Education Blog for Healthcare Professionals

Three Things We Shouldn’t Do

Stephan Moll, MD writes…  The American Society of Hematology (ASH) has identified 3 things that physicians dealing with DVT, PE and anticoagulation should avoid – published today [ref 1].

SUMMARY OF THE RECOMMENDATIONS

  1. Thrombophilia testing:  Avoid thrombophilia testing in patients who have a DVT or PE in the setting of a transient major risk factor (major surgery, trauma, or prolonged immobility).
  2. IVC filters:  Avoid placing IVC (inferior vena cava) filters in patients with DVT or PE, except in special circumstances (patient with acute DVT who cannot be anticoagulated).
  3. FFP or PCCs:  Avoid giving FFP (fresh frozen plasma) or PCC (prothrombin complex concentrate) in patients on warfarin who have elevated INRs but are not bleeding.

 

CHOOSING WISELY® INITIATIVE

The Choosing Wisely® campaign is a quality improvement initiative of the ABIM (American Board of Internal Medicine) Foundation. The goal of this initiative is to (a) identify tests and medical practices that are not supported by evidence and that may lead to adverse outcomes and financial costs and (b) encourage physicians and patients to question such tests, procedures and treatments.

ASH has joined the Choosing Wisely® campaign and identified various hematologic topics.  A systematic review of the evidence on these topics was performed by experts in the field.  Of the total of five recommendations, 3 deal with VTE and anticoagulation therapy [ref 1].  The other two deal with (a) avoidance of liberal red cell transfusions in anemic patients, and (b) limiting routine CT surveillance in certain lymphoma patients [ref 1].

 

THE THREE VTE AND ANTICOAGUALTION TOPICS IN MORE DETAIL

1.  Thrombophilia Testing

  • ASH Recommendation:  ASH recommends against thrombophilia testing in adult patients diagnosed with venous thromboembolism (VTE) in the context of a major transient VTE risk factor such as surgery, trauma or prolonged immobility.  In this scenario, thrombophilia testing does not influence duration or intensity of treatment.
  • Comment:  This recommendation is in regards to VTE associated with major risk factors.  “Major transient risk factors” are NOT the following: contraceptives, pregnancy, hormonal therapy, airline travel, minor surgery (arthroscopic surgeries, etc.) or partial immobility (boot immobilizer, etc.).  Patients who develop VTE associated with such minor VTE risk factors may be candidates for thrombophilia testing.  Such patients should seek guidance from an expert in VTE.

2.  IVC Filters

  • ASH Recommendation:  ASH recommends against the routine use of IVC filters, because (a) there is a paucity of data supporting the use and benefit of IVC filters, and (b) they can be associated with complications and adverse outcomes.
  • Comment:  The main indication for an IVC filter is the presence of an acute DVT in a patient who cannot be safely anticoagulated.  When IVC filters are necessary, retrievable filters are strongly recommended over permanent filters.

3.  Use of FFP or PCCs to reverse warfarin in the absence of bleeding or emergencies

  • ASH Recommendation:  ASH recommends against the use of FFP or PCCs to reverse warfarin in the absence of bleeding, emergent surgery, or emergent invasive procedures.
  • Comment: Most non-bleeding patients can be managed by interrupting or reducing warfarin, or giving small doses of vitamin K.

 

REFERENCE

  1. Hicks LK et al. The ASH Choosing Wisely® Campaign: Five Hematologic Tests and Treatments to Question. Blood. Pre-published on the web, Dec 4th, 2013.

 

Disclosure:  No relevant disclosures.

Last updated:  Dec 4th, 2013

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