Two Things Physicians Should Avoid

Stephan Moll, MD writes (Dec 17, 2014)… The American Society of Hematology (ASH) published last week as part of its Choosing Wisely® campaign two things that physicians dealing with DVT, PE and anticoagulants should avoid [ref 1].



CHOOSING WISELY® INITIATIVE

The Choosing Wisely® campaign is a quality improvement initiative of the ABIM (American Board of Internal Medicine) Foundation. The goal of this initiative is to (a) identify tests and medical practices that are not supported by evidence and that may lead to adverse outcomes and financial costs and (b) encourage physicians and patients to question such tests, procedures and treatments.

ASH joined the Choosing Wisely® campaign and in 2013 identified five hematologic topics for this campaign, three of which dealt with DVT, PE and anticoagulants [ref 1] – these have previously been discussed on Clot Connect (link here). Five additional topics were identified this year, two of which deal with thrombosis topics [ref 2].

THE TWO NEW RECOMMENDATIONS

1. Length of Anticoagulation Treatment for DVT and PE

ASH recommendation: “Do not treat with an anticoagulant for > 3 months in a patient with a first venous thromboembolic event (VTE) occurring in the setting of a major transient risk factor”.

transient risk factor”. Comment: This recommendation is in keeping with existing evidence-based guidelines: the ACCP 2012 guidelines state that “for a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B [1B: Strong recommendation, moderate-quality evidence]; Grade 2B [2B: Weak recommendation, moderate-quality evidence] if provoked by a nonsurgical risk factor and low or moderate bleeding risk) [ref 3].It is worth highlighting that the risk of recurrent VTE in patients associated with minor risk factors (contraceptives, estrogen replacement therapy or pregnancy, minor surgery, minor immobility such as long-distance travel) appears to be intermediate [ref 4,5] and that for several conditions, such as VTE associated with longer or shorter airline travel or minor surgeries (such as outpatient arthroscopic surgery), the risk of recurrence is not known or only poorly defined; individualized treatment decisions need to be made. Therefore, the Choosing Wisely® recommendation to treat for not longer than 3 months is referring only to VTE associated with a major transient risk factor.

2. Heparin-Induced Thrombocytopenia (HIT)

ASH recommendation: “Do not test or treat for suspected HIT in patients with a low pre-test probability of HIT”.

Comment: The “4T score” [ref 6; link to the score here ] is easy to use in clinical practice and is a helpful way to assess the likelihood that a patient on may have HIT [ref 6]. A low probability 4Ts score appears to be a robust means of excluding HIT; patients with intermediate and high probability scores require further evaluation [ref 7]. The ASH recommendation makes sense.



REFERENCES

Hicks LK et al. Five hematologic tests and treatments to question. Blood 2013, Dec 4;124(24):3524-8. Hicks LK et al. Five hematologic tests and treatments to question. Hematology 2014:599-603. Kearon C et al. Antithrombotic Therapy for VTE Disease Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2)(Suppl):e419S–e494S. Le Gal G et al. Risk of recurrent venous thromboembolism after a first oestrogen-associated episode. Data from the REVERSE cohort study. Thromb Haemost 2010;104(3):498-503. Iorio A et al. Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. Arch Intern Med 2010;170(19):1710-1716. Lo GK et al. Evaluation of pretest clinical score (4 T’s) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost 2006;4(4):759-765 Cuker A et al. Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood 2012 Nov 15;120(20):4160-7.

Disclosures: None

Last updated: Dec 17,2014

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