Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5—Discontinuation of anticoagulant therapy in small animals

Abstract

Objectives: To systematically evaluate the evidence supporting the timing and mechanisms of permanent or temporary discontinuation of antiplatelet or anticoagulant medications in small animals Design: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality (poor, fair, or good), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. Settings: Academic and referral veterinary medical centers.Results: Databases searched included Medline via PubMed and CAB abstracts. Two specific courses of inquiry were pursued, one focused on appropriate approaches to use for small animal patients receiving antiplatelet or anticoagulant drugs and requiring temporary discontinuation of this therapy for the purposes of invasive procedures (eg, surgery), and the other aimed at decision-making for the complete discontinuation of anticoagulant medications. In addition, the most appropriate methodology for discontinuation of heparins was addressed. Conclusions:To better define specific patient groups, a risk stratification characterization was developed. It is recommended to continue anticoagulant therapy through invasive procedures in patients at high risk for thrombosis that are receiving anticoagulant therapy, while consideration for discontinuation in patients with low to moderate risk of thrombosis is reasonable. In patients with thrombosis in whom the underlying cause for thrombosis has resolved, indefinite treatment with anticoagulant medication is not recommended. If the underlying cause is unknown or untreatable, anticoagulant medication should be continued indefinitely. Unfractionated heparin therapy should be slowly tapered rather than discontinued abruptly. K E Y W O R D Saspirin, clopidogrel, CURATIVE, heparin, rivaroxaban 88

Fatal hemoptysis after bronchoscopic biopsy in a dog

“…These guidelines were not available at the time of this case; however, it is unclear how much role platelet inhibition played in resultant hemorrhage. Of interest, the periprocedural use of aspirin was not associated with an increased bleeding risk in people undergoing transbronchial biopsy . Nevertheless, it is prudent to discontinue any anticoagulant/antiplatelet treatment before biopsy, as primary hemostasis is important in controlling hemorrhage.…”

Clinical application of the American College of Veterinary Emergency and Critical Care (ACVECC) Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE) guidelines to small animal cases

“…Following the development of the first consensus guidelines for the rational use of antithrombotics in dogs and cats at risk of thrombosis, the Consensus working group created a series of clinical cases that could be used to demonstrate how guideline recommendations could be applied. The body of work conducted as part of the Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE) initiative encompasses a summary of the guidelines, as well as the individual domain manuscripts that provided the Population/Patient, Intervention, Control, Outcome (PICO) questions and evidence summaries used to generate the guidelines . The aim of this manuscript is to provide additional direction on the practical application of these guidelines.…”

“…Therapeutic recommendations for dogs and cats were tailored to specific case vignettes based on the CURATIVE guidelines regarding antithrombotic drug choices and dosing protocols, as outlined in Domains 2 and 3 . Where appropriate, guidelines describing therapeutic monitoring (Domain 4) and discontinuation of antithrombotics (Domain 5) were included.…”

Safe and effective anticoagulation in small animals – Is that too much to ask? Long‐awaited first steps

“…This special issue of the Journal features perhaps the most ambitious collaboration on the subject of coagulation in companion animals to date; the ACVECC C onsens u s on the R ational use of A n t ithrombotics i n V eterinary Critical Car e (CURATIVE) attempts to stratify the risk of developing thrombosis in various conditions and establish guidelines for the management of small animals with antithrombotics . Five domains were created for this initiative and they were grouped as follows: (i) Defining populations at risk, (ii) Defining rational therapeutic use, (iii) Defining evidence‐based protocols, (iv) Refining and monitoring antithrombotic therapies, and (v) Discontinuing antithrombotic therapies . Such a wide encompassing scope for reaching consensus is uncommon even in human medicine, where it is more likely to encounter a consensus statement for the use of a single agent in relation to a single condition.…”

“…Domain 5 is one of the shorter domains but perhaps one of the most interesting . Establishing the indications for antithrombotic therapy, the preferred agent and dosage may be the appropriate focus for investigations, but there are legitimate concerns in regards to when antithrombotics are no longer required, how they should be discontinued and when temporary pauses are required to facilitate medical or surgical procedures . Unsurprisingly, there was virtually no evidence in companion animals to base recommendations on, and this domain was challenged by the fact that risk stratification for development of thrombosis in animals is rudimentary.…”