The use of direct oral anticoagulants for extended duration thromboprophylaxis in medically ill patients: a systematic review and meta-analysis

Alshouimi, Reema A; Rammah, Shahad M Al; Alzahrani, Mohammed; Badreldin, Hisham A.; Yami, Majed S. Al; Almohammed, Omar A.

doi:10.1007/s11239-019-01900-2

Cited by 7 publications

(4 citation statements)

References 16 publications

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“…Deep vein thrombosis (DVT) and pulmonary embolism (PE) when discussed together constitute venous thromboembolism (VTE) and continue to be a leading source of morbidity and mortality in high-risk surgical patients with over 900,000 cases reported yearly [1]. Studies have reported VTE development in high-risk settings ranging from 21 to 90 days after hospital discharge [2,3] with a 25% incidence rate even 4-6 weeks after some high-risk surgical procedures [4].…”

Section: Introductionmentioning

confidence: 99%

Is Extended‐Duration (Post‐Hospital Discharge) Venous Thromboembolism Chemoprophylaxis Safe and Efficacious in High‐Risk Surgery Patients? A Systematic Review

et al. 2020

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Background The risk of venous thromboembolism (VTE) persists beyond hospitalization in surgical patients, yet post-hospital discharge chemoprophylaxis regimens are not common. The purpose of this study is to systematically review the literature regarding extended-duration (post-hospital discharge) venous thromboembolism chemoprophylaxis and to determine whether it is warranted in high-risk surgical patients, as determined by its safety and efficacy. Method We searched four online databases for articles evaluating extended-duration (post-hospital discharge) VTE chemoprophylaxis regimens in surgical patients between the years January 2000 and February 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. GRADE methodology and the Cochrane Risk of Bias Assessment Tool for Randomized Controlled Trials were used to grade the quality of evidence and assess risk of bias. Results Nineteen studies with 10,544 patients were analyzed. The duration for extended-duration VTE chemoprophylaxis ranged from 7 to 42 days. In our study cohort, high-risk patients not prescribed extended-duration VTE chemoprophylaxis had a mean VTE incidence rate of 12.23%, while patients receiving 28-30 days of chemoprophylaxis had a mean VTE incidence rate of 4.37% (p = 0.006). The risk of bleeding events did not correlate with the duration of chemoprophylaxis. Conclusion Extended-duration VTE chemoprophylaxis in high-risk surgical patients decreased the incidence of thrombotic complications without increasing the risk of bleeding events. Further research is needed to establish guidelines for the optimal duration of VTE chemoprophylaxis in high-risk surgical patients. Level of evidence III.

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Section: Introductionmentioning

confidence: 99%

Is Extended‐Duration (Post‐Hospital Discharge) Venous Thromboembolism Chemoprophylaxis Safe and Efficacious in High‐Risk Surgery Patients? A Systematic Review

et al. 2020

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“…Placing value on the avoidance of a major bleeding complication, we elected a 1% rate of 90‐day HA‐MB as a threshold that would be permissible for thromboprophylaxis. Alshouimi estimated that EDT reduces risk for symptomatic VTE compared with a “hospital‐only” prophylaxis regimen by 41% yielding a number needed to treat of 314 to prevent one VTE event, yet an associated relative risk of major bleeding of 1.95 (95% CI, 1.25‐3.04) and a number needed to harm of 343 was described 41 . At the threshold of 2% 90‐day risk for HA‐VTE, we observed that a HA‐VTE IMRS ≥7 was associated with a 69% increase risk for thrombosis.…”

Section: Discussionmentioning

confidence: 99%

“…that expressly studied the benefit of postdischarge extended duration thromboprophylaxis (MARINER) did not meet the primary end point. The close margin of safety reported in MARINER has been identified as a potential barrier in the broader application of postdischarge EDT 14,41. However, if a patient's personalized postdischarge thrombosis and bleeding risk may be estimated at the time of discharge, then that information may inform decision making regarding the prescription of EDT, and the net clinical benefit may be improved.…”

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confidence: 99%

Post‐discharge thrombosis and bleeding in medical patients: A novel risk score derived from ubiquitous biomarkers

Woller

Stevens

Fazili

et al. 2021

Research and Practice in Thrombosis and Haemostasis

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Background Some hospitalized medical patients experience venous thromboembolism (VTE) following discharge. Prophylaxis extended beyond hospital discharge (extended duration thromboprophylaxis [EDT]) may reduce this risk. However, EDT is costly and can cause bleeding, so selecting appropriate patients is essential. We formerly reported the performance of a mortality risk prediction score (Intermountain Risk Score [IMRS]) that was minimally predictive of 90‐day hospital‐associated venous thromboembolism (HA‐VTE) and major bleeding (HA‐MB). We used the components of the IMRS to calculate de novo risk scores to predict 90‐day HA‐VTE (HA‐VTE IMRS) and major bleeding (HA‐MB IMRS). Methods From 45 669 medical patients we randomly assigned 30 445 to derive the HA‐VTE IMRS and the HA‐MB IMRS. Backward stepwise regression and bootstrapping identified predictor covariates from the blood count and basic chemistry. These candidate variables were split into quintiles, and the referent quintile was that with the lowest event rate for HA‐VTE and HA‐MB; respectively. A clinically relevant rate of HA‐VTE and HA‐MB was used to inform outcome rates. Performance was assessed in the derivation set of 15 224 patients. Results The HA‐VTE IMRS and HA‐MB IMRS area under the receiver operating curve (AUC) in the derivation set were 0.646, and 0.691, respectively. In the validation set, the HA‐VTE IMRS and HA‐MB IMRS AUCs were 0.60 and 0.643. Conclusions Risk scores derived from components of routine labs ubiquitous in clinical care identify patients that are at risk for 90‐day postdischarge HA‐VTE and major bleeding. This may identify a subset of patients with high HA‐VTE risk and low HA‐MB risk who may benefit from EDT.

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“…For example, while DOACs may be preferable to heparins for thromboprophylaxis in orthopedic surgery patients (Anderson et al, 2019;Khatri et al, 2021), LMWH or UFH is recommended in hospitalized patients for major general surgical indications (Anderson et al, 2019). Similarly, thromboprophylaxis with LMWH in hospitalized medical patients was found to be associated with a reduced bleeding risk, in comparison with DOAC therapy, without inferior efficacy (Neumann et al, 2020), and the results of a 2019 meta-analysis support the use of thromboprophylaxis with LMWH (7-10 days) in medical patients, following discharge from hospital, in favor of an extended (>30 day) DOAC regimen on the basis of bleeding risk (Alshouimi et al, 2019). In the initial treatment of cancer-associated VTE, DOACs were reported in a 2019 meta-analysis to have greater efficacy but to be associated with an increased risk of major and clinically significant bleeding (Li et al, 2019a).…”

Section: B Heparin In Relation To Alternative Anticoagulantsmentioning

confidence: 95%

Pharmacology of Heparin and Related Drugs: An Update

et al. 2023

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The use of direct oral anticoagulants for extended duration thromboprophylaxis in medically ill patients: a systematic review and meta-analysis

Cited by 7 publications

References 16 publications

Is Extended‐Duration (Post‐Hospital Discharge) Venous Thromboembolism Chemoprophylaxis Safe and Efficacious in High‐Risk Surgery Patients? A Systematic Review

Is Extended‐Duration (Post‐Hospital Discharge) Venous Thromboembolism Chemoprophylaxis Safe and Efficacious in High‐Risk Surgery Patients? A Systematic Review

Post‐discharge thrombosis and bleeding in medical patients: A novel risk score derived from ubiquitous biomarkers

Pharmacology of Heparin and Related Drugs: An Update

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