Profilassi e Terapia Dvt
Post on 08-Feb-2016
Embed Size (px)
DESCRIPTIONprofilassi e terapia dvt
inDr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino1The VTE clinical practice recommendations were developed to guide practicing clinicians onthe best approaches for the prophylaxis and treatment of VTE, based on clinical evidence.the ASCO guidelines are divided into recommendations forpreventative care, in particular in cancer patients undergoing surgery or on chemotherapy,and recommendations for treating established blood clots, such as thrombi in the legs or lungs.
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino2Cancer patients undergoing surgery are at higher risk for development of blood clots in thepostoperative period compared to noncancer patients undergoing surgery. Patients withmetastatic cancer on chemotherapy are at increased risk for thrombosis or blood clots. Theguidelines talk about strategies to prevent thrombosis in people at risk or at higher risk.When Cancer patients, develop a [an acute symptomatic] thrombosis, it is more difficult totreat the clot, because the clot is more resistant treatment, and also the patientsare at higher risk for bleeding on anticoagulants that we use, in thrombosis [treatment].
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino1. ASCO Guidelines3Di fatto per solo il 16% dei pz ricoverati per patologie mediche riceve profilassi. In particolare le divergenze riguardano sia luso della profilassi primaria e secondaria (pz. Con dvt diagnosticata) che la durata della stessa.
Hospitalised cancer patients are not being properly protected from the occurrence ofa VTE event. A recent study revealed that most acutely ill hospitalised patients had indicationsfor thromboprophylaxis; however, only 16% actually received prophylactic treatment. Patientswith cancer had a significantly reduced likelihood of receiving prophylaxis.There are unmet needs in that populationthey are not all getting medication to preventthrombosis. We want to make sure that every patient who has surgery with cancer and isat risk for postoperative thrombosis gets some sort of prophylaxis: patients with cancerhospitalised for a pain crisis, or because of one of their limbs is paralysed, or for an infection.Gap= divergenzaThese types of patients should receive prophylaxis provided they are not at high risk forbleeding. The use of prophylaxis in an end-of-life scenario is not clear-cut and raises moraland ethical issues. And then there [are] patients who already have developed a thrombosis and they need to betreated with an anticoagulant to prevent that clot from extending or breaking off.long-term low-molecular-weight heparin must be used in this situation.However, the duration of therapy is not well-defined.Haematologists or oncologists that use long-term low-molecular-weight heparin just continuethe drug for a longer periodbeyond 6 months, but we actually don't have the studies. The trialwe did [was] for 6 months, so [the recommendation is] based on extrapolation rather than actualtrial results.
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino4In merito alla profilassi, le LMWH sono da considerare il trattamento standard nei pz con cancro.Recenti studi ne hanno mostrato uguale sicurezza e maggiore efficacia rispetto al warfarin.I vantaggi sono inoltre:Low-molecular-weight heparin is an injectiondaily, subcutaneouslyso you don't have to deal withthe problems of lack of appetite, vomiting, stuff like that.(lack of absorption) interactions with other medications are avoided in this way.You get much more consistent [anticoagulant] blood levels, and higher effect of anticoagulant withlow-molecular-weight heparin than you do with warfarin. There's theoretically a lower bleeding risk
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino5La dia riporta i dati dello studio clot: dalteparina 200 IU/kg, for a month e poi [150 IU/kg] for the next 5 mesi. The control arm was dalteparin for a week followed by 6 months of warfarin with the INR adjusted to [a target of] 2 to 3. .Risultati:Il rischio di recidiva stato ridotto del 50% with the long-term dalteparin.Narrator:In the event that dalteparin cannot be used, other options recommended in the ASCOguidelines for the initial primary or secondary prophylaxis of established VTE includeenoxaparin, heparin, fondaparinux, and tinzaparin. However, for long-term treatment, dalteparinis the first-line recommendation, followed by warfarin.
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino6In presenza di dvt conclamata dunque, low-molecularweightheparin is the preferred approach for both initial and long-term treatment over 6 months.Indefinite anticoagulation therapy should be considered for patients with active cancer after6 months. In addition, anticoagulation is recommended for patients with central nervous systemmalignancies and elderly patients.In merito al monitoraggio della terapia, si raccomanda a periodic check of the platelet count, a monitoring anti-Factor Xa levels can be considered in very obese patients or those with impairedrenal function.The guidelines also warn to avoid anticoagulation in the presence of intracranial bleeding o diatesi emorr. Preesistente.
A vena cava filter is only indicated for patients with contraindications to anticoagulants orpatients with recurrent VTE despite long-term low-molecular-weight heparin therapy.Dr. Levine clarifies that monitoring should includeregular clinical evaluation of the patient to make sure that bleeding is not occurring and should
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino7If you can prevent a thrombosis, it's much easier to prevent it than treat it, because generallywith prevention you're using a lower dose of the medication, so there's a lower risk of bleeding.Prevention is usually just a short period where[as] treatment, you have to treat for a long time.I want to stress that not everybody that's hospitalised with cancer is a candidate for prophylaxis.There are some patients who are bleeding when they come in: well, you can't give them ananticoagulant. There are some patients that are at end of life. So, people have to use theircommon sense
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino8We don't use long-term low-molecular-weight heparin in ambulatory patients [who arereceiving chemotherapy]. Patients with multiple myeloma who are receiving thalidomide pluschemotherapy or thalidomide plus a steroiddexamethasoneseem to be at very high riskof thrombosis.although there have not been any good randomised trials evaluatingvarious methods, the guidelines recommend using low-molecular-weight heparin or adjusteddosewarfarin in these patients. Further, he notes that this recommendation was based on aconsensus of the panel.And we really recommend doing more research and randomised studies in that area.
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino9Cancer patients undergoing pelvic or orthopaedic surgery should receive low-molecularweightheparin as prophylaxis.All of these patients postoperatively should also [wear] graduated compression stockings.Il regime combinato di profilassi farmacologica e meccanica indicato nei pazienti a pi alto rischio e dovrebbe avere durata di 7-10 giorni, anche successivamente alla dimissione.Patients at highest risk should be on a combined regimen of pharmacologic and mechanicalprophylaxis, according to the guidelines, and this should be continued 7-10 days postoperativelyas well as post-discharge for some patients.
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino10Come quantificare la condizione di rischio tromboembolico nel pz neoplastico? I singoli fattori di rischio vanno ricercati nelle tre categorie che determinano la condizione di rischio tromboembolico globale del paziente neoplastico. RF legati al paziente, alla patologia, al trattamento.Narrator:Some of the main risk factors for VTE in malignant disease, whichclinicians should take into consideration when treating these patients.Dr. Levine:Some of the things you think about are: have they had a previous blood clot? If they've had ablood clot before they got cancer, and now you are starting them on [chemotherapy] treatment,well, then you might think about some sort of primary prevention. You might think about theburden of cancer; do they have widely metastatic disease? Unless we are dealing with myelomathalidomide or lenalidomide, we don't generally have good ways of preventing thrombosis inambulatory cancer patients.
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino11Overall, Dr. Levine recommends that practicing physicians use their clinical judgment in combinationwith the ASCO guidelines for VTE prophylaxis in cancer patients who are eitherat risk for VTE or have established VTE.Dr. Levine:If they have active malignancies, and they don't have a blood clot, they've just gone into hospital,because they are really sick: well, is there anything we should be doing there to try to preventthrombosis? And if theyre [at] high risk for bleeding, you can't give them an anticoagulant, but youmight put on some compression stockings. Similarly, if they are undergoing major surgery, it's wellknown that even if you don't have cancer, that you are at higher risk for thrombosis after surgery.So, having a cancer makes it even higher risk, so it's well known that you use prophylaxis withmedication and you also are going to use graduated compression stockings. Then [there is] thisspecial group of ambulatory cancer patients where if they don't have myeloma and they don't havea previous history of thrombosis, then we don't use prophylaxis. On the other hand, if they havemyeloma and they are getting thalidomide and steroids, then we recommend low-molecular-weightheparin or [an] adjusted dose of warfarin. If you step back and look at that algorithm, that's commonsense and good medicine
Dr. Ssa Marina MinozziOncologia La SapienzaPolo Pontino12For secondary p