Controversial Issues in Thromboprophylaxis with Low-Molecular Weight Heparins in Palliative Care

Tassinari, Davide; Santelmo, Carlotta; Scarpi, Emanuela; Tombesi, Paola; Sartori, Sergio

doi:10.1016/j.jpainsymman.2008.04.006

Cited by 9 publications

(14 citation statements)

References 8 publications

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“…1 Approximately 10% of patients with cancer who are treated in palliative care units are diagnosed with symptomatic thromboembolism, 2 and more than half of patients in inpatient hospice units are believed to have asymptomatic deep venous thrombosis. 3 …”

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confidence: 99%

“…5 A proposed benefit of anticoagulation in hospice care, where the goal is promoting quality of life rather than lengthening survival, is that treatment may reduce bothersome symptoms of thromboembolism such as pain, edema, and dyspnea. 1 However, no studies of adequate size have been conducted to definitively determine the effect of anticoagulation on symptoms or survival in hospice patients. 8 …”

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confidence: 99%

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Predictors of anticoagulation in hospice patients with lung cancer

Holmes

Bain

Zalpour

et al. 2010

Cancer

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BACKGROUND Guidelines recommend lifelong anticoagulation in patients with cancer and a history of thromboembolism, but the use of anticoagulation in hospice has not been described. A retrospective study of medication data was conducted to determine patterns of anticoagulant use and predictors of type of anticoagulant prescribed for hospice patients with lung cancer. METHODS Medication data were evaluated for 16,896 hospice patients with lung cancer in 2006 to determine patient and hospice characteristics that predicted anticoagulant prescription. Independent predictors of warfarin versus low molecular weight heparin (LMWH) prescription were identified using a logistic regression model. RESULTS One of every 11 patients was prescribed an anticoagulant, most commonly warfarin. Compared with patients prescribed LMWH, patients prescribed warfarin were older (71.6 vs 65.8 years, P<.001), were more likely white (81.2% vs 74.3%, P = .03), had a longer stay in hospice (median 21 days vs 17 days, P = .001), and were more likely to have ≥3 comorbid illnesses (37.5% vs 25.0%, P<.001). The strongest independent predictor of type of anticoagulant prescribed was geographic region, with hospices in the Northeast more likely to prescribe LMWH. CONCLUSIONS Anticoagulant use is prevalent in patients with lung cancer enrolled in hospice. This study highlights the need to understand the benefits and risks of anticoagulation at the end of life.

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confidence: 99%

Predictors of anticoagulation in hospice patients with lung cancer

Holmes

Bain

Zalpour

et al. 2010

Cancer

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“…Many patients found it preferable to use warfarin since maintenance of a stable INR was reported to require frequent monitoring and these repeated blood tests had a negative impact on quality of life. The health economic implications of using LMWH in advanced cancer patients need to be considered and some services have suggested the cost of LMWH to be prohibitive 35. The majority of patients or carers can be taught to administer the drug, negating the potential additional cost of community nursing involvement 32…”

Section: Treatment Of Symptomatic Vtementioning

confidence: 99%

Management of cancer-associated thrombosis in people with advanced disease

Noble

Johnson²

2012

BMJ Support Palliat Care

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The management of venous thromboembolism in the cancer population is clearly established. Low molecular weight heparin has a greater efficacy than warfarin in the treatment of cancer-associated thrombosis and is recommended as the preferred therapy. However, the evidence informing these recommendations excluded patients with poor prognosis or performance status, thrombocytopenia, bleeding or brain metastases. Furthermore, there is limited data on the management of venous thromboembolism resistant to anticoagulation, a phenomenon frequently encountered in the advanced cancer population. This paper will review the management of cancer-associated thrombosis with a particular focus on challenging clinical situations faced by palliative care teams looking after patients with advanced disease.

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“…However, because of growing awareness of the risk of venous thromboembolism in palliative care patients [3][4][5][6][7][8][9], attitudes towards primary prophylaxis are changing, with increasingly frequent prescriptions during the past decades [10][11][12]. This practice is controversial [7,10,13,14], however, because thromboprophylaxis principally aims to prevent sudden death from pulmonary embolism and is therefore a potentially lifeprolonging therapy, which may be viewed as counterintuitive to palliative care philosophy and inappropriate on grounds of futility [7,[14][15][16]. Moreover, in contrast to the growing body of literature discussing the thrombotic risk of palliative care inpatients [3][4][5][6][7][8][9][10]13], few articles address their risk of bleeding, the associated consequences and the risk factors involved [15,17].…”

Section: Introductionmentioning

confidence: 99%

“…Moreover, in contrast to the growing body of literature discussing the thrombotic risk of palliative care inpatients [3][4][5][6][7][8][9][10]13], few articles address their risk of bleeding, the associated consequences and the risk factors involved [15,17]. Although sometimes considered to be similar in palliative care patients and other patient populations [14], these parameters have never been investigated specifically in the palliative care context. A better knowledge of the risk of bleeding in palliative care inpatients could facilitate decision making with regard to primary prophylaxis initiation or continuation.…”

Section: Introductionmentioning

confidence: 99%

Bleeding risk of terminally ill patients hospitalized in palliative care units: the RHESO study

Tardy

Picard

Guirimand³

et al. 2017

Journal of Thrombosis and Haemostasis

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Background The value of primary thromboprophylaxis in patients admitted to palliative care units is debatable. Moreover, the risk of bleeding in these patients is unknown. Objectives Our primary aim was to assess the bleeding risk of patients in a real-world practice setting of hospital palliative care. Our secondary aim was to determine the incidence of symptomatic deep vein thrombosis and to identify risk factors for bleeding. Patients/Methods In this prospective, observational study in 22 French palliative care units, 1199 patients (median age, 71 years; male, 45.5%), admitted for the first time to a palliative care unit for advanced cancer or pulmonary, cardiac or neurologic disease were included. The primary outcome was adjudicated clinically relevant bleeding (i.e. a composite of major and clinically relevant non-major bleeding) at 3 months. The secondary outcome was symptomatic deep vein thrombosis. Results The most common reason for palliative care was cancer (90.7%). By 3 months, 1087 patients (91.3%) had died and 116 patients had presented at least one episode of clinically relevant bleeding (fatal in 23 patients). Taking into account the competing risk of death, the cumulative incidence of clinically relevant bleeding was 9.8% (95% confidence interval [CI], 8.3-11.6). Deep vein thrombosis occurred in six patients (cumulative incidence, 0.5%; 95% CI, 0.2-1.1). Cancer, recent bleeding, antithrombotic prophylaxis and antiplatelet therapy were independently associated with clinically relevant bleeding at 3 months. Conclusions Decisions regarding the use of thromboprophylaxis in palliative care patients should take into account the high risk of bleeding in these patients.

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Controversial Issues in Thromboprophylaxis with Low-Molecular Weight Heparins in Palliative Care

Cited by 9 publications

References 8 publications

Predictors of anticoagulation in hospice patients with lung cancer

Predictors of anticoagulation in hospice patients with lung cancer

Management of cancer-associated thrombosis in people with advanced disease

Bleeding risk of terminally ill patients hospitalized in palliative care units: the RHESO study

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