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Journal of the American Academy of... May 2024Perioperative management of antithrombotic agents requires practical and medical considerations. Discontinuing antithrombotic therapies increases the risk of thrombotic... (Review)
Review
Perioperative management of antithrombotic agents requires practical and medical considerations. Discontinuing antithrombotic therapies increases the risk of thrombotic adverse events including cerebrovascular accidents, myocardial infarction, pulmonary embolism, deep vein thrombosis, and retinal artery occlusion. Conversely, continuation of antithrombotic therapy during surgical procedures has associated bleeding risks. Currently, no guidelines exist regarding management of antithrombotic agents in the perioperative period for cutaneous surgeries and practice differs by surgeon. Here, we review the data on antithrombotic medications in patients undergoing cutaneous surgery including medication-specific surgical and postoperative bleeding risk if the medications are continued, and thromboembolic risk if the medications are interrupted. Specifically, we focus on vitamin K antagonist (VKA) (warfarin), direct-acting oral anticoagulants (DOAC) (rivaroxaban, apixaban, edoxaban, dabigatran), antiplatelet medications (aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole), unfractionated heparin, low molecular weight heparin (enoxaparin and dalteparin), fondaparinux, bruton tyrosine kinase inhibitors (BTKi) (ibrutinib, acalabrutinib), and dietary supplements (i.e., garlic, ginger, gingko).
PubMed: 38735483
DOI: 10.1016/j.jaad.2024.01.096 -
Journal of Blood Medicine 2024Venous thromboembolism is a leading cause of morbidity and mortality in patients with active cancer who require anticoagulation treatment. Choice of anticoagulant is... (Review)
Review
Venous thromboembolism is a leading cause of morbidity and mortality in patients with active cancer who require anticoagulation treatment. Choice of anticoagulant is based on careful balancing of the risks and benefits of available classes of treatment: vitamin K antagonists, low-molecular-weight heparin (LMWH), and direct oral anticoagulants (DOACs). Results from randomized controlled trials have shown the consistent efficacy of DOACs versus LMWH in the treatment of cancer-associated venous thromboembolism (VTE). However, increased major gastrointestinal bleeding was observed for edoxaban and rivaroxaban, but not apixaban, compared with LMWH dalteparin. Most guidelines recommend DOACs for the treatment of cancer-associated VTE in patients without gastrointestinal or genitourinary cancer, and with considerations for renal impairment and drug-drug interactions. These updates represent a major paradigm shift for clinicians in the Middle East and North Africa. The decision to prescribe a DOAC for a patient with cancer is not always straightforward, particularly in challenging subgroups of patients with an increased risk of bleeding. In patients with gastrointestinal malignancies who are at high risk of major gastrointestinal bleeds, apixaban may be the preferred DOAC; however, caution should be exercised if patients have upper or unresected lower gastrointestinal tumors. In patients with gastrointestinal malignancies and upper or unresected lower gastrointestinal tumors, LMWH may be preferred. Vitamin K antagonists should be used only when DOACs and LMWH are unavailable or unsuitable. In this review, we discuss the overall evidence for DOACs in the treatment of cancer-associated VTE and provide treatment suggestions for challenging subgroups of patients with cancer associated VTE.
PubMed: 38686358
DOI: 10.2147/JBM.S411520 -
Pharmacoepidemiology and Drug Safety May 2024Guidelines recommend low-molecular-weight heparins (LMWHs) for patients with cancer-associated thrombosis. However, until recently, only dalteparin and tinzaparin were... (Comparative Study)
Comparative Study
Structured benefit-risk assessment for enoxaparin, in the context of its label extension, for the extended treatment of deep vein thrombosis and pulmonary embolism, and prevention of its recurrence in patients with active cancer.
PURPOSE
Guidelines recommend low-molecular-weight heparins (LMWHs) for patients with cancer-associated thrombosis. However, until recently, only dalteparin and tinzaparin were approved in the European Economic Area (EEA) for these patients. This study compares the benefit-risk profile of enoxaparin with dalteparin and tinzaparin for the extended treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrence in adult patients with active cancer.
METHODS
A semi-quantitative structured benefit-risk assessment was conducted for the label-extension application of enoxaparin based on the benefit-risk action team descriptive framework: define decision context; determine key benefit and risk outcomes; identify data sources; extract data; interpret results.
RESULTS
The key benefits were defined as reduced all-cause mortality and venous thromboembolism (VTE) recurrence (including symptomatic DVT, fatal PE or non-fatal PE); the key risks were major and non-major bleeding of clinical significance, and heparin-induced thrombocytopenia (HIT). Enoxaparin demonstrated comparable effects for the reduction of VTE recurrence and all-cause mortality versus other EEA-approved LMWHs (dalteparin, tinzaparin). There was no evidence of a significant difference between enoxaparin and the comparator groups with regard to incidence of major and non-major bleeding. The data on HIT were too limited to assess the difference between the two groups.
CONCLUSIONS
The assessment demonstrated a favourable benefit-risk profile for enoxaparin similar to that of other EEA-approved LMWHs for the treatment of DVT and PE and the prevention of recurrence in patients with active cancer and thus supported the label-extension approval.
Topics: Humans; Enoxaparin; Pulmonary Embolism; Venous Thrombosis; Risk Assessment; Neoplasms; Dalteparin; Tinzaparin; Heparin, Low-Molecular-Weight; Anticoagulants; Secondary Prevention; Hemorrhage; Adult
PubMed: 38680090
DOI: 10.1002/pds.5795 -
BMC Medicine Apr 2024Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12... (Randomized Controlled Trial)
Randomized Controlled Trial
Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial.
BACKGROUND
Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy.
METHODS
Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding.
RESULTS
Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 10/L were independent predictors of minor bleeding events.
CONCLUSIONS
This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH.
TRIAL REGISTRATION
ISRCTN65203415.
Topics: Humans; Male; Female; Aged; Stents; Aged, 80 and over; Anticoagulants; Platelet Aggregation Inhibitors; Heparin, Low-Molecular-Weight; Dalteparin; Treatment Outcome; Surgical Procedures, Operative; Hemorrhage; Placebos; Perioperative Care
PubMed: 38649992
DOI: 10.1186/s12916-024-03391-2 -
The Journal of Laryngology and Otology Apr 2024To determine if systemic administration of low-molecular-weight heparin impacts venous compromise in loco-regional flap reconstruction for head and neck subsites.
OBJECTIVE
To determine if systemic administration of low-molecular-weight heparin impacts venous compromise in loco-regional flap reconstruction for head and neck subsites.
METHODS
This prospective study was conducted on patients who had developed features of venous compromise of the flap. The case group received low-molecular-weight heparin (dalteparin).
RESULTS
Of the 73 patients who developed venous congestion, low-molecular-weight heparin was administered in 47 patients. In the low-molecular-weight heparin subset, 23 patients had either reversal or non-progression of venous compromise (48.9 per cent). Of the patients who had no response to low-molecular-weight heparin rescue, complete necrosis was seen in 4 and partial flap necrosis was observed in 19. The corresponding numbers in the control group were 13 and 12, respectively (odds ratio 23.9, = 0.002). Additionally, the low-molecular-weight heparin arm had a lower incidence of partial or complete flap necrosis ( = 0.002).
CONCLUSION
Low-molecular-weight heparin salvage, when instituted early, is likely to result in a significant reduction in flap-related morbidity.
PubMed: 38602066
DOI: 10.1017/S0022215124000562 -
Blood Coagulation & Fibrinolysis : An... Apr 2024Venous thromboembolism (VTE) is a preventable cause of significant morbidity and mortality in hospitalized patients world-wide. In Australia, the low-molecular weight... (Observational Study)
Observational Study
Venous thromboembolism (VTE) is a preventable cause of significant morbidity and mortality in hospitalized patients world-wide. In Australia, the low-molecular weight heparins (LMWHs) enoxaparin or dalteparin are usually used as first-line prophylaxis for VTE, though there is uncertainty whether dalteparin has the same effectiveness as enoxaparin in real-world settings. This is relevant because dalteparin is less renally cleared and may be more cost effective than enoxaparin. The aim of this study was to explore VTE event incidence in a general cohort of hospitalized adult inpatients who were prescribed enoxaparin or dalteparin for VTE prophylaxis. A retrospective observational study was conducted at a quaternary hospital in Brisbane, Australia, of patients who had experienced a hospital-acquired VTE from 1 September 2021 to 1 March 2023. Patients were identified from routinely collected data following an in-hospital VTE event, and further data was retrieved retrospectively from the integrated electronic Medical Record (ieMR). Incidence and type of VTE events, LMWH-prescribing patterns, and risk factors were assessed. The incidence of VTE events were similar across the dalteparin and enoxaparin cohorts (42.1 events/10 000 patients vs. 34.4 events/10 000 patients, respectively), although patients prescribed enoxaparin had a higher number of risk factors, particularly obesity and active cancer. Our research indicates comparable incidence of VTE in patients prescribed dalteparin compared with enoxaparin in an Australian hospital general cohort of adult inpatients. Dalteparin may be as effective as enoxaparin for VTE prophylaxis in a real-world cohort of patients, and as such dalteparin may be considered a suitable alternative to enoxaparin for VTE prophylaxis. Further research including large randomized controlled trials are required to confirm these results.
Topics: Adult; Humans; Dalteparin; Enoxaparin; Venous Thromboembolism; Heparin, Low-Molecular-Weight; Retrospective Studies; Australia; Anticoagulants
PubMed: 38358899
DOI: 10.1097/MBC.0000000000001281 -
Polymers Jan 2024We have developed a functionalized silk fibroin (BSF) that can serve as an improved fundamental material for dressings by specifically capturing growth factors secreted...
We have developed a functionalized silk fibroin (BSF) that can serve as an improved fundamental material for dressings by specifically capturing growth factors secreted during the healing process and supplying them to cells accumulated in the wound area to enhance the tissue regeneration efficiency. When considering the design of heparin-modified BSF, there is a difficulty with binding to high-molecular-weight polysaccharides without disrupting the hydrophobic crystalline structure of the BSF. In this study, a low-molecular-weight pharmaceutical heparin, dalteparin, was selected and cross-linked with the tyrosine residue presence in the BSF non-crystalline region. When targeting 3D porous applications like nanofiber sheets, as it is crucial not only to enhance biological activity but also to improve handling by maintaining stability in water and mechanical strength, a trade-off between improved cell affinity and reduced mechanical strength depending on crystalline structure was evaluated. The use of dalteparin maintained the mechanical strength better than unfractionated heparin by reducing the effect on disturbing BSF recrystallization. Film surface hydrophilicity and cell proliferation induction were significantly higher in the dalteparin group. For BSF functionalization, using purified heparin was an effective approach that achieved a balance between preserving the mechanical properties and induction of tissue regeneration, offering the potential for various forms in the future.
PubMed: 38337209
DOI: 10.3390/polym16030321 -
Medicina (Kaunas, Lithuania) Jan 2024There was an error in the original publication [...].
Correction: Arce-Huamani et al. Efficacy and Safety of Apixaban versus Dalteparin as a Treatment for Cancer-Associated Venous Thromboembolism: A Systematic Review and Meta-Analysis. 2023, , 1867.
There was an error in the original publication [...].
PubMed: 38256435
DOI: 10.3390/medicina60010134