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ASH identifies three VTE, anticoagulation practices that should be avoided
The American Society of Hematology recently identified three practices that physicians who deal with deep vein thrombosis, pulmonary embolism and anticoagulation should avoid.
The evidence-based recommendations were prepared as part of the Choosing Wisely campaign, a quality improvement initiative of the American Board of Internal Medicine Foundation.
Choosing Wisely is designed to (a) identify medical practices that are not supported by evidence and may lead to adverse outcomes and financial costs, and (b) encourage physicians and patients to question such tests, procedures and treatments.
Stephan Moll
ASH joined the Choosing Wisely campaign, and experts in the field performed a systematic review of the evidence on multiple hematologic topics. The society then released a list of five common hematology procedures, treatments and tests that are not always necessary.
Three of the recommendations relate to venous thromboembolism and anticoagulation therapy.
They are:
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Avoid thrombophilia testing in patients who have a DVT or PE in the setting of a transient major risk factor.
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Avoid placing inferior vena cava (IVC) filters in patients with DVT or PE, except in special circumstances (such as patients with acute DVT who cannot be anticoagulated).
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Avoid giving fresh frozen plasma or prothrombin complex concentrate in patients on warfarin who have elevated international normalized ratios but are not bleeding.
The other recommendations urge clinicians to avoid liberal red cell transfusions in anemic patients and limit routine CT surveillance in certain patients with lymphoma.
Here is a more detailed overview of the recommendations that relate to VTE and anticoagulation:
Thrombophilia testing
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ASH recommendation: ASH recommends against thrombophilia testing in adult patients diagnosed with VTE in the context of a major transient VTE risk factor such as major surgery, trauma or prolonged immobility. In this scenario, thrombophilia testing does not influence duration or intensity of treatment.
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Comment: This recommendation is in regards to VTE associated with major risk factors. "Major transient risk factors" are not the following: contraceptives, pregnancy, hormonal therapy, airline travel, minor surgery (arthroscopic surgeries, etc) or partial immobility (boot immobilizer, etc). Patients who develop VTE associated with such minor VTE risk factors may or may not be candidates for thrombophilia testing. Such patients should seek guidance from an expert in VTE.
IVC filters
- ASH recommendation: ASH recommends against the routine use of IVC filters because (a) there is a paucity of data supporting the use and benefit of them, and (b) they can be associated with complications and adverse outcomes.
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Comment: The primary indication for an IVC filter is the presence of an acute DVT in a patient who cannot be safely anticoagulated. When IVC filters are necessary, retrievable filters are strongly recommended over permanent filters.
Use of FFP or PCC
- ASH recommendation: ASH recommends against the use of frozen fresh plasma or prothrombin complex concentrate to reverse warfarin in the absence of bleeding, emergent surgery or emergent invasive procedures.
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Comment: Most non-bleeding patients can be managed by interrupting or reducing warfarin, or by giving small doses of vitamin K. It is only in the case of major bleeding, or the need to reverse warfarin for urgent surgery, that a 4-factor prothrombin complex concentrate (Kcentra, CSL Behring) together with vitamin K should be given. When a prothrombin complex concentrate is not available, frozen fresh plasma and vitamin K should be given.
Conclusion
These recommendations by ASH are valuable. Although they do not represent novel scientific/clinical knowledge or surprising conclusions, they do address three issues of significant clinical relevance.
The fact that these topics have now been more formally addressed in these practice recommendations and are being promoted by a society will hopefully lead to more awareness about them and changes in practice. They make sense and are noncontroversial and straightforward, so there is no reason that they should not be accepted by the clinical community.
Reference:
Hicks LK. Blood. 2013;doi:10.1182/blood-2013-07-518423.
For more information:
Stephan Moll, MD, is an associate professor in the Department of Medicine and Division of Hematology-Oncology at the University of North Carolina School of Medicine in Chapel Hill, N.C., and medical director of the Clot Connect patient and health care professional education program (www.clotconnect.org), an initiative of the University of North Carolina Hemophilia and Thrombosis Center. He can be reached at the UNC Hemophilia and Thrombosis Center, 170 Manning Drive, 3rd Floor Physicians Office Building, Campus Box 7035, Chapel Hill, NC 27599-7016; email: smoll@med.unc.edu.
Disclosure: Moll has been a consultant for CSL Behring.