Unmet clinical needs in the management of venous thromboembolism in at-risk patients
Review suggests inconsistency of recommendations and paucity of precise risk assessment tools and biomarkers.
- Low-molecular-weight heparin (LMWH) is the anticoagulant of choice in pregnant women and obese patients for venous thromboembolism (VTE) prophylaxis; however, LMWH dose adjustment is a significant problem in these patients.
- In elderly, LMWH showed a better safety and efficacy profile than unfractionated heparin (UFH) for thromboprophylaxis; however, the benefit of VTE prophylaxis needs to be evaluated against the bleeding risk.
- In high-risk patients, guideline recommendations are inconsistent and physician’s views are heterogeneous on VTE prophylaxis.
- This review highlights the need for the development of user-friendly, population-adapted VTE risk assessment tools and clinically valuable biomarkers.
- In this study, a gap analysis was performed to highlight unmet needs in VTE management and discover the high-risk patients.
- 44 key opinion leaders from 12 different countries or regions were interviewed with a pre-determined questionnaire.
- A comprehensive literature search was conducted on VTE in the specific patient groups (pregnant women, elderly and obese patients) during 2015-2017.
- Findings from the qualitative and quantitative research were discussed in a Thrombosis Think Tank meeting in 2018.
- Funding: Editorial assistance was supported by Sanofi.
- Management of VTE during pregnancy and post-partum:
- LMWH is the preferred anticoagulant for prophylaxis and treatment of VTE during pregnancy, but there is an inconsistency in the ideal LMWH dose.
- Experts agreed that anti-Xa monitoring for LMWH dosing in pregnant women at very high risk is widely used and likely beneficial.
- Effects of direct oral anticoagulants (DOACs) on the foetus or the newborn child are currently unknown.
- A history of VTE or heritable thrombophilia is an established risk factor of VTE during pregnancy.
- Predictive utility of all conventional and candidate VTE biomarkers is unclear during pregnancy and puerperium.
- Guidelines and opinions differ on risk stratification, duration of prophylaxis and the safety of DOACs during pregnancy.
- Development of more precise risk assessment tools and biomarkers is needed.
- Management of VTE in elderly:
- LMWH showed a better safety and efficacy profile over UFH for thromboprophylaxis in elderly.
- Although DOACs are considered convenient in elderly patients outside the hospital setting, safety remains unclear.
- The experts agreed on careful benefit-risk assessments during thromboprophylaxis.
- Drug compliance, bleeding risks and co-morbidities should be considered while prescribing thromboprophylaxis.
- The experts noted disparities in risk assessment guidance and thromboprophylaxis practice across countries.
- Management of VTE in obese patients:
- The interviewed physicians prefer LMWHs over DOACs for thromboprophylaxis in obese patients.
- The efficacy and safety of DOACs have not been adequately investigated for thromboprophylaxis.
- Clinical practice guidelines highlight the need for the development of dosing regimens.
- However, it is uncertain whether dose adjustment should be based on weight, body mass index or a fixed-dose regimen.
- Majority of experts agree on LMWH dose adjustment based on patient’s weight
Brenner B, Arya R, Beyer-Westendorf J, Douketis J, Hull R, Elalamy I, Imberti D, Zhai Z. Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in at-risk patient groups: pregnancy, elderly and obese patients. Thromb J. 2019;17:24. doi: 10.1186/s12959-019-0214-8. PMID: 31889915.