Prevention of venous thromboembolism in medical patients and outpatients

Abstract

The majority of fatal cases of pulmonary embolism in hospitalized patients occur in acutely ill, medically treated patients. Current guidelines, based on a large number of prospective, randomized, controlled trials evaluating the safety and efficacy of pharmacologic venous thromboembolism (VTE) prophylaxis in medical patients, now recommend using VTE prophylaxis in this population. Unfortunately, prophylaxis rates in medical patients are unacceptably low, despite efforts to develop strategies for improving implementation of prophylaxis regimens. Studies indicate that a substantial proportion of patients with VTE present after hospital discharge, but no clinical trials evaluating VTE prophylaxis for medical outpatients have yet been published. In this Review, we examine the literature on VTE prophylaxis in hospitalized medical patients, and evaluate the available data for the outpatient setting.

A population-based study of acute medical conditions associated with bullous pemphigoid

“…If this increase in pulmonary emboli is demonstrated in other cohorts, it may lead to a recommendation to include anticoagulation as adjuvant therapy for bullous pemphigoid. In other inflammatory disorders known to be associated with increased risks of thrombosis, such as Behçet’s syndrome and lupus erythematosus with positivity for lupus anticoagulant, anticoagulation is now considered for periods of increased risk 18 . A clinical trial of anticoagulation for people with bullous pemphigoid would be very hard to perform in view of low numbers of participants.…”

Risk of venous thromboembolism in people admitted to hospital with selected immune-mediated diseases: record-linkage study

“…Although VTE has traditionally been considered a surgical condition, the vast majority of hospitalised patients with symptomatic VTE have not undergone recent surgery [4]. Indeed, up to 80% of in-hospital fatal PEs occur in nonsurgical patients [4].…”

“…Indeed, up to 80% of in-hospital fatal PEs occur in nonsurgical patients [4]. Patients with inflammatory bowel disease [5], rheumatoid arthritis [6], type 1 diabetes [7] and systemic lupus erythematosus (SLE) [8] are at an increased risk of VTE, suggesting that there may be a more general association between immune-mediated diseases and VTE.…”

Antisense inhibition of coagulation factor XI prolongs APTT without increased bleeding risk in cynomolgus monkeys

“…In the last decade, anticoagulant therapy has expanded to also include prevention of thrombosis following knee or hip surgery because of deep vein thrombosis or pulmonary embolism where it has been associated with significant reductions in mortality and morbidity. 1,2 The growing role of anticoagulant therapy in the treatment and prevention of thrombosis is continually balanced by the potential complications and risks associated with excess bleeding. Although improvements in the therapeutic index of anticoagulant therapy have recently been made with the advent of small molecule inhibitors of factor Xa (rivaroxaban) or thrombin (dabigatron) relative to vitamin K antagonists, risks of bleeding still remain to be the key limitations for broader clinical application.…”