Presentation on theme: "VTE Prophylaxis in the Cancer Patient The Science and Medicine of"— Presentation transcript:
1VTE Prophylaxis in the Cancer Patient The Science and Medicine of Cancer and Thrombosis ManagementVTE Prophylaxisin the Cancer PatientScope, Trials, Guidelines and SolutionsSamuel Z. Goldhaber, MDProfessor of MedicineHarvard Medical SchoolCardiovascular DivisionDirector, Venous Thromboembolism Research GroupBrigham and Women’s HospitalBoston, MA
2Learning Objectives Epidemiology/ Scope of the Problem Prophylaxis Paradigm ShiftSurgeon General’s Call To ActionMedicare’s “Never Events”Prophylaxis ModalitiesElectronic, Computerized AlertsHuman, Physician-to-Physician AlertsGuidelines: NCCN, ASCO, ACCP
6At-Risk for VTEThe high death rate from PE (exceeding acute MI!) and the high frequency of undiagnosed PE causing “sudden cardiac death” emphasize the need for improved preventive efforts.Failure to institute prophylaxis is a much bigger problem with Medical Service patients than Surgical Service patients.
7At-Risk for VTETwo quality improvement initiatives show that among at-risk-for-VTE Medical Service patients, Medical Oncology patients are the least likely group to receive VTE prophylaxis.80% of omitted prophylaxis on Medical Services occurred in Medical Oncology patients.
8Annual At-Risk for VTE: U.S. Hospitals 7.7 million Medical Service inpatients3.4 million Surgical Service inpatientsBased upon ACCP guidelines for VTE prophylaxisAnderson FA Jr, et al. Am J Hematol; 2007; 82:
9Outpatient and Inpatient VTE Are Linked 74% of VTEs present in outpatients.42% of outpatient VTE patients have had recent surgery or hospitalization.Only 40% had received VTE prophylaxis.Spencer FA, et al. Arch Intern Med 2007; 167:
11Surgical Medical ENDORSE: 68,183 Patients 52% at risk for VTE (50% receive ACCP recommended prophylaxis)SurgicalMedical42% at risk for VTE64% at risk for VTE40% receive ACCP recommended prophylaxis59% receive ACCP recommended prophylaxis
12VTE Prophylaxis Paradigm Shift Cancer and Medical Conditions in the Crosshairs
13Ten Years Ago…Most Americans had not heard of DVT (deep vein thrombosis) or PE (pulmonary embolism)Virtually no awarenessMedia attention was limited to featuring a few celebrities who were strickenNo state or congressional resolutionsNo patient advocacyNo Medicare input
14VTE Awareness in 2009 Growing interest in VTE’s public health threat Known as the most preventable illness in hospitalized patientsPublicity is increasing among health care professionals and the publicPatient advocacy is a realityCongress and most States have adopted months for “Thrombosis Awareness”Medicare has declared certain DVTs or PEs as “Never Events” and will not reimburse
15Old Prophylaxis Paradigm MD individualizes prophylaxis prescription and ultimately has complete “yes” or “no” authority to prescribe or withhold prophylaxisHospital, government auditors, patients, and families do not challenge the MD’s decision to withhold prophylaxis. Instead, they “defer to the physician’s medical judgment”
16New Prophylaxis Paradigm Hospital monitors VTE prophylaxis prescribing and insists upon guideline-based practiceElectronic reminders and automated electronic orders ultimately ensure appropriate prophylaxis for at-risk patientsHospital’s financial and medicolegal penalty for failure to prophylax may be “passed on” to the responsible attending physicianCancer patients represent high-risk, “must prophylax” subgroup
17SURGEON GENERAL: CALL TO ACTION TO PREVENT DVT AND PE September 15, 2008
19Medicare’s “Never Events” Medicare’s most recent strategy to reduce medical errors is to withhold payment to hospitals for treatment of serious preventable illnesses or complications termed “never events.” The initial 3 were:Foreign object retained postopAir embolism removing CVCBlood transfusion incompatibility
20Medicare’s “Never Events” On October 1, 2008, Medicare added:DVT or pulmonary embolism occurring after total knee or hip replacement.Medicare will not pay the incremental cost to manage the complication. Nor will the patient be responsible.The hospital will bear the additional financial burden.
32Primary End Point Intervention Control %Freedom from DVT/ PE Time (days)306090%Freedom from DVT/ PE92949698100Number at riskIntervention1255977900853Control1251976893839Kucher N, et al. NEJM 2005;352:
33Electronic Alerts Halve Rate of PE and Maintain Effectiveness VTE Rate:Pre-Alert 2005—3.3/1000Post-Alert 2006—1.7/1000Post-Alert 2007—1.7/1000Thromb Haemost 2008; 100:
34“Human” Physician Alert As we planned a multicenter randomized trial applying the electronic alert strategy to a broad array of hospitals across the U.S., we learned that replication of our electronic alert was not feasible.Therefore, we crafted a strategy that employed a “human” rather than electronic alerting system.The physician alert consisted of a direct page from a hospital staff member to the Attending Physician.The primary end point was reduction in symptomatic VTE within 90 days of randomization.
35Physician Alert: Results 2493 patients (82% on Medical Services) from 25 study sites were randomized to the intervention (n=1238) versus the control group (n=1255).Patients whose physicians were alerted were more than twice as likely to receive VTE prophylaxis (46.0% versus 20.6%, p<0.0001).The symptomatic VTE rate was lower in the intervention group (2.7% versus 3.4%; hazard ratio, 0.79; 95% confidence interval, 0.50 to 1.25), but the difference did not achieve statistical significance.Major bleeding at 30 days in the alert group was similar to the control group.Risk score validated in e-alert
36Physician Alert: Results Piazza G. Circulation 2009;119:100%98%96%94%92%90%Time after initial enrollment (days)Freedom from Primary EndpointWilcoxon P-value: 0.307; Long-Rank P-value: 0.309Human Alert No Alert
37Current Status of ASCO and NCCN Guidelines for VTE Prophylaxis in Cancer Patients
38Hospitalized Patients with Cancer ASCO GuidelinesHospitalized Patients with CancerRole of VTE ProphylaxisEvidencePatients with cancer should be considered candidates for VTE prophylaxis with anticoagulants (UFH, LMWH, or fondaparinux) in the absence of bleeding or other contraindications to anticoagulationMultiple RCTs of hospitalized medical patients with subgroups of patients with cancer. The 8th ACCP guidelines strongly recommend (1A) prophylaxis with either low-dose heparin or LMWH for bedridden patients with active cancer.
39Role of VTE Prophylaxis Ambulatory Patients with Cancer Without VTE Receiving Systemic ChemotherapyRole of VTE ProphylaxisEvidenceRoutine prophylaxis with an antithrombotic agents is not recommended except as noted belowRoutine prophylaxis in ambulatory patients receiving chemotherapy is not recommended due to conflicting trials, potential bleeding, the need for laboratory monitoring and dose adjustment, and the relatively low incidence of VTE.LMWH or adjusted dose warfarin (INR ~ 1.5) is recommended in myeloma patients on thalidomide or lenalidomide plus chemotherapy or dexamethasoneThis recommendation is based on nonrandomized trial data and extrapolation from studies of postoperative prophylaxis in orthopedic surgery and a trial of adjusted-dose warfarin in breast cancer
40Patients with Cancer Undergoing Surgery Role of VTE ProphylaxisEvidenceAll patients undergoing major surgical intervention for malignant disease should be considered for thromboprophylaxis with low- dose UFH, LMWH, or fondaparinux starting as early as possible for at least 7-10 days unless contraindicated.RCTs of UFH and those comparing the effects of LMWH and UFH on DVT rates on patients with cancer indicate broadly similar prophylactic efficacies for these two agentsMechanical methods may be added to anticoagulation in very high risk patients but should not be used alone unless anticoagulation in contraindicated.A Cochrane review of 19 studies
41Undergoing Surgery (continued) Patients with CancerUndergoing Surgery (continued)Role of VTE ProphylaxisEvidenceLMWH for up to 4 weeks may be considered after major abdominal/pelvic surgery with residual malignant disease, obesity, and a previous history of VTERecent RCTs suggest that prolonging prophylaxis up to 4 weeks is more effective than short-course prophylaxis in reducing postoperative VTE.
42Treatment of Patients with Established VTE to Prevent Recurrence Role of VTE ProphylaxisEvidenceLMWH is the preferred approach for the initial 5-10 days in cancer patient with established VTE.LMWH for 3-6 months is more effective than vitamin K antagonists given for a similar duration for preventing recurrent VTE.LMWH for at least 6 months is preferred for long-term anticoagulant therapy. Vitamin K antagonists with a targeted INR of 2-3 are acceptable when LMWH is not available. The CLOT study demonstrated a relative risk reduction of 49% with LMWH vs. a vitamin K antagonist. Dalteparin sodium approved by the FDA for extended treatment of symptomatic VTE to reduce the risk of recurrence of VTE in patients with cancer (FDA 2007)
43Role of VTE Prophylaxis Treatment of Patients with Established VTE to Prevent Recurrence (continued)Role of VTE ProphylaxisEvidenceAnticoagulation for an indefinite period should be considered for patients with active cancer (metastatic disease, continuing chemotherapy)In the absence of clinical trials, benefits and risks of continuing LMWH beyond 6 months is a clinical judgment in the individual patient. Caution is urged in elderly patients and those with intracranial malignancy.Inferior vena cava filters are reserved for those with contraindications to anticoagulation or PE despite adequate long-term LMWH.Consensus recommendations due to lack of date in cancer-specific populations
44Anticoagulants in the Absence of Established VTE to Improve Survival Role of VTE ProphylaxisEvidenceAnticoagulants are not currently recommended to improve survival in patients with cancer without VTE.RCTs and meta-analysis of warfarin, UFH and LMWH have reported encouraging but variable results generally showing clinical benefit only in subgroup analyses.
45Summary of the Guidelines Updates Summary of Major Changes in the Version of the Venous Thromboembolic Disease Guidelines
46Changes in 2009 NCCN Guidelines Stage 1 Immediate:“Stage 1 Immediate: Concomitant with diagnosis or while diagnosis and risk assessment (heparin phase)” changed to “Stage 1 Immediate: At diagnosis or during diagnostic evaluation”Low –molecular-weight-heparin: New footnote “6” was added that states, “Although each of the low molecular weight heparins (LMWH), have been studies in randomized control trials in cancer patients, dalteparin’s efficacy in this population is supported by the highest quality evidence and it is the only LMWH approved by the FDA for this indication.”Unfractionated heparin (IV): target aPTT range changed from “ x control) to “ x control…” (Also for VTE-H) in these patients.
47Changes in 2009 NCCN Guidelines Stage 3 Chronic:“Third bullet: “Consider indefinite anticoagulation….” changed to “Recommend indefinite anticoagulation….”Fourth bullet: “For catheter associated thrombosis, anticoagulate as long as catheter is in place and for at least 3 months after catheter removal”.
48Changes in 2009 NCCN Guidelines 6Although each of the low molecular weight heparins (LMWH) have been studied in randomized controlled trials in cancer patients, dalteparin’s efficacy in this population is supported by the highest quality evidence and is the only LMWH approved by the FDA for this indication.Lee AYY, Levine MN, Baker RI, Bowden C, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism on patients with cancer. New Eng J Med 2003;349(2):
49(VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism The NCCN panel recommends VTE thromboprophylaxis for all hospitalized patients with cancer who do not have contraindications to such therapy, and the panel also emphasized that an increased level of clinical suspicion of VTE should be maintained for cancer patients. Following hospital discharge, it is recommended that patients at high-risk of VTE (e.g. cancer surgery patients) continue to receive VTE prophylaxis for up to 4 weeks post-operation. Careful evaluation and follow-up of cancer patients in whom VTE is suspected and prompt treatment and follow-up for patients diagnosed with VTE is recommended after the cancer status of the patient is assessed and the risks and benefits of treatment are considered.
50(VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism Stage 1 Immediate: At diagnosis or during diagnostic evaluation:Low-molecular-weight heparin (LMWH)Dalteparin (200 units/kg subcutaneous daily)Enoxaparin (1 mg/kg subcutaneous every 12 hours)Tinzaparin (175 units/kg subcutaneous daily)Fondaparinux (5 mg [<50 kg]; 7.5 mg [ kg]; 10 mg [> 100 kg] subcutaneous dailyUnfractionated heparin (IV) (80 units/kg load, then 18 units/kg per hour, target aPTT of x control or per hospital SOP)
51(VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism Additional VTE risk factors for surgical oncology patients with a previous episode of VTE include anesthesia times longer than 2 hours, advanced stage disease, bed rest, > 4 days and patients age 60 years or older. Extended prophylaxis out to 4 weeks post-surgery was associated with a greater than 50% reduction in venographic VTE
52(VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism Stage 2 Acute: Short term, during transition to chronic phase:LMWH (category 1) is preferred as monotherapy without warfarin in patients with proximal DVT or PE and prevention of recurrent VTE in patients with advanced or metastatic cancerIf UFH or factor Xa antagonist, transition to LMWH or warfarinWarfarin (2.5-5 mg every day initially, subsequent dosing based on INR value; target INR )
53Therapeutic Anticoagulation Failure INRSwitch to heparin (LMWH preferred) or fondaparinuxIncrease warfarin dose and treat with parenteral agent until INR target achieved or consider switching to heparin (LMWH preferred) or fondaparinuxPatientonwarfarinCheckSub-therapeutic
54Therapeutic Anticoagulation Failure aPTTIncrease dose of heparinor Switch to LMWHor Switch to fondaparinuxand Consider placementof IVC filterand Consider HITIncrease dose of heparin to reach therapeutic levelPatientonheparinCheckaPTT levelsSub-therapeutic
55Improving VTE Prophylaxis in Cancer “Immunize” cancer patients with LMWH unless MD “opts out”—analogous to flu vaccine or pneumonia vaccinePay attention to the Continuum of Care and to VTE risk at the time of Discharge—Order discharge LMWHWithhold payments to hospitals when DVT/ PE develops after total hip or knee replacement—Medicare began this practice in October 2008
56ConclusionsVTE prophylaxis has enjoyed a paradigm shift. Gone are the days when the imperial physician reigned unchallenged on VTE prophylaxis decisions. Hospitals and Medicare are scrutinizing implementation of prophylaxis.Hospital-acquired VTE is not supposed to happen any longer. Medicare is declaring some VTEs “Never Events” and will not reimburse hospitals for additional treatment.Effective VTE prophylaxis in cancer patients usually requires anticoagulation with LMWH but when bleeding risk is too high, use mechanical measures.DVT prophylaxis in cancer patients is under-utilized and requires increased vigilance and prophylaxis-focused intervention
57ConclusionsDVT prophylaxis following cancer surgery for four weeks is recommended; longer periods may be necessary depending on risk assessmentDVT prophylaxis following established DVT in cancer for at least 6 months is recommended and for longer, indefinite periods with active cancer and/or chemotherapy.Heart healthy lifestyle and statins reduce VTE riskElectronic, computerized alerts can reduce symptomatic VTE by at least 40%.When “human” alerts are used, symptomatic VTE is reduced by about 20%.PE/ DVT patients with cancer warrant LMWH monotherapy.