Low quality treatment with VKA, which is a common condition, is related to the occurrence of the PTS in patients with DVT. Strategies aimed at improving the quality of long-term anticoagulation might have the potential to reduce the incidence of this complication.

Tailoring biological treatment to individual patients with RA starting adalimumab using drug levels and short-term outcome is cost-effective. Results underscore the potential merit of personalised biological treatment in RA.

There is a diminishing risk of recurrent venous thromboembolism over time and a stabilization after 9 months independent of the duration of the initial treatment with vitamin K antagonists. These findings have important implications for decision making about the optimal duration of treatment with vitamin K antagonists.

Determining the optimal duration of vitamin K antagonist (VKA) therapy for patients with venous thromboembolism (VTE) requires a weighting of the benefits and risks of treatment. The objectives of our study were to investigate patient variability in health state valuations associated with VKA therapy and treatment preferences, and to investigate the extent to which valuations and treatment preferences are associated with prior experience with these health states and other patient characteristics. Valuations of outcomes after VTE scaled from 0 (tantamount to death) to 1 (tantamount to perfect health) were elicited from 53 patients who had experienced VTE, 23 patients who had experienced major bleeding during treatment, and 48 patients with the post-thrombotic syndrome. In addition, patients' treatment preferences were evaluated using treatment trade-off questions. Median health state valuations ranged from 0.33 for 'non-fatal haemorrhagic stroke' to 0.96 for 'no VKA treatment'. Variability between patients was substantial. Patients' treatment preferences also varied: 25% of patients chose cessation of treatment, regardless of the probability of recurrent VTE presented, whereas 23% of patients were never willing to choose cessation of treatment. Differences in valuations and treatment preferences were not associated with type of event experienced. Due to the substantial and unpredictable variability in valuations and treatment preferences, recommendations regarding treatment duration should be tailored to patients' specific values and concerns.

No abstract

To cite this article: Prandoni P, Hutten BA, van Dongen CJJ, Pesavento R, Prins MH. Quality of oral anticoagulant treatment and risk of subsequent recurrent thromboembolism in patients with deep vein thrombosis. J Thromb Haemost 2007; 5: 1555.While poor quality of oral anticoagulant therapy has been reported to be consistently associated with a higher incidence of later post-thrombotic syndrome in patients with deep vein thrombosis (DVT) of the lower extremities [1,2], whether poor anticoagulation quality may predict the development of subsequent recurrent venous thromboembolism (VTE) is uncertain, as information coming from two recent studies is conflicting [3,4].We followed for up to 5 years 200 consecutive patients with a first episode of acute proximal DVT who had been treated with unfractionated or low-molecular weight heparin followed by 3-6 months of oral anticoagulant therapy. Patients who had indication for long-term anticoagulation were excluded from our evaluation. The main demographic and clinical characteristics of the study patients are shown in Table 1. The median duration of follow-up was 4.9 years (interquartile range, 3.9-4.9). The time spent in the targeted therapeutic range (INR, 2.0-3.0) and beneath the lower limit of the therapeutic range was calculated using linear interpolation. Overall, approximately 60% of time was spent in the therapeutic range, and 33% was spent beneath this range. A total of 58 of the 200 patients (29.0%) spent more than 50% of their time in the lowest INR category. Following discontinuation of oral anticoagulant therapy, recurrent VTE as assessed by objective tests developed in 25 patients (12.5%). The median time to recurrence was 35 months (interquartile range, 15-50). Of these 25 patients, six belonged to the 58 (10.3%) who spent more than 50%, and 19 to the 142 (13.4%) who spent < 50% of their time in the lowest INR category. The multivariate model including age (> 65 vs. < 65 years), gender and body mass index showed the lack of association between percentage of time spent beneath an INR level of 2.0 (> 50% vs. £ 50%) and risk of recurrent VTE (odds ratio, 0.74; 95% CI, 0.28-1.98).Our findings are consistent with those from a wide observational cohort study recently performed in the Netherlands [3], but are apparently in contrast to those obtained by Palareti et al. [4] in their prospective cohort study. However, it should be specified that Palareti et al. included only patients with idiopathic DVT, confined their evaluation to the first 3 months, and defined poor quality of anticoagulation as producing an INR beneath 1.5. At least when adopting the criteria used for this investigation, low quality of anticoagulation does not seem to be associated with an increased risk of subsequent recurrent VTE. However, as the quality of oral anticoagulant treatment has the potential firstly to prevent VTE recurrences occurring during the period of treatment [5], and secondly to prevent the occurrence of late post-thrombotic sequelae [1,2], patients and their attending phys...

No abstract