Thrombophilia medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Asiri Ediriwickrema, M.D., M.H.S. [2]
Overview
Treatment for thrombophilia depends on the underlying hypercoagulable state and the clinical presentation.[1][2][3] The mainstay of therapy for thrombophilia is anticoagulation with either warfarin, low molecular weight heparin, direct Xa inhibitors, or direct thrombin inhibitors.[4][5][6] Treatment should be tailored to the individual patient. All patients on anticoagulation should be monitored for bleeding.
Medical Therapy
- The 2016 guidelines from the American College of Chest Physicians (ACCP) recommend that patients with provoked venous thrombosis from reversible risk factors should receive 3-6 months of anticoagulation.[4]
- Response to anticoagulation can be monitored clinically, with repeat ultrasongraphy for deep vein thrombosis or measuring D-dimer levels after treatment
- The 2016 guidelines from the ACCP recommend that direct oral anticoagulants (DOACs), including direct Xa inhibitors and direct thrombin inhibitors, be used for long term treatment of most patients.[4]
- Low molecular weight heparin is recommended for anticoagulation for the following acquired thrombophilias:
- Post-surgery prophylaxis[9][10][11]
- The duration of anticoagulation after surgery is variable. Most clinical trials have evaluated anticoagulation for 10-35 days
- General recommendations for thrombophrophylaxis is 7-10 days for standard risk patients and 10-35 days for higher risk patients as described in the algorithims below and for patients undergoing abdominal and pelvic surgeries for gynecologic malignancies.[12]
- DOACs may be considered as agents for extended thromboprophylaxis after total hip replacement and total knee replacement.
- Pregnancy and postpartum[7]
- Patients who develop acute thrombosis during pregnancy should be anticoagulated for the remainder of the their pregnancy and 6 weeks postpartum for a minimum of 3 months
- A similar duration of anticoagulation is recommended for patients with high risk thrombophilias as described in the algorithims below
- Malignancy[8]
- Alternative agents include Warfarin and Fondaparinux
- Post-surgery prophylaxis[9][10][11]
Treatment algorithms for both acquired and inherited thrombophilias are presented below:
- Thromboprophylaxis or indefinate anticoagulation may be required for certain inherited thrombophilias
References
- ↑ DeLoughery TG. Hemostasis and Thrombosis: Springer International Publishing; 2014.
- ↑ Cohoon KP, Heit JA (2014). "Inherited and secondary thrombophilia". Circulation. 129 (2): 254–7. doi:10.1161/CIRCULATIONAHA.113.001943. PMC 3979345. PMID 24421360.
- ↑ Seligsohn U, Lubetsky A (2001). "Genetic susceptibility to venous thrombosis". N Engl J Med. 344 (16): 1222–31. doi:10.1056/NEJM200104193441607. PMID 11309638.
- ↑ 4.0 4.1 4.2 Streiff MB, Agnelli G, Connors JM, Crowther M, Eichinger S, Lopes R; et al. (2016). "Guidance for the treatment of deep vein thrombosis and pulmonary embolism". J Thromb Thrombolysis. 41 (1): 32–67. doi:10.1007/s11239-015-1317-0. PMC 4715858. PMID 26780738.
- ↑ Martinelli I, Franchini M, Mannucci PM (2008). "How I treat rare venous thromboses". Blood. 112 (13): 4818–23. doi:10.1182/blood-2008-07-165969. PMID 18805965.
- ↑ De Stefano V, Grandone E, Martinelli I (2013). "Recommendations for prophylaxis of pregnancy-related venous thromboembolism in carriers of inherited thrombophilia. Comment on the 2012 ACCP guidelines". J Thromb Haemost. 11 (9): 1779–81. doi:10.1111/jth.12330. PMID 23789890.
- ↑ 7.0 7.1 Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO; et al. (2012). "VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e691S–736S. doi:10.1378/chest.11-2300. PMC 3278054. PMID 22315276.
- ↑ 8.0 8.1 Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M; et al. (2003). "Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer". N Engl J Med. 349 (2): 146–53. doi:10.1056/NEJMoa025313. PMID 12853587. Review in: ACP J Club. 2004 Jan-Feb;140(1):10 Review in: J Fam Pract. 2003 Nov;52(11):843-4
- ↑ Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S; et al. (2012). "Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e278S–325S. doi:10.1378/chest.11-2404. PMC 3278063. PMID 22315265.
- ↑ Bergqvist D, Agnelli G, Cohen AT, Eldor A, Nilsson PE, Le Moigne-Amrani A; et al. (2002). "Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer". N Engl J Med. 346 (13): 975–80. doi:10.1056/NEJMoa012385. PMID 11919306.
- ↑ Agnelli G (2004). "Prevention of venous thromboembolism in surgical patients". Circulation. 110 (24 Suppl 1): IV4–12. doi:10.1161/01.CIR.0000150639.98514.6c. PMID 15598646.
- ↑ Muntz J (2010). "Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues". Am J Surg. 200 (3): 413–21. doi:10.1016/j.amjsurg.2009.05.045. PMID 20409525.