recurrence and major bleedings were abstracted. Pooled incidence rates (IR) including 95% confidence intervals (95% CIs) on efficacy and safety data of LMWH administration on primary prophylaxis, as well as on secondary prophylaxis in children following symptomatic thromboembolism (TE) were shown. We included 2251 pediatric patients derived from 35 single-arm studies from 12 study countries who were eligible for analysis in the present systematic review. Pooled incidence rates (95% CI) to develop first TE on primary prophylaxis, further TE event on LMWH secondary prophylaxis, or a major bleeding event on LMWH were 0.047 (0.023 to 0.091), 0.052 (0.037 to 0.073) for efficacy, and 0.054 (0.039 to 0.074) for safety (treatment data only), respectively. Efficacy and safety data are comparable with adult data. The present systematic review suggests that use of LMWH in children as primary prophylaxis and in treatment of symptomatic thrombosis is effective and safe. However, properly designed randomized controlled trials are needed.
Topics: Adolescent; Anticoagulants; Child; Child, Preschool; Drug-Related Side Effects and Adverse Reactions; Heparin, Low-Molecular-Weight; Humans; Infant; Infant, Newborn; Venous Thromboembolism
PubMed: 22187405
DOI: 10.1055/s-0031-1297173 -
Cureus Jul 2023Venous thromboembolism (VTE) is a condition often seen in patients diagnosed with cancer and is recognized as a predictor of poor outcomes in these patients. The... (Review)
Review
Venous thromboembolism (VTE) is a condition often seen in patients diagnosed with cancer and is recognized as a predictor of poor outcomes in these patients. The probability of VTE recurring is generally higher in people with cancer than in those without; hence, addressing this issue is essential when making healthcare decisions. Therefore, our systematic review was primarily designed to compare low-weight- molecular heparin (LMWH) to warfarin in reducing recurrent VTE among cancer patients. However, other outcomes were also evaluated, such as mortality and bleeding events observed more in cancer patients. The selection of relevant articles was carried out using a database search and a manual search, which involved reviewing reference lists of articles eligible for inclusion in the current review. The methodological quality of each included study was then assessed using Cochrane's risk of bias tool in the Review Manager software (RevMan 5.4.1). Additionally, pooled results were examined using the Review Manager software and presented as forest plots. Our search of electronic databases elicited a total of 2163 articles, of which only six were deemed eligible for inclusion and analysis. Data pooled from the six studies demonstrated the effectiveness of LMWH in minimizing the reoccurrence of VTE over warfarin [risk ratio (RR): 0.67; 95% CI: 0.47 - 0.95; p = 0.03]. However, LMWH had a similar effect statistically as warfarin on the major bleeding events (RR: 1.05; 95% CI: 0.62 - 1.77; p = 0.85), minor bleeding events (RR: 0.80; 95% CI: 0.54 - 1.20; p = 0.28), and all-cause mortality (RR: 1.00; 95% CI: 0.88 - 1.13; p = 0.99). While LMWH demonstrated its effectiveness in minimizing the incidence of VTE recurrence over warfarin in cancer patients, it had no statistical difference in terms of mortality or bleeding events when compared to warfarin. Based on our findings, we recommend that LMWH continues to be used as a first-line treatment regimen to mitigate recurrent VTE in cancer patients.
PubMed: 37533609
DOI: 10.7759/cureus.41268 -
European Journal of Clinical Nutrition Mar 2023To determine the minimum amount of oat β-glucan (OBG) required to reduce glycaemic responses (MinDose), we conducted a systematic review and meta-regression analysis of... (Review)
Review
The importance of molecular weight in determining the minimum dose of oat β-glucan required to reduce the glycaemic response in healthy subjects without diabetes: a systematic review and meta-regression analysis.
To determine the minimum amount of oat β-glucan (OBG) required to reduce glycaemic responses (MinDose), we conducted a systematic review and meta-regression analysis of acute, crossover, single-meal feeding trials that examined the effects of adding OBG or oat bran to a carbohydrate-containing test-meal versus a control test-meal containing an equivalent amount of available-carbohydrate (avCHO) from the same or similar source. Medline, Embase, and Cochrane Library were searched up to 18 August 2021. The primary outcome was glucose incremental-area-under-the-curve (iAUC). Secondary outcomes included insulin iAUC, and glucose and insulin incremental peak-rise (iPeak). Two independent reviewers extracted data. Results were expressed as ratio-of-means (RoM) with 95% confidence intervals (CIs). Linear associations were assessed by random effects meta-regression. MinDose was defined as the dose at which the upper 95% CI of the regression line cut the line of no effect (i.e., RoM = 1). Fifty-nine comparisons (n = 340) were included; 57 in healthy subjects without diabetes and two in subjects with diabetes; 24 high-MW (>1000 kg/mol), 22 medium-MW (300-1,000 kg/mol), and 13 low-MW (<300 kg/mol). In healthy subjects without diabetes the associations between OBG dose and glucose iAUC and iPeak were linear (non-linear p value >0.05). MinDoses for glucose iAUC for high-MW, medium-MW and low-MW OBG, respectively, were estimated to be 0.2 g, 2.2 g and 3.2 g per 30 g avCHO; MinDoses for glucose iPeak were less than those for iAUC. Insufficient data were available to assess MinDose for insulin, however, there was no evidence of a disproportionate increase in insulin. More high-quality trials are needed to establish MinDose in individuals with diabetes.
Topics: Humans; Blood Glucose; Molecular Weight; Healthy Volunteers; Avena; Diabetes Mellitus; Insulin; Regression Analysis; Glucose
PubMed: 35768556
DOI: 10.1038/s41430-022-01176-5 -
Journal of General Internal Medicine Aug 2016Adults who require long-term anticoagulation with low-molecular-weight heparin (LMWH) such as cancer patients or the elderly may be at increased risk of fractures. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Adults who require long-term anticoagulation with low-molecular-weight heparin (LMWH) such as cancer patients or the elderly may be at increased risk of fractures.
OBJECTIVE
To determine the effects of LMWH therapy of at least 3 months' duration on fractures and bone mineral density (BMD) in non-pregnant adult populations.
METHODS
We systematically reviewed electronic databases (e.g., MEDLINE, EMBASE), conferences and bibliographies until June 2015 and included comparative studies in non-pregnant adult populations that examined the effects of LMWH (≥3 months) on fractures and BMD. We synthesized evidence qualitatively and used random-effects meta-analysis to quantify the effect of LMWH on fractures.
RESULTS
Sixteen articles reporting 14 studies were included: 10 clinical trials (n = 4865 participants) and four observational cohort studies (3 prospective, n = 221; 1 retrospective, n = 30). BMD and fractures were secondary outcomes in the majority of trials, while they were primary outcomes in the majority of observational studies. In participants with venous thromboembolism and underlying cardiovascular disease or cancer (5 RCTs, n = 2280), LMWH for 3-6 months did not increase the relative risk of all fractures at 6-12 months compared to unfractionated heparin, oral vitamin K antagonists or placebo [pooled risk ratio (RR) = 0.58, 95 % CI: 0.23-1.43; I(2) = 12.5 %]. No statistically significant increase in the risk of fractures at 6-12 months was found for cancer patients (RR = 1.08, 95 % CI: 0.31-3.75; I(2) = 4.4 %). Based on the data from two prospective cohort studies (n = 166), LMWH for 3-24 months decreased mean BMD by 2.8-4.8 % (depending on the BMD site) compared to mean BMD decreases of 1.2-2.5 % with oral vitamin K antagonists.
CONCLUSIONS
LMWH for 3-6 months may not increase the risk of fractures, but longer exposure for up to 24 months may adversely affect BMD. Clinicians should consider monitoring BMD in adults on long-term LMWH who are at increased risk of bone loss or fracture.
Topics: Adult; Bone Density; Clinical Trials as Topic; Drug Administration Schedule; Fractures, Bone; Heparin, Low-Molecular-Weight; Humans; Observational Studies as Topic; Treatment Outcome
PubMed: 26895998
DOI: 10.1007/s11606-016-3603-8 -
The Journal of Trauma and Acute Care... Aug 2022Trauma patients have simultaneously high venous thromboembolism (VTE) and bleeding risk. Optimal chemoprophylaxis regimens remain unclear. This study aims to answer... (Meta-Analysis)
Meta-Analysis
Relationship between anti-Xa level achieved with prophylactic low-molecular weight heparin and venous thromboembolism in trauma patients: A systematic review and meta-analysis.
BACKGROUND
Trauma patients have simultaneously high venous thromboembolism (VTE) and bleeding risk. Optimal chemoprophylaxis regimens remain unclear. This study aims to answer three questions for trauma patients. Is there any association between anti-Xa and VTE? Does dose adjustment improve prophylactic anti-Xa rates? Does dose adjustment improve anti-Xa adequacy and VTE compared with standard dosing?
METHODS
Systematic search of MEDLINE, Embase, Scopus, and Web of Science occurred in May 2021. Two author reviews included trauma studies that evaluated low molecular weight heparin chemoprophylaxis, reported anti-Xa level, and evaluated more than one outcome. Data were dually extracted and estimated effects were calculated using RevMan 5.4 applying the Mantel-Haenszel method. Analysis 1 compared patients with peak anti-Xa of 0.2 IU/mL or greater or trough 0.1 IU/mL or greater to those with lower anti-Xa using VTE as the primary outcome. Analysis 2 reported the effect of dose adjustment on anti-Xa. Analysis 3 compared standard dosing to dose adjustment with the primary outcome being anti-Xa adequacy; secondary outcomes were VTE, pulmonary embolism, and bleeding complications.
RESULTS
There were 3,401 studies evaluated with 24 being included (19 retrospective studies, 5 prospective studies). In analysis 1, achieving adequate anti-Xa was associated with reduced odds of VTE (4.0% to 3.1%; odds ratio [OR], 0.52; p = 0.03). Analysis 2 demonstrated that 768 (75.3%) patients achieved prophylactic anti-Xa with adjustment protocols. Analysis 3 suggested that dose-adjusted chemoprophylaxis achieves prophylactic anti-Xa more frequently (OR, 4.05; p = 0.007) but without VTE (OR, 0.72; p = 0.15) or pulmonary embolism (OR, 0.48; p = 0.10) differences. In subgroup analysis, anti-Xa dose adjustment also suggested no VTE reduction (OR, 0.68; p = 0.08).
CONCLUSION
Patients with higher anti-Xa levels are less likely to experience VTE, and anti-Xa guided chemoprophylaxis increases anti-Xa adequacy. However, dose adjustment, including anti-Xa guided dosing, may not reduce VTE.
LEVEL OF EVIDENCE
Systematic Review Meta-Analysis, Level IV.
Topics: Anticoagulants; Enoxaparin; Heparin, Low-Molecular-Weight; Humans; Molecular Weight; Prospective Studies; Pulmonary Embolism; Retrospective Studies; Venous Thromboembolism
PubMed: 35195094
DOI: 10.1097/TA.0000000000003580