Tratamiento anticoagulante en pacientes médicos con situaciones clínicas complejas / Anticoagulant treatment of medical patients with complex clinical conditions

La información disponible sobre el tratamiento o profilaxis con fármacos anticoagulantes en pacientes ambulatorios con enfermedades médicas y situaciones clínicas complejas es escasa, y no existen guías de práctica clínica y/o recomendaciones específicas para este subgrupo de sujetos, quienes son frecuentemente atendidos por los internistas. Entendemos por situaciones clínicas complejas aquellas en que por la comorbilidad, edad, pronóstico vital o tratamiento múltiple con fármacos de los pacientes, se configura una situación clínica de interacciones enfermedad-enfermedad; enfermedad-fármaco o fármaco-fármaco que no se incluye dentro de los escenarios sobre los que habitualmente se generan las evidencias científicas. El objetivo de esta revisión narrativa es recopilar y adaptar las recomendaciones de guías clínicas y revisiones sistemáticas a situaciones clínicas complejas, donde puede ser conflictivo la aplicación directa de recomendaciones basadas en estudios que no incorporan a pacientes con dicha complejidad y comorbilidad

There is scarce available information on the treatment or prophylaxis with anticoagulant drugs of outpatients with medical diseases and complex clinical conditions. There are no clinical practice guidelines and/or specific recommendations for this patient subgroup, which are frequently treated by internists. Complex clinical conditions are those in which, due to comorbidity, age, vital prognosis or multiple treatment with drugs, a clinical situation arises of disease-disease, disease-drug or drug-drug interactions that is not included within the scenarios that commonly generate the scientific evidence. The objective of this narrative review is collecting and adapting of the clinical guidelines recommendations and systematic reviews to complex clinical conditions, in which the direct application of recommendations based on studies that do not include patients with this complexity and comorbidity could be problematic

Anticoagulant treatment of medical patients with complex clinical conditions. / Tratamiento anticoagulante en pacientes médicos con situaciones clínicas complejas.

There is scarce available information on the treatment or prophylaxis with anticoagulant drugs of outpatients with medical diseases and complex clinical conditions. There are no clinical practice guidelines and/or specific recommendations for this patient subgroup, which are frequently treated by internists. Complex clinical conditions are those in which, due to comorbidity, age, vital prognosis or multiple treatment with drugs, a clinical situation arises of disease-disease, disease-drug or drug-drug interactions that is not included within the scenarios that commonly generate the scientific evidence. The objective of this narrative review is collecting and adapting of the clinical guidelines recommendations and systematic reviews to complex clinical conditions, in which the direct application of recommendations based on studies that do not include patients with this complexity and comorbidity could be problematic.

Consenso Delphi-RAND de la Sociedad Española de Medicina Interna sobre controversias en terapia y profilaxis anticoagulante en enfermedades médicas. Proyecto INTROMBIN (INcertidumbre en TROMBoprofilaxis en Medicina INterna) / Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine)

El objetivo de este estudio ha sido conocer la opinión de los internistas sobre el manejo de la anticoagulación y profilaxis tromboembólica en escenarios clínicos complejos en los que el balance riesgo/beneficio de la intervención es estrecho y elaborar un documento de consenso sobre el uso de fármacos anticoagulantes en este grupo de pacientes. Para ello, se identificaron por consenso las áreas clínicas de mayor incertidumbre, se elaboró una encuesta con 20 escenarios desplegados en 40 preguntas clínicas y se realizó una revisión bibliográfica específica. La encuesta se distribuyó entre los internistas de la Sociedad Española de Medicina Interna (SEMI) y fue cumplimentada por 290 de sus miembros. El proceso de consenso se desarrolló mediante una modificación del método Delphi-RAND de adecuación en un proceso anonimizado de doble ronda que permite al panel de expertos identificar áreas de acuerdo y de incertidumbre. En nuestro caso, además, se incorporaron al panel los resultados de la encuesta, innovación metodológica que permite aportar información adicional de la práctica clínica habitual. El resultado del proceso es un conjunto de 19 recomendaciones formuladas por expertos de la SEMI que permite establecer pautas de actuación sobre el tratamiento anticoagulante en escenarios complejos (alto riesgo o hemorragia activa, corta expectativa vital, coexistencia de tratamiento antiagregante o comorbilidades como enfermedad renal, hepática, etc.), que no son infrecuentes en la práctica clínica habitual

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice

Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine). / Consenso Delphi-RAND de la Sociedad Española de Medicina Interna sobre controversias en terapia y profilaxis anticoagulante en enfermedades médicas. Proyecto INTROMBIN (INcertidumbre en TROMBoprofilaxis en Medicina INterna).

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice.