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2.
Eur J Haematol ; 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32441350

RESUMO

Venous thromboembolism (VTE) remains the second most common cause of death in cancer patients.1 Direct oral anticoagulants (DOACs) have revolutionized treatment of VTE, though cancer patients were underrepresented in early trials.2-4 Low-molecular weight heparins (LMWH) have been the gold-standard for treatment of cancer-associated thrombosis (CAT)5,6 until publication of several randomized controlled trials (RCT) exploring DOACs for CAT.7,8 In 2019, two systematic reviews and meta-analyses evaluated two RCTs7,8 and showed a trend toward reduced VTE recurrence and increased major bleeding with DOACs compared with LMWH.9,10 We performed an updated systematic review and meta-analysis on the efficacy and safety of DOACs for CAT.

3.
Obstet Gynecol Surv ; 75(3): 190-198, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32232497

RESUMO

Importance: Mechanical heart valves (MHVs) pose significant thrombogenic risks to pregnant women and their fetuses, yet the choice of anticoagulation in this clinical setting remains unclear. Various therapeutic strategies carry distinct risk profiles that must be considered when making the decision about optimal anticoagulation. Objective: We sought to review existing data and offer recommendations for the anticoagulation of pregnant women with MHVs, as well as management of anticoagulation in the peripartum period. Evidence Acquisition: We performed a literature review of studies examining outcomes in pregnant women receiving systemic anticoagulation for mechanical valves, and also reviewed data on the safety profiles of various anticoagulant strategies in the setting of pregnancy. Results: Warfarin has been shown to increase rates of embryopathy and fetal demise, although it has traditionally been the favored anticoagulant in this setting. Low-molecular-weight heparin, when dosed appropriately with close therapeutic monitoring, has been shown to be safe for both mother and fetus. Conclusions: We favor the use of low-molecular-weight heparin with appropriate dosing and monitoring for the anticoagulation of pregnant women with MHVs. Data suggest that this approach minimizes the thrombotic risk associated with the valve while also providing safe and effective anticoagulation that can be easily managed in the peripartum period.

4.
J Thromb Thrombolysis ; 49(4): 602-605, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32219721

RESUMO

Thrombotic Microangiopathy (TMA) is a heterogeneous collection of syndromes that encompasses TTP, HUS, and other processes characterized by thrombocytopenia, microangiopathic hemolytic anemia, and, if untreated, organ failure and death. Novel therapies have recently been approved for the management of certain thrombotic microangiopathies, including caplacizumab for immune-mediated TTP, and eculizumab for atypical HUS. These options have complicated the standard workflow, which includes initiation of plasma exchange until ADAMTS13 testing can be resulted. Given such results may take several days, there is indecision regarding the appropriate initial management of TMA. Decisions regarding caplacizumab and eculizumab are complex, and include considerations over costs, side effects, and efficacy. In the following forum, we discuss the current data and pose possible management strategies in patients with TMA before final diagnosis can be obtained.

5.
Eur J Haematol ; 104(2): 79-87, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31729076

RESUMO

Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.

6.
Eur J Haematol ; 104(1): 55-58, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31594025

RESUMO

OBJECTIVE: Evans syndrome, the combination of immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) or autoimmune neutropenia, is associated with a high rate of relapsed/refractory disease. There are limited data on the efficacy of splenectomy for this condition. We reviewed patient outcomes after splenectomy for Evans syndrome compared to ITP at our institution. METHODS: We performed a retrospective analysis of patients who underwent splenectomy for autoimmune cytopenias over a 23-year period with the intention of comparing disease relapse rates after splenectomy in patients with Evans syndrome and in those with ITP. RESULTS: During the study period, 77 patients underwent splenectomy for ITP and seven underwent splenectomy for Evans syndrome. In the Evans cohort, splenectomy led to an 85.7% initial response rate with a 42.8% rate of relapse within one year and a long-term (one-year) response rate of 42.8%. In the ITP cohort, the initial response rate was 90.9% with a long-term response rate of 70.1%. CONCLUSION: Our data suggest that long-term remission rates after splenectomy are lower in adults with Evans syndrome compared to those with ITP, although splenectomy may still be an acceptable treatment for certain patients with Evans syndrome. Our findings underscore the need for further research and development of additional therapeutic strategies for this patient population.

7.
Res Pract Thromb Haemost ; 3(4): 589-598, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31624778

RESUMO

Hemostatic complications are common in patients with ventricular assist devices. The pathophysiologic mechanisms that lead to dysregulated hemostasis involve complex interactions between device surface, sheer stress, and blood flow. These factors lead to various manifestations that require a thorough understanding of the interplay among platelets, coagulation factors, and red cells. In this article, we review the pathophysiology of hematologic complications (bleeding, acquired von Willebrand disease, heparin-induced thrombocytopenia, hemolysis, stroke and pump thrombosis), the clinical manifestations, and the management of each. We summarize the evidence available for management of these entities and provide a pragmatic clinical review.

8.
Drugs ; 79(15): 1625-1634, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31440911

RESUMO

Compared with warfarin, the direct-acting oral anticoagulants (DOAC) have fewer pharmacokinetic drug interactions. However, significant drug interactions do exist with documented changes in DOAC concentrations, which can exceed 100%. Unlike warfarin, DOACs have no validated surrogate test to monitor the intensity of anticoagulation. However, several analyses of major outcomes trials with DOACs have demonstrated that serum concentrations do affect both the thrombotic benefits and the hemorrhagic risks of these agents. This paper reviews the known significant pharmacokinetic interactions with DOACs and includes considerations for their use in the presence of interacting medications.

9.
Res Pract Thromb Haemost ; 3(3): 498-502, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31294334

RESUMO

Despite therapeutic anticoagulation, patients with venous thromboembolism (VTE) not uncommonly present with findings of progressive thrombosis, sometimes within the first several weeks of treatment. While the prevailing strategy in these scenarios is to assume the current anticoagulant is ineffective and to switch to a different drug class, this practice may be unnecessary. Numerous trials of heparins and vitamin K antagonists for VTE have demonstrated that asymptomatic thrombus propagation despite therapeutic anticoagulation is common. While similar, serial imaging studies after initial VTE have not been replicated in trials of the direct oral anticoagulants, we reason that asymptomatic thrombus propagation detected within the first month of VTE diagnosis can be managed with continuation of the current anticoagulant strategy and close follow-up for worsening or recurrent symptoms.

12.
Acta Haematol ; 142(1): 8-12, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30970354

RESUMO

As the adverse effects of iron deficiency are better recognized, the use of oral and intravenous iron has increased dramatically. Oral iron is often poorly tolerated, with up to 70% or more of patients noting gastrointestinal issues; this may affect adherence to therapy. In addition, many patients will not respond to oral iron due to their underlying illness. Intravenous iron is being used more frequently to replete iron stores. True anaphylaxis is very rare, but complement-mediated infusion reactions may be seen in up to 1 in every 200 patients. Previous concerns about intravenous iron increasing the risk of infection or cardiovascular disease are unfounded.


Assuntos
Doenças Cardiovasculares/etiologia , Ferro/efeitos adversos , Administração Intravenosa , Administração Oral , Anemia Ferropriva/tratamento farmacológico , Humanos , Hipofosfatemia/etiologia , Ferro/administração & dosagem , Fatores de Risco
13.
J Thromb Thrombolysis ; 47(4): 585-589, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30673943

RESUMO

Peripherally-inserted central catheters (PICCs) are commonly used during hospitalization. Unfortunately, their use can be complicated by catheter-related thrombosis (CRT). Current guidelines recommend 3-6 months of anticoagulation for patients with CRT after catheter removal. This recommendation is based on extrapolation of data on lower extremity thrombosis, as data is lacking regarding the efficacy and safety of more specific management strategies. Many providers feel catheter removal alone is a reasonable treatment option, particularly for patients at risk for bleeding. We performed a retrospective analysis of hospitalized adult patients diagnosed with CRT at our center. We determined rates of progressive thrombosis and bleeding in cohorts of patients who underwent catheter removal vs those who had catheters removed and received anticoagulation. Among 83 total patients, 62 were treated with PICC removal alone, while 21 underwent PICC removal followed by therapeutic anticoagulation. Patients treated with PICC removal alone were more likely to have hematologic malignancy, receive chemotherapy, develop thrombocytopenia, and have brachial vein thrombosis. No patients in the PICC removal plus anticoagulation arm developed progressive thrombosis, while 6.4% of patients treated with catheter removal alone developed a secondary VTE event, including one PE, three DVTs, and five patients (8%) who developed progressive symptoms leading to initiation of anticoagulation. Major bleeding was significantly more common in the PICC removal + anticoagulation arm (28.5% vs. 4.8% p = 0.007). Catheter-removal alone results in significantly reduced major bleeding compared with catheter-removal plus anticoagulation. In select patients, catheter removal alone may be an option for CRT.


Assuntos
Anticoagulantes/administração & dosagem , Cateterismo Periférico , Remoção de Dispositivo , Padrão de Cuidado , Trombose/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/terapia
14.
Eur J Haematol ; 102(1): 53-62, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30267448

RESUMO

Thrombosis of unusual venous sites encompasses a large part of consultative hematology and is encountered routinely by practicing hematologists. Contrary to the more commonly encountered lower extremity venous thrombosis and common cardiovascular disorders, the various thromboses outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review attempts to outline the most up to date literature on cerebral, retinal, upper extremity, hepatic, portal, splenic, mesenteric, and renal vein thrombosis, focusing on the incidence, pathophysiology, provoking factors, and current recommended treatments for each type of unusual thrombosis to provide a useful and practical review for the hematologist.


Assuntos
Trombose Venosa/diagnóstico , Trombose Venosa/terapia , Síndrome de Budd-Chiari/diagnóstico , Síndrome de Budd-Chiari/etiologia , Síndrome de Budd-Chiari/terapia , Veias Cerebrais/patologia , Gerenciamento Clínico , Humanos , Veias Mesentéricas/patologia , Veia Porta/patologia , Veias Renais/patologia , Veia Retiniana/patologia , Veia Esplênica/patologia , Extremidade Superior/patologia , Trombose Venosa/etiologia
16.
Eur J Haematol ; 102(1): 3-19, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30203452

RESUMO

Anticoagulation has multiple roles in the treatment of cardiovascular disease, including in management of acute myocardial infarction, during percutaneous coronary intervention, as stroke prophylaxis in patients with atrial arrhythmias, and in patients with mechanical heart valves. Clinical anticoagulation choices in the aforementioned diseases vary widely, due to conflicting data to support established agents and the rapid evolution of evidence-based practice that parallels more widespread use of novel oral anticoagulants. This review concisely summarizes evidence-based guidelines for anticoagulant use in cardiovascular disease, and highlights new data specific to direct oral anticoagulants.


Assuntos
Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Cardiopatias/sangue , Cardiopatias/terapia , Algoritmos , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Ensaios Clínicos como Assunto , Terapia Combinada/efeitos adversos , Terapia Combinada/métodos , Gerenciamento Clínico , Cardiopatias/complicações , Cardiopatias/diagnóstico , Humanos , Prevenção Secundária , Resultado do Tratamento
17.
Platelets ; 30(6): 796-798, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30422039

RESUMO

Chronic liver disease (CLD) alters normal hemostatic and thrombotic systems via multiple mechanisms including reduced platelet function and number, leading to challenging peri-operative planning. Hepatic thrombopoietin (TPO) synthesis is reduced in CLD, leading to several recent randomized, placebo-controlled trials examining the utility of TPO-mimetics to increase platelet counts prior to surgery. While these trials do suggest that TPO-mimetics are efficacious at increasing platelet counts in patients with CLD and have led to several recent drug approvals in this space by the U.S. Food & Drug Administration, it remains unclear whether these results translate to the relevant clinical endpoint of reduced perioperative bleeding rate and severity. In this article, we review several recently-published, phase 3 trials on the TPO-mimetics eltrombopag, avatrombopag and lusutrombopag, and discuss the clinical significance of their results.


Assuntos
Hemorragia/etiologia , Hepatopatias/complicações , Trombocitopenia/sangue , Trombopoetina/uso terapêutico , Doença Crônica , Hemorragia/patologia , Humanos , Hepatopatias/sangue , Hepatopatias/patologia
18.
Obstet Gynecol Surv ; 73(7): 418-422, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30062383

RESUMO

In women with postpartum hemorrhage, the need to transfuse a large amount of blood products is frequent. The ABCD of massive transfusions-Assessment/Activation, Blood products, Complications, and Drugs-can help manage this complex situation. There needs to be a defined method to activate the massive transfusion protocol and a well-defined means to assess the coagulation status of the patient by either traditional laboratory tests or point of care methods such as thromboelastography. Recent data supports more aggressive use of plasma in the massively transfused patient. Obstetricians need to be vigilant in assessing compilations, especially hypothermia. Given the increased use of antithrombotic drugs in bleeding patients, one needs to consider reversal of these agents. Finally, consideration of the role of other agents such as antifibrinolytic agents in the management of the bleeding patient is important. It is important for every hospital to have a well-defined massive transfusion protocol to streamline the care of postpartum hemorrhage.


Assuntos
Antifibrinolíticos/uso terapêutico , Transfusão de Sangue/métodos , Hemorragia Pós-Parto/diagnóstico por imagem , Hemorragia Pós-Parto/terapia , Ácido Tranexâmico/uso terapêutico , Testes de Coagulação Sanguínea , Feminino , Humanos , Hipotermia/diagnóstico , Hipotermia/etiologia , Gravidez , Tromboelastografia
19.
Am J Nephrol ; 48(2): 96-107, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30110670

RESUMO

The terminal complement-inhibitor eculizumab has dramatically changed the management of patients with atypical hemolytic uremic syndrome (aHUS), and has also shown promise for treating certain forms of secondary HUS (sHUS), including that caused by drugs and solid-organ/hematopoietic stem cell transplant. While effective, eculizumab is costly and inconvenient. In this review, we evaluate the literature on eculizumab cessation in these diseases to better inform clinicians who consider stopping therapy. Reported relapse rates in aHUS after stopping eculizumab are as high as 30%, suggesting indefinite therapy is reasonable and that patients who choose to stop should be closely monitored. In sHUS, relapse is rare, justifying short courses of eculizumab.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Síndrome Hemolítico-Urêmica Atípica/tratamento farmacológico , Inativadores do Complemento/uso terapêutico , Guias de Prática Clínica como Assunto , Suspensão de Tratamento/normas , Anticorpos Monoclonais Humanizados/economia , Síndrome Hemolítico-Urêmica Atípica/economia , Inativadores do Complemento/economia , Inativadores do Complemento/normas , Humanos , Recidiva , Fatores de Tempo , Suspensão de Tratamento/economia
20.
Eur J Haematol ; 101(6): 728-736, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30129979

RESUMO

While cardiovascular disease is common, occasionally hematologists and other practitioners will encounter patients with arterial thrombosis/infarction in unusual sites, without clear cause or obvious diagnostic and treatment paradigms. Contrary to the more commonly encountered cerebrovascular accident and cardiovascular disorders, the various infarctions outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review outlines the current literature on arterial thrombosis, with consideration given to anatomic sources and hypercoagulable associations, while focusing on the epidemiology, pathophysiology, provoking factors, and current recommended treatments for intracardiac thrombus, primary aortic mural thrombus, visceral infarctions, and cryptogenic limb ischemia to provide a useful and practical review for the practitioner.


Assuntos
Artérias/patologia , Trombose/diagnóstico , Trombose/etiologia , Gerenciamento Clínico , Humanos , Especificidade de Órgãos , Trombofilia/sangue , Trombofilia/complicações , Trombose/terapia
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