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1.
Implement Sci ; 14(1): 75, 2019 07 24.
Artigo em Inglês | MEDLINE | ID: mdl-31340835

RESUMO

BACKGROUND: The study covered in- and out-of-hospital care in a region in north-western Spain. The intervention evaluated took the form of a change in the hospital drugs formulary. Before the intervention, the formulary contained four of the five low molecular weight heparins (LMWHs) marketed in Spain. The intervention consisted of withdrawing two LMWHs (bemiparin and dalteparin) from the formulary and restricting the use of another (tinzaparin), leaving only enoxaparin as an unrestricted prescription LMWH. Accordingly, the aim of this study was to evaluate the effect on in- and outpatient drug prescriptions of removing and restricting the use of several LMWHs in a hospital drugs formulary. METHODS: We used a natural, before-after, quasi-experimental design with a control group and monthly data from January 2011 to December 2016. Based on data drawn from official Public Health Service sources, the following dependent variables were extracted: defined daily doses (DDD) per 1000 inhabitants per day (DDD/TID), DDD per 100 stays per day, and expenditure per DDD. RESULTS: The two compounds that were removed from the formulary registered an immediate decrease at both an intra- and out-of-hospital level (66.6% and 55.6% for bemiparin and 73.0% and 92.2% for dalteparin, respectively); similarly, the compound that was restricted also registered an immediate decrease (36.1% and 9.0% at the in- and outpatient levels, respectively); in contrast, the remaining LMWH (enoxaparin) registered an immediate, significant increase at both levels (44.9% and 32.6%, respectively). The intervention led to an immediate reduction of 6.8% and a change in trend in out-of-hospital cost/DDD; it also avoided an expenditure of €477,317.1 in the 21 months following the intervention. CONCLUSIONS: The results indicate that changes made in a hospital drugs formulary towards more efficient medications may lead to better use of pharmacotherapeutic resources in its health catchment area.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Enoxaparina/uso terapêutico , Formulários de Hospitais como Assunto , Heparina de Baixo Peso Molecular/uso terapêutico , Análise de Séries Temporais Interrompida , Dalteparina/provisão & distribução , Enoxaparina/economia , Enoxaparina/provisão & distribução , Heparina de Baixo Peso Molecular/economia , Heparina de Baixo Peso Molecular/provisão & distribução , Humanos , Espanha , Tinzaparina/provisão & distribução
2.
Rev Col Bras Cir ; 46(2): e2075, 2019 May 09.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31090863

RESUMO

Total knee arthroplasty is an elective procedure performed on relatively healthy individuals. However, due to the inherent risk of venous thromboembolism, drugs are used for its prophylaxis. The objective of the present study was to conduct a systematic review of the literature to compare the efficacy of enoxaparin and rivaroxaban in preventing this complication and the risk of intraoperative bleeding. We reviewed the SciELO, Pubmed and Cochrane databases with the descriptors knee arthroplasty, rivaroxaban and enoxaparin through the PICO search strategy. Inclusion criteria were the articles during the study period comparing both drugs in knee arthroplasty. Relevant criteria to study eligibility were articles published since 2010 and with a sample of more than 20 patients; studies obtained in their entirety; and studies with follow-up of more than 12 months. The variables used to compare the articles were the most common postoperative complications of knee arthroplasties: venous thromboembolism and bleeding. We used the Review Man software, version 5.3, for structuring the review. In the studies analyzed, considering symptomatic venous thromboembolism, rivaroxaban resulted in higher benefits when compared to enoxaparin.


Assuntos
Anticoagulantes/uso terapêutico , Artroplastia do Joelho/efeitos adversos , Enoxaparina/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Rivaroxabana/uso terapêutico , Tromboembolia Venosa/prevenção & controle , Perda Sanguínea Cirúrgica , Humanos , Complicações Pós-Operatórias/etiologia , Hemorragia Pós-Operatória/induzido quimicamente , Fatores de Risco , Resultado do Tratamento , Tromboembolia Venosa/etiologia
3.
Clin Appl Thromb Hemost ; 25: 1076029619840701, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30987427

RESUMO

Heparin and its low-molecular-weight heparin derivatives are widely used clinical anticoagulants. These drugs are critical for the practice of medicine in applications, including kidney dialysis, cardiopulmonary bypass, and in the management of venous thromboembolism. Currently, these drugs are derived from livestock, primarily porcine intestine and less frequently bovine intestine and bovine lung. The worldwide dependence on the pig as a single dominant animal species has made the supply chain for this critical drug quite fragile, leading to the search for other sources of these drugs, including the expanded use of bovine tissues. A number of laboratories are now also examining the similarities between heparin and low-molecular-weight heparins prepared from porcine and ovine tissues. This study was designed to compare low-molecular-weight heparin prepared from ovine heparin through chemical ß-elimination, a process currently used to prepare the low-molecular-weight heparin, enoxaparin. Using top-down, bottom-up, and compositional analyses as well as bioassays, low-molecular-weight heparin derived from ovine intestine was shown to closely resemble enoxaparin. Moreover, the compositions of daughter low-molecular-weight heparins prepared from three unfractionated ovine parent heparins were compared. Ovine enoxaparins had similar molecular weight and in vitro anticoagulant activities as Lovenox. Some disaccharide compositional, oligosaccharide composition at the reducing and nonreducing ends and intact chain compositional differences could be observed between porcine enoxaparin and ovine low-molecular-weight heparin. The similarity of these ovine and porcine heparin products suggests that their preclinical evaluation and ultimately clinical assessment is warranted.


Assuntos
Anticoagulantes/química , Enoxaparina/química , Heparina de Baixo Peso Molecular/química , Animais , Anticoagulantes/uso terapêutico , Bovinos , Enoxaparina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Peso Molecular , Ovinos , Suínos , Tromboembolia Venosa/tratamento farmacológico
4.
Cochrane Database Syst Rev ; 3: CD010019, 2019 03 06.
Artigo em Inglês | MEDLINE | ID: mdl-30839095

RESUMO

BACKGROUND: Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of the review first published in 2014. OBJECTIVES: To compare the efficacy and safety of outpatient versus inpatient treatment in low-risk patients with acute PE for the outcomes of all-cause and PE-related mortality; bleeding; adverse events such as haemodynamic instability; recurrence of PE; and patients' satisfaction. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 26 March 2018. We also undertook reference checking to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. DATA COLLECTION AND ANALYSIS: Two review authors selected relevant trials, assessed methodological quality, and extracted and analysed data. We calculated effect estimates using risk ratio (RR) with 95% confidence intervals (CIs), or mean differences (MDs) with 95% CIs. We used standardised mean differences (SMDs) to combine trials that measured the same outcome but used different methods. We assessed the quality of the evidence using GRADE criteria. MAIN RESULTS: One new study was identified for this 2018 update, bringing the total number of included studies to two and the total number of participants to 451. Both trials discharged patients randomised to the outpatient group within 36 hours of initial triage and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimes. There was no clear difference in treatment effect for the outcomes of short-term mortality (30 days) (RR 0.33, 95% CI 0.01 to 7.98, P = 0.49; low-quality evidence), long-term mortality (90 days) (RR 0.98, 95% CI 0.06 to 15.58, P = 0.99, low-quality evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57, P = 0.30; low-quality evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14, P = 0.20; low-quality evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; P = 0.96, low-quality evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85, P = 0.51, low-quality evidence), and participant satisfaction (RR 0.97, 95% CI 0.90 to 1.04, P = 0.39; moderate-quality evidence). We downgraded the quality of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and because the effect of missing data and the absence of publication bias could not be verified. PE-related mortality, and adverse effects such as haemodynamic instability and compliance, were not assessed by the included studies. AUTHORS' CONCLUSIONS: Currently, only low-quality evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding and recurrence of PE.


Assuntos
Assistência Ambulatorial , Enoxaparina/uso terapêutico , Hospitalização , Embolia Pulmonar/terapia , Doença Aguda , Adulto , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Intervalos de Confiança , Enoxaparina/efeitos adversos , Hemorragia/epidemiologia , Humanos , Embolia Pulmonar/mortalidade , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico
5.
J Arthroplasty ; 34(4): 729-734, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30685257

RESUMO

BACKGROUND: Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS: The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. RESULTS: In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. CONCLUSION: It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE: Therapeutic Level III. DISCLAIMER: All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.


Assuntos
Anticoagulantes/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Padrões de Prática Médica/estatística & dados numéricos , Tromboembolia Venosa/prevenção & controle , Idoso , Aspirina/uso terapêutico , Bases de Dados Factuais , Enoxaparina/uso terapêutico , Feminino , Fondaparinux , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos/efeitos adversos , Ortopedia , Fatores de Risco , Rivaroxabana , Estados Unidos , Tromboembolia Venosa/etiologia , Trombose Venosa/etiologia , Varfarina/uso terapêutico
6.
J Arthroplasty ; 34(4): 789-800.e6, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30685261

RESUMO

BACKGROUND: The purpose of this study is to perform a meta-analysis to compare outcomes of venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) vs other anticoagulants in patients who received total knee (TKA) or total hip arthroplasty (THA). METHODS: MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched until June 30, 2017 for eligible randomized controlled studies. RESULTS: Thirty-two randomized controlled studies were included. LMWH provided better protection against VTE than placebo. In both TKA and THA patients, the rates of VTE were lower with factor Xa inhibitors than LMWH. In THA patients, the rate of deep vein thrombosis (DVT) was lower with factor Xa inhibitors than LMWH. In TKA patients, the rates of VTE and DVT were similar between LMWH and direct thrombin inhibitors. In THA patients, the rate of VTE was lower with direct thrombin inhibitors than with LMWH, while the DVT rates were similar. The pulmonary embolism rates were similar between all 3 classes of drugs in TKA and THR patients, as were the major bleeding rates. Nonmajor and minor bleeding rates were also similar between the 3 drug classes. CONCLUSION: LMWH is associated with a higher rate of VTE than factor Xa inhibitors in TKA and THA patients. Direct thrombin inhibitors are associated with a lower rate of VTE in THA patients, but their effectiveness with respect to DVT and pulmonary embolism prophylaxis is similar to that of LMWH in TKA and THA patients.


Assuntos
Antitrombinas/uso terapêutico , Artroplastia do Joelho/efeitos adversos , Enoxaparina/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Fibrinolíticos/uso terapêutico , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular , Humanos , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Fatores de Risco , Tromboembolia Venosa/etiologia , Trombose Venosa/etiologia , Trombose Venosa/prevenção & controle
7.
Eur J Obstet Gynecol Reprod Biol ; 234: 53-57, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30660037

RESUMO

Enoxaparin treatment has emerged as an important approach to prevent recurrent miscarriage, but the use of enoxaparin for the prevention of recurrent miscarriage has not been well established. We conduct a systematic review and meta-analysis to evaluate the efficacy of enoxaparin to prevent recurrent miscarriage. PubMed, Embase, and the Cochrane Central Register of Controlled Trials are searched. Randomized controlled trials (RCTs) assessing the influence of enoxaparin (or plus aspirin) treatment versus placebo on prevention of recurrent miscarriage are included. Three RCTs are included in the meta-analysis. Compared with control intervention for recurrent miscarriage, enoxaparin treatment has no substantial influence on live births (RR = 1.07; 95% CI = 0.77-1.47; P = 0.69), miscarriage rate (RR = 0.82; 95% CI = 0.31-2.17; P = 0.68), gestational age (Std. MD=-0.13; 95% CI=-0.78 to 0.52; P = 0.69), birth weight (Std. MD = 0.05; 95% CI=-0.41 to 0.51; P = 0.82), but leads to the increase in pre-eclampsia (RR = 3.42; 95% CI = 1.15-10.11; P = 0.03). Enoxaparin treatment has no additional benefits for women with recurrent miscarriage.


Assuntos
Aborto Habitual/prevenção & controle , Anticoagulantes/uso terapêutico , Enoxaparina/uso terapêutico , Aborto Habitual/tratamento farmacológico , Aspirina/uso terapêutico , Feminino , Humanos , Nascimento Vivo/epidemiologia , Pré-Eclâmpsia/induzido quimicamente , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa
8.
Semin Thromb Hemost ; 45(1): 94-99, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30630208

RESUMO

In trials assessing venous thromboembolism (VTE) treatment, obese patients are under-represented or excluded. The main objective of this article is to examine the safety of weight-based enoxaparin dosing in obesity, as assessed by anti-factor Xa (anti-Xa) activity, bleeding, and recurrence. A 5-year retrospective audit of patients with acute VTE, weighing > 100 kg, prescribed enoxaparin 1 mg/kg twice daily, with an anti-Xa level 2 to 6 hours post-dose. The primary outcome was anti-Xa levels, and the secondary outcomes were bleeding and recurrence. Results were compared with patients weighing < 100 kg (n = 64), and obese patients prescribed doses < 1 mg/kg (n = 28). One-hundred sixty-six patients weighing > 100 kg with VTE were identified, with 64 excluded for not fulfilling criteria. The remaining 102 patients had a median weight of 130 kg (range: 105-222 kg). The median peak anti-Xa level was 0.93 U/mL, with 56% of levels being in the proposed therapeutic range (0.5-1.0 U/mL), 40% > 1.0 U/mL, and 4% < 0.5 U/mL. The median anti-Xa levels and distribution were not significantly different between patients > 100 kg and patients < 100 kg, while obese patients prescribed < 1 mg/kg were more frequently subtherapeutic (21%). Regardless of weight, the majority of patients with moderate renal impairment (eGFR 30-59 mL/min) had an anti-Xa level > 1.0 U/mL (61%). In the obese patients, there was no major bleeding or recurrence within 30 days. In comparison, patients weighing < 100 kg, despite similar peak anti-Xa levels, had higher rates of bleeding and recurrence. This was likely due to their older age and comorbidities, particularly renal impairment and cancer. These data support weight-based dosing of enoxaparin in obesity with no maximum dose, ensuring therapeutic drug levels, with anti-Xa levels suggested in obese patients with clinical risk factors for bleeding.


Assuntos
Anticoagulantes/uso terapêutico , Enoxaparina/uso terapêutico , Obesidade/complicações , Tromboembolia Venosa/tratamento farmacológico , Adulto , Idoso , Anticoagulantes/farmacologia , Enoxaparina/farmacologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/patologia , Estudos Retrospectivos , Tromboembolia Venosa/patologia , Adulto Jovem
9.
Orthopedics ; 42(1): 48-55, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-30602046

RESUMO

Thromboembolic events after total joint arthroplasty are potentially devastating complications. This study evaluated the efficacy of 4 different anticoagulants in preventing deep venous thrombosis and pulmonary embolism after total joint arthroplasty. The demographics and anticoagulant use (warfarin, enoxaparin, and aspirin with and without outpatient mechanical pumps) for patients who underwent primary unilateral total joint arthroplasties performed by a single surgeon from January 2013 to October 2014 were retrospectively reviewed. All patients underwent lower extremity ultrasound at the 3-week postoperative visit. A total of 613 primary unilateral total joint arthroplasties met the study inclusion criteria. There were 288 primary total knee arthroplasties and 325 primary total hip arthroplasties. The patients were 62.2% female, having a mean age of 67.6±10.6 years and a mean body mass index of 30.2±5.9 kg/m2. There were 119 patients in group 1 (aspirin alone), 40 patients in group 2 (aspirin plus pumps), 246 patients in group 3 (warfarin), and 208 patients in group 4 (enoxaparin). The overall 3-week symptomatic and asymptomatic deep venous thrombosis and symptomatic pulmonary embolism rates in the entire cohort were 5.7% and 0.3%, respectively. The venous thromboembolism rate was significantly affected by the anticoagulant of choice (P<.01). Compared with aspirin alone, warfarin decreased the risk of venous thromboembolism (P<.01). Increasing age led to increased risk of venous thromboembolism (P=.05). This study indicated that aspirin chemoprophylaxis alone was not as efficacious as warfarin and enoxaparin in preventing asymptomatic and symptomatic venous thromboembolism found during routine postoperative surveillance with lower extremity ultrasound. Aspirin alone may be inadequate and should be augmented with an outpatient mechanical pump as part of multimodal prophylaxis. [Orthopedics. 2019; 42(1):48-55.].


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Aspirina/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose Venosa/prevenção & controle , Idoso , Anticoagulantes/uso terapêutico , Quimioprevenção , Quimioterapia Combinada , Enoxaparina/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Trombose Venosa/etiologia , Varfarina/uso terapêutico
10.
J Obstet Gynaecol ; 39(4): 451-454, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30580649

RESUMO

A caesarean section (CS) is a major risk factor for a venous thromboembolism, and enoxaparin, a low-molecular-weight heparin, has been widely used for thromboprophylaxis. However, it remains unclear whether an enoxaparin thromboprophylaxis has an acceptable safety profile when given early after CS compared to delayed administration, especially in the presence of an epidural catheter. This study aimed to survey cases in which enoxaparin administration was performed within 24 hours of CS and to evaluate patient outcomes with or without epidural anaesthesia. The number of eligible cases were 578: 328 patients received an epidural anaesthesia (epidural group), and 250 did not (non-epidural group). In both groups, no patient developed a spinal epidural haematoma. A wound or a subcutaneous bleeding occurred in 22 (6.7%) and 20 (8.0%) cases in the epidural and non-epidural groups, respectively. One patient developed a mild pulmonary embolism, and one case of asymptomatic deep vein thrombosis was detected. An enoxaparin administration within 24 hours of CS appears to be reasonable, regardless of an epidural anaesthesia. Impact statement What is already known on this subject? A venous thromboembolism (VTE) after a caesarean section (CS) remains a significant cause of maternal morbidity and mortality. Therefore, a thromboprophylaxis using enoxaparin, a low-molecular-weight heparin, has been widely recommended and accepted. However, there is no consensus regarding the optimal timing to initiate an enoxaparin administration after CS in the presence of an epidural catheter. What do the results of this study add? This is the largest study that has collected cases receiving enoxaparin within 24 hours of a CS. Irrespective of the presence of an epidural catheter, no patient developed a spinal epidural haematoma after an early administration of enoxaparin. Furthermore, the incidence of haemorrhagic complications did not increase. What are the implications of these findings for clinical practice and/or further research? Given the significant incidence of VTE after CS and the extremely low frequency of spinal epidural haematomas, it can be justified to initiate thromboprophylaxis with enoxaparin soon after CS. However, appropriately designed, large clinical trials are necessary to examine the safety and efficacy of an early enoxaparin administration after CS. Based on such studies, the starting time of thromboprophylaxis after a CS should be decided.


Assuntos
Anticoagulantes/uso terapêutico , Cesárea/efeitos adversos , Enoxaparina/uso terapêutico , Complicações Cardiovasculares na Gravidez/prevenção & controle , Transtornos Puerperais/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Adulto , Feminino , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/etiologia , Transtornos Puerperais/etiologia , Resultado do Tratamento , Tromboembolia Venosa/etiologia
11.
Eur J Gastroenterol Hepatol ; 31(1): 34-42, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30188408

RESUMO

BACKGROUND AND OBJECTIVE: Portal vein thrombosis (PVT) is a common complication in cirrhosis, and when complete, it increases morbidity and mortality in liver transplant candidates. The aim of the study was to assess the hemostatic status, as well as clinical characteristics of thrombus and patients, as predictors of therapeutic efficacy of anticoagulation for the treatment of PVT in cirrhotics. PATIENTS AND METHODS: Patients with cirrhosis consecutively treated for PVT with enoxaparin were enrolled. All patients underwent evaluation of coagulation status and thrombophilia screening. Thrombus characteristics and extension were evaluated at baseline and during follow-up. Anticoagulation was continued until recanalization or up to 12 months. Variables correlated with the response to anticoagulation were used to create a predictive score that was validated in an external multicenter cohort. RESULTS: A total of 65 patients were included and had partial PVT in most cases (72%). Treatment with enoxaparin resulted in an overall response rate of 66% (43/65) after a median time of 4.4 months and 76% (33/43) within the first 6 months. At multivariate analysis, efficacy of anticoagulation correlated with the severity of liver disease, complete verus partial PVT, age of the thrombus, and time interval from treatment start (<6 months). The areas under the curve of the statistical model for predicting the response to anticoagulation were 0.84 and 0.76 for the training (n=65) and validation (n=60) cohorts, respectively. CONCLUSION: Early diagnosis and early treatment are key factors for the successful management of PVT in cirrhosis, so that screening of PVT and prompt start of anticoagulant treatment should be mandatory.


Assuntos
Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Técnicas de Apoio para a Decisão , Enoxaparina/uso terapêutico , Cirrose Hepática/complicações , Veia Porta , Trombose Venosa/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Biomarcadores/sangue , Testes de Coagulação Sanguínea , China , Diagnóstico Precoce , Enoxaparina/efeitos adversos , Feminino , Humanos , Itália , Cirrose Hepática/sangue , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Veia Porta/diagnóstico por imagem , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Trombose Venosa/sangue , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia
12.
J. vasc. bras ; 18: e20180021, 2019.
Artigo em Português | LILACS | ID: biblio-984688

RESUMO

O tromboembolismo venoso (TEV) é uma doença frequente e de alta morbimortalidade, sendo considerada a maior causa evitável de mortalidade em pacientes hospitalizados. Apesar da incidência altíssima de TEV em todos os países e das evidências de que a tromboprofilaxia reduz as complicações tromboembólicas em pacientes clínicos e cirúrgicos, e a custo baixo, persistem grandes dúvidas quanto à segurança desse tipo de intervenção nos pacientes e quanto à tromboprofilaxia ideal. Inúmeros estudos e recomendações baseadas em evidências comprovam a eficácia da profilaxia na prevenção do TEV e/ou da morte dos pacientes, mas ainda hoje ela é subutilizada. Neste artigo, apresentamos uma ampla revisão dos métodos de profilaxia existentes até os dias atuais, publicados em diretrizes e estudos nacionais e internacionais sobre tromboprofilaxia


Venous thromboembolism (VTE) is a common disease with high rates of morbidity and mortality and is considered the number one cause of avoidable mortality among hospitalized patients. Although VTE incidence is extremely high in all countries and there is ample evidence that thromboprophylaxis inexpensively reduces the rate of thromboembolic complications in both clinical and surgical patients, a great deal of doubt remains with respect to patient safety with this type of intervention and in relation to the ideal thromboprophylaxis methods. Countless studies and evidence-based recommendations confirm the efficacy of prophylaxis for prevention of VTE and/or patient deaths, but it remains underutilized to this day. This article presents a wide-ranging review of existing prophylaxis methods up to the present, from guidelines and national and international studies of thromboprophylaxis


Assuntos
Humanos , Masculino , Feminino , Prevenção de Doenças , Tromboembolia Venosa/prevenção & controle , Pacientes Internados , Embolia Pulmonar/terapia , Fatores de Risco , Guias de Prática Clínica como Assunto/normas , Enoxaparina/uso terapêutico , Extremidade Inferior , Inibidores do Fator Xa/uso terapêutico , Rivaroxabana/uso terapêutico , Dabigatrana/uso terapêutico , Hemorragia/complicações , Anticoagulantes/uso terapêutico
13.
Gastroenterol. hepatol. (Ed. impr.) ; 41(10): 611-617, dic. 2018. tab, graf
Artigo em Inglês | IBECS | ID: ibc-178232

RESUMO

Background and aim: Treatment for portal vein thrombosis (PVT) is not well established. Nevertheless, anticoagulation therapy can seemingly be used as first-line therapy. However, there are limited data on the role of this treatment in patients with PVT and cirrhosis. We sought to assess the safety and efficacy of anticoagulation therapy in a series of patients with non-malignant PVT and liver cirrhosis. Methods: We analyzed the data of 32 patients with cirrhosis and PVT between March 2009 and September 2015. All patients received anticoagulation treatment. PVT was diagnosed within the context of biannual hepatocellular carcinoma screening in these patients. Results: Recanalisation was achieved in 23 patients: complete in 17 patients (53.1%) and partial in 6 patients (18.7%). The median time for achieving a complete response was 7 months (95% CI: 6-8). We did not discover any risk factors associated with repermeation (partial or complete). None of the patients presented with thrombosis progression while receiving anticoagulation. Nine patients who achieved complete recanalisation and stopped anticoagulation therapy suffered rethrombosis (52%). There were no differences between the patients who achieved complete or partial recanalisation (35%) and those who did not (33%) in relation to the onset of hepatic events during follow-up. Three patients (9%) presented with bleeding complications: two variceal bleeding episodes and one brain hemorrhage. Conclusions: In cirrhotic patients with non-malignant PVT, anticoagulation therapy led to partial or complete recanalisation in 70% of patients, with a broad safety profile. Due to the existing rethrombosis rate, long-term anticoagulation should be considered


Antecedentes y objetivo: El tratamiento de la trombosis de la vena porta (TVP) no está bien consolidado. Sin embargo, parece que el tratamiento anticoagulante puede ser el tratamiento inicial. Con todo, hay datos limitados sobre el papel de este tratamiento en pacientes con TVP y cirrosis. Intentamos evaluar la seguridad y eficacia del tratamiento anticoagulante en una serie de pacientes con TVP benigna y cirrosis hepática. Métodos: Analizamos datos de 32 pacientes con cirrosis y TVP entre marzo de 2009 y septiembre de 2015. Todos los pacientes recibieron tratamiento anticoagulante. La TVP se diagnosticó en el contexto de la detección bianual de carcinoma hepatocelular en estos pacientes. Resultados: La recanalización se logró en 23 pacientes: completa en 17 pacientes (53,1%) y parcial en 6 pacientes (18,7%). La mediana de tiempo para conseguir esta respuesta completa fue 7 meses (IC95: 6-8). No descubrimos ningún factor asociado con la posibilidad de reinfiltración (parcial o completa). Ninguno de los pacientes presentó progresión de la trombosis durante la anticoagulación. Nueve pacientes que lograron una recanalización completa y suspendieron el tratamiento anticoagulante presentaron retrombosis (52%). No hubo diferencias entre los pacientes que lograron la recanalización completa o parcial (35%) y los que no lograron la recanalización (33%) en relación con el desarrollo de sucesos hepáticos durante el seguimiento. Tres pacientes (9%) presentaron complicaciones hemorrágicas: dos episodios de sangrado varicoso y una hemorragia cerebral. Conclusiones: En pacientes cirróticos con TVP benigna, el tratamiento anticoagulante produjo la recanalización parcial o completa en el 70% de los pacientes, con un amplio perfil de seguridad. Debido a la tasa de retrombosis existente, se debe considerar la anticoagulación a largo plazo


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Cirrose Hepática/complicações , Trombose Venosa/tratamento farmacológico , Veia Porta/fisiopatologia , Enoxaparina/uso terapêutico , Estudo Observacional , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/cirurgia , Anticoagulantes/uso terapêutico
14.
J Thromb Thrombolysis ; 46(4): 502-506, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30136019

RESUMO

Despite advantages of low molecular weight heparin (LMWH), enoxaparin over heparin (UFH) for venous thromboembolism (VTE), a hospital's prescribing trends analysis showed use of each was about equal. In an attempt to increase LMWH over UFH use, electronic medical record (EMR) changes for medical service patients and education via multidisciplinary grand rounds was provided to all services. This was a unique opportunity to study LMWH and UFH use pre and post interventions at our institution. Citrix Pharmacy data was extracted for 3 months pre and post intervention (August 2016-February 2017). Inclusion criteria were age > 18 and LMWH or UFH VTE prophylaxis. Exclusion criteria were one time or duplicate orders and VTE treatment doses. Primary endpoint was hospital services VTE use with focus on medicine service which had both interventions compared to single intervention among all other services. LMWH use increased from 51 to 57.3% (p < 0.001) and UFH use decreased from 49 to 42.7% (p < 0.001) for all services. For medicine service, LMWH use increased 52.5-59.6% (p < 0.001) and UFH use decreased 47.5-40.4% (p < 0.001). For other services, LMWH use increased 48.8-53.6% (p = 0.005) and UFH use decreased 51.2-46.4% (p = 0.005). EMR changes and prescribers' grand rounds education resulted in 7.1% increase of LMWH use for medicine and 4.8% increase for all other services. The net increase (95% CI) in LMWH use in medicine service is 2.3% (- 1.91%, 6.56%) compared to the other services p = 0.281. Future studies are needed to reassess the effects of continued education and outcome of interventions.


Assuntos
Enoxaparina/uso terapêutico , Heparina/uso terapêutico , Melhoria de Qualidade , Trombose Venosa/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Prescrições de Medicamentos , Educação Médica , Humanos , Pré-Medicação/estatística & dados numéricos , Pré-Medicação/tendências , Visitas com Preceptor , Adulto Jovem
15.
Medicine (Baltimore) ; 97(31): e11384, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30075504

RESUMO

BACKGROUND: Although low-molecular-weight heparin (LMWH) is recommended as the first-line treatment in patients with active cancer and venous thromboembolism (VTE), many patients are more willing to choose oral anticoagulants. We collected currently available data to evaluate the efficacy and safety of the oral direct factor Xa inhibitor rivaroxaban compared with enoxaparin in patients with cancer and VTE. METHODS: We retrieved electric databases, including Medline/PubMed and EMBASE, from inception through January, 2018. We included articles comparing enoxaparin with rivaroxaban in patients with cancer and VTE. Recurrences of VTE, incidence of major bleeding and deaths were compared between groups. Poole analysis was conducted in Review Manager Version 5.2. RESULTS: A total of 4 articles and 667 patients were included in the final analysis. Pooled analysis showed that rivaroxaban was associated with a non-significantly lower recurrence of VTE (risk ratio [RR] = 0.55, 95% confidence interval (95%CI): 0.28-1.06, I = 0%). Patients treated with rivaroxaban had a similar major bleeding risk compared with those administrated with enoxaparin (RR = 0.84, 95%CI: 0.39-1.83, I = 0%). No significant difference was observed in mortality between the 2 groups (RR = 0.51, 95%CI: 0.15-1.80, I = 89%). CONCLUSION: Rivaroxaban is as effective and safe as enoxaparin for the prevention of recurrent VTE in patients with malignancy. Rivaroxaban is a potential option for patients with cancer and VTE.


Assuntos
Anticoagulantes/uso terapêutico , Enoxaparina/uso terapêutico , Neoplasias/complicações , Rivaroxabana/uso terapêutico , Tromboembolia Venosa/complicações , Tromboembolia Venosa/prevenção & controle , Humanos
16.
BMJ Case Rep ; 20182018 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-29866676

RESUMO

Cerebral venous sinus thrombosis usually occurs in patients with a precipitating condition such as thrombophilic disorders, pregnancy or due to medications, such as oestrogens. Some case reports have reported the co-occurrence of cerebral venous sinus thrombosis in patients with hyperthyroidism. However, the association of cerebral venous sinus thrombosis with hyperthyroidism remains contentious. We present the case of a patient who presented with a clinical picture of cerebral venous sinus thrombosis with no obvious precipitating factor. Further investigations revealed the presence of hyperthyroidism due to Graves' disease, which was thought to be the provocative disorder for cerebral venous sinus thrombosis. We would like to draw the attention of clinicians to a possible causative association between cerebral venous sinus thrombosis and hyperthyroidism.


Assuntos
Doença de Graves/complicações , Trombose dos Seios Intracranianos/etiologia , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Anticoagulantes/uso terapêutico , Antitireóideos/uso terapêutico , Carbimazol/uso terapêutico , Angiografia por Tomografia Computadorizada , Enoxaparina/uso terapêutico , Doença de Graves/tratamento farmacológico , Humanos , Imagem por Ressonância Magnética , Masculino , Flebografia , Propranolol/uso terapêutico , Trombose dos Seios Intracranianos/diagnóstico por imagem , Trombose dos Seios Intracranianos/tratamento farmacológico , Varfarina/uso terapêutico
17.
BMJ Case Rep ; 20182018 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-29866692

RESUMO

Ergotism is an ischaemic complication due to vasoconstriction throughout the body due to ingestion of ergotamine. A 34-year-old Hispanic man with HIV infection treated with saquinavir, ritonavir and abacavir/lamivudine presented to the emergency department complaining of left foot pain 1 week prior to admission. The affected extremity was cold with absence of pedal and tibial pulses. Arterial Doppler revealed absent arterial flow from the popliteal artery later confirmed by arteriography. Medication reconciliation revealed a recent prescription for migraine headache containing ergotamine. Drug was discontinued and the patient was started on cilostazol, enoxaparin and nitroglycerin patches on the affected limb. Complete resolution of symptoms and arteriography findings occurred 2 days after therapy began.


Assuntos
Fármacos Anti-HIV/efeitos adversos , Inibidores do Citocromo P-450 CYP3A/efeitos adversos , Ergotamina/efeitos adversos , Ergotismo/etiologia , Infecções por HIV/tratamento farmacológico , Cefaleia/tratamento farmacológico , Isquemia/induzido quimicamente , Ritonavir/efeitos adversos , Saquinavir/efeitos adversos , Vasoconstritores/efeitos adversos , Adulto , Fármacos Anti-HIV/uso terapêutico , Anticoagulantes/uso terapêutico , Cilostazol , Didesoxinucleosídeos/uso terapêutico , Combinação de Medicamentos , Interações de Medicamentos , Enoxaparina/uso terapêutico , Ergotismo/tratamento farmacológico , Humanos , Isquemia/diagnóstico , Isquemia/tratamento farmacológico , Lamivudina/uso terapêutico , Extremidade Inferior/irrigação sanguínea , Masculino , Nitroglicerina/uso terapêutico , Tetrazóis/uso terapêutico , Artérias da Tíbia/diagnóstico por imagem , Ultrassonografia Doppler em Cores , Vasodilatadores/uso terapêutico
18.
Medicine (Baltimore) ; 97(26): e11183, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29952969

RESUMO

RATIONALE: Portal vein thrombosis (PVT) is relatively common in patients with liver cirrhosis waiting for liver transplantation (LT). Anticoagulation is an important non-invasive treatment strategy for patients with cirrhosis and PVT. PATIENT CONCERNS: This is the case of a 51-year-old man who presented with cryptogenic liver cirrhosis associated with ascites. Computed tomography (CT) and Doppler ultrasonography (US) showed a partially obstructive thrombus of the portal vein (Yerdel Grade II). DIAGNOSIS: Portal vein thrombosis (Yerdel Grade II); liver cirrhosis. INTERVENTIONS: The PVT was completely recanalized after 4 months of treatment with the low molecular weight heparin (LMWH) medication enoxaparin but discontinuation of anticoagulants led to PVT recurrence. The patient's condition deteriorated, even though re-treating the anticoagulation with enoxaparin significantly reduced the PVT. OUTCOMES: The thrombus was removed by a thrombectomy and LT was performed successfully without any vascular complications. LESSONS: Patients with cirrhosis and PVT who are waiting LT can be effectively treated with LMWH anticoagulants. Careful use of anticoagulation is generally safe. Early initiation of anticoagulation treatment may be associated with a high rate of portal vein recanalization.


Assuntos
Anticoagulantes/uso terapêutico , Enoxaparina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Cirrose Hepática/congênito , Veia Porta/patologia , Trombose Venosa/tratamento farmacológico , Humanos , Cirrose Hepática/complicações , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Trombectomia/métodos , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler , Trombose Venosa/etiologia , Trombose Venosa/cirurgia , Listas de Espera
19.
Saudi Med J ; 39(6): 586-591, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29915853

RESUMO

OBJECTIVES: To show the levels of vascular endothelial growth factor (VEGF), soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) in patients with end-stage renal disease (ESRD) and to show the associations with clinical findings such as demographic features, laboratory findings, comorbidities, and medications. METHODS: A total of 73 people, consisting of patients with ESRD (n=38) and healthy subjects (n=35) in Gulhane Education and Research Hospital, Ankara, Turkey, were included in this cross-sectional study between the years 2011 and 2013. Blood samples were obtained and plasma VEGF, sVEGFR-1 analyzes were performed. Results: The VEGF level of ESRD group was not significantly higher (0.280±0.264) than the control group (0.321±0.210) (p=0.475). The sVEGFR-1 level of ESRD group was significantly higher (0.217±0.135) than the control group (0.068±0.047) (p less than 0.001). The correlation between VEGF and sVEGFR-1 was significant and negative (r=-0.246, p=0.036). Average VEGF level of ESRD patients using recombinant human erythropoietin (rhEPO) was significantly higher (0.567±0.28) than the ESRD patients not using rhEPO (0.246±0.24) (p=0.025). CONCLUSION: Our study is the first showing the significance of sVEGFR-1 in ESRD patients, and associations with comorbidities, medications. Especially our finding of rhEPO and VEGF may illuminate a reasonable positive effect of rhEPO on angiogenesis. Soluble vascular endothelial growth factor receptor-1 and VEGF may be important markers in the pathophysiology of ESRD.


Assuntos
Doenças Cardiovasculares/epidemiologia , Falência Renal Crônica/sangue , Falência Renal Crônica/epidemiologia , Fator A de Crescimento do Endotélio Vascular/sangue , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangue , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Aspirina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Comorbidade , Estudos Transversais , Enoxaparina/uso terapêutico , Eritropoetina/uso terapêutico , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Insulina/uso terapêutico , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/uso terapêutico
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