For the treatment of cancer-associated VTE, LMWHs are recommended over warfarin (Grade 2B) and DOACs (all Grade 2C). Warfarin therapy in cancer-associated VTE is often made more difficult by wildly fluctuating international normalized ratios, procedure-related interruptions, as well as numerous drug-drug and drug-food interactions. While DOACs have been widely used in the treatment of VTE, there is very little data supporting their use in patients with active cancer until now with the publication of the Hokusai VTE Cancer study.
Guest Authors: Elizabeth Scheffel, PharmD and Christa George, PharmD, BCPS, BCACP, CDE
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According to the 2016 CHEST VTE Guidelines, at least 3 months of therapy is recommended for an unprovoked DVT or PE (Grade 1B). Thereafter, the clinician is expected to weigh the risks and benefits to determine if extended therapy is appropriate. Balancing the risk of mortality from recurrent VTE versus major bleeding has been challenging. A validated clinical decision tool is sorely needed! Until recently, no risk assessment tool has been validated and therefore none have been widely adopted in practice.
Guest Author: Carol Chan, Pharm.D.
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For the acute treatment of venous thromboembolism, the direct oral anticoagulants (DOACs) have increasingly replaced injectable anticoagulant therapy followed by warfarin. For patients with an unprovoked deep vein thrombosis or pulmonary embolism who may benefit from long-term extended prophylaxis for the secondary prevention of VTE, the choice is less clear. Should a DOAC be used? If so, which one and what's the best dose? What about low-dose aspirin? Is extended therapy needed at all? The EINSTEIN CHOICE study adds important new insights to the growing body of literature.
Guest Author: Sarah Anderson, PharmD, BCPS
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For over two decades LMWHs have been routinely used to provide therapeutic coverage in patients who must temporarily stop warfarin. Current guidelines suggest using injectable anticoagulants during warfarin interruption (aka bridging) in patients with atrial fibrillation based on patients’ risk of arterial thrombosis. Using the CHADS2 score to assess risk, the guidelines recommend (grade 2C) bridge therapy if the CHADS2 score is 5 or higher and not bridging if the CHADS2 score is 2 or lower. But what about patients with a CHADS2 score of 3 or 4?