Stephan Moll writes…
2012 has been a year with significant progress in the field of venous thromboembolism and anticoagulation. The three most noteworthy, clinically relevant developments were probably (a) the publication of the new ACCP (American College of Chest Physician) guidelines on antithrombotic therapy in February 2012; (b) The FDA-approval of rivaroxaban (Xarelto) in November 2012 for the acute treatment of venous thromboembolism (VTE) and long-term secondary prevention; and (c) The FDA-approval of apixaban (Eliquis) in December 2012 for atrial fibrillation and the prevention of arterial thromboembolism. Here I have listed and summarized the 10 top publications of 2012 in the field of venous thromboembolism and anticoaguation as I see them – the ones clinically most relevant.
Disclosure: I have consulted for Janssen, Boehringer-Ingelheim and Daiichi.
Last updated: Feb 7th, 2013
Stephan Moll, MD writes…
Apixaban (Eliquis®) is FDA-approved for the prevention of stroke and systemic arterial thromboembolism in patients with atrial fibrillation (Clot Connect discussion of the approval on Dec 28th, 2012 is here). Here is the management guideline for apixaban Read the rest of this entry »
Stephan Moll, MD writes…
Xarelto® is FDA approved for treatment of venous thromboembolism (VTE), prevention of VTE after hip and knee replacement surgery, and for atrial fibrillation. A number of practical management questions are encountered by physicians, pharmacists, and other health care professional taking care of patients on Xarelto®, such as (a) dosing in renal impairment, (b) conversion of a patient on warfarin to Xarelto®, (c) discontinuation of Xarelto® at times of surgery, dental procedures, colonoscopy, and other procedures, and (d) management of bleeding on Xarelto®. These issues may best be addressed in a health care system by the establishment of a structured treatment algorithm/guide/help for the entire hospital or physician practice. Read the rest of this entry »
Stephan Moll, MD writes…
Today (Dec 28th, 2012) the FDA approved apixaban for the prevention of stroke and systemic arterial thromboembolism in patients with atrial fibrillation, based on the ARISTOTLE study [ref 1]. The FDA press release is here. Read the rest of this entry »
Stephan Moll, MD writes… Well, it is not clear whether it does. A clinically relevant study (ASPIRE study) was published this week (Nov 22nd,2012) in the N Engl J Med [ref 1]. In patients who had a previous unprovoked (= idiopathic) DVT or PE and who had completed standard length (often considered to be 3-6 months) of warfarin therapy, aspirin did not prevent recurrent VTE. However aspirin was effective in preventing further thrombotic event (a conglomerate of arterial and venous events). Aspirin did not lead to an increase in risk of major bleeding. The findings are discrepant to the earlier WARFASA study, published in May 2012 in the N Engl J Med, which showed that Aspirin had efficacy in preventing recurrent VTE [ref 2]. The ASPIRE authors have also included a revealing, meta-analysis of this week’s study plus the previous WARFASA study [ref 2].
Stephan Moll, MD writes…
Today is a very exciting day for patients and health care professionals: the oral anticoagulant Xarelto® (rivaroxaban) was FDA approved today (Nov 2nd, 2012) for the use in patients with DVT and PE – for the acute treatment of DVT and PE, as well as for the secondary long-term prevention of recurrent venous thromboembolism (VTE). The FDA announcement can be read, here. Why is this exciting? Because therapy with Xarelto is much easier for patients and health care professionals than the often cumbersome therapy with warfarin.
Stephan Moll, MD writes…
The CDC published an alert on Oct 26th, 2012, that they are investigating 12 cases of TTP (thrombotic thrombocytopenic purpura) in drug users who injected intravenously the opioid pain medication Opana ER® (oxymorphone extended-release), a medication made as a tablet and meant for oral use. The tablet was pulverized by the drug users to allow i.v. injection (detailed CDC alert here).
Relevance for clinicans involved in the care of patients with TTP: Inquire in the history taking about drug abuse and injection of Opana ER.
Last updated: Oct 29th, 2012
Stephan Moll, MD writes… The more than 20 chapters and 801 pages of the respected 2012 ACCP Antithrombotic Therapy Guidelines – beautifully evidence-based, but always very cumbersome to read for the clinician looking for quick management guidance -, have now been summarized by the ACCP into a visually appealing, uncluttered, clinician-user-friendly document, referred to as “ACCP 2012 Reference Guide” (link to it here). This was a much-needed development. The only thing missing now is that one can buy this (90 page summary) as a hard copy for even better, i.e. quicker reference. This is a highly recommended document for anybody involved in clinical decision-making in regard to antithrombotics in patients at risk for or with established arterial or venous thromboembolism. A very nice, new resource. Read the rest of this entry »
Beth Waldron, Program Director of Clot Connect, writes…
The claim: “Eating lunch at your desk could increase your risk of DVT”—was the dramatic headline from UK’s Marie Claire magazine which caught my attention. (1) The online story went on to say that “Almost 75 per cent of office staff aged 21-30 who work 10-hour days don’t get up to take a break. This could double chances of a fatal blood clot.” The story was light on citing scientific evidence to back up this claim, so, as someone interested in DVT education (and admittedly, who eats at her desk routinely), I decided to investigate if this assertion is true: Does eating lunch at your desk increase blood clot risk?
The answer: Yes. The act of eating lunch at your desk, in and of itself, does not increase blood clot risk; but the immobility associated with prolonged sitting at your desk, does.
The research facts: The association between immobility and venous thromboembolism (VTE) is well-accepted in the literature. The term VTE includes deep vein thrombosis (DVT; blood clots in the legs) and pulmonary embolism (PE; blood clots in the lungs) . Immobility associated with hospitalization, prolonged bedrest, cramped airline and long-distance travel increases VTE risk and has received notable attention from both the health care community and the media. The association between prolonged sitting at work and VTE risk has received much less acknowledgement, even thought the association between sitting and VTE was first reported in the New England Journal of Medicine in 1954.(2) The term “eThrombosis” was coined in a case report from 2003, in which occurrence of a DVT in a patient who sat prolonged periods at a computer was described.(3)
A 2010 study from New Zealand found that “prolonged work- and computer-related seated immobility was associated with a 2.8 fold increased risk of VTE.”(4) Additionally, the risk of VTE was found to increase by 10% for each additional hour seated.(4) The risk of VTE was significantly increased in persons who had their own desk at work and in those who usually ate lunch at their desk.(4)
A 2011 US study reporting results from the large and well-respected Nurses Health Study found that “the risk of pulmonary embolism was more than twofold in women who spent the most time sitting compared with those who spent the least time sitting”.(5)
Seated immobility, no matter the reason why one is seated—if from long-travel, desk work, computer use, video games or even watching television— slows blood flow in the legs, which may contribute to clot formation. After just 90 minutes of sitting, the flow of blood to the popliteal vein (behind the knee) is reduced by 40%.(6)
The practical implications:
1. Cause of VTE affects treatment decisions
Recognition that prolonged sitting at work can contribute to VTE has serious implications. Twenty-five percent of VTE cases are considered idiopathic, ie no clear risk factor precipitating the VTE event can be identified.(7) Given the sedentary nature of the modern office environment, could it be that occupational risks are a greater provoking factor in some VTE cases than is commonly realized? It is a question warranting further study and discussion since an accurate assessment of whether a VTE was provoked or idiopathic affects decisions related to the length of anticoagulant treatment.
2. Everyone should know the risk of VTE, including healthy office workers who do not perceive themselves at risk from simply sitting at their desk.
VTE is a common medical condition and preventing blood clots associated with immobility and venous stasis is simple: movement. In recent years, greater public emphasis has been placed on the negative health consequences (obesity, diabetes, heart disease, etc) of a sedentary lifestyle, but rarely is VTE mentioned in an appeal to increase physical activity. Greater public awareness is needed that immobility—in all its various forms—is a risk factor for potentially life-threatening blood clots.
3. Occupational strategies to reduce risk and prevent VTE
If you spend your work days sitting at a desk, there are things you can do to reduce your blood clot risk:
Get up every hour and stretch your legs. Take a short walk around the office. Get outside at lunch for a longer walk.
If you can’t get away from your desk, exercise your legs while you’re sitting. The CDC recommends(8):
- Raising and lowering your heels while keeping your toes on the floor.
- Raising and lowering your toes while keeping your heels on the floor.
- Tightening and releasing your leg muscles
- “Eating lunch at your desk could increase your risk of DVT” http://www.marieclaire.co.uk/news/health/538820/eating-lunch-at-your-desk-could-increase-your-risk-of-dvt.html
- “Thrombosis of the Deep Leg Veins Due to Prolonged Sitting” John Homans N Engl J Med 1954 Jan 250:148-149
- “eThrombosis: the 21st century variant of venous thromboembolism associated with immobility.” Beasley R, Raymond N, Hill S, Nowitz M, Hughes R. Eur Respir J. 2003 Feb;21(2):374-6.
- “Prolonged work- and computer-related seated immobility and risk of venous thromboembolism” Healy B, Levin E, Perrin K, Weatherall M, Beasley R. J R Soc Med. 2010 Nov;103(11):447-54.
- “Physical inactivity and idiopathic pulmonary embolism in women: prospective study” Kabrhel C, Varraso R, Goldhaber SZ, Rimm E, Camargo CA Jr. BMJ. 2011 Jul 4;343.
- “Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects: implications for prevention of travel-related deep vein thrombosis.” Hitos K, Cannon M, Cannon S, Garth S, Fletcher JP. J Thromb Haemost. 2007 Sep;5(9):1890-5.
- “Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study” Heit JA, O’Fallon WM, Petterson TM, Lohse CM, Silverstein MD, Mohr DN, Melton LJ 3rd Arch Intern Med. 2002 Jun 10;162(11):1245-8.
- CDC DVT prevention recommendations: http://www.cdc.gov/ncbddd/dvt/documents/DVT-Tip-sheet.pdf
Following the diagnosis of deep vein thrombosis or pulmonary embolism, a patient may ask “When will my clot and pain go away?” An answer, written for patients, can be found on Clot Connect‘s patient education blog, here.
This is the first in a series of posts designed to answer many of the most commonly asked questions Clot Connect receives.