September 25, 2014Most Treatment Strategies for Venous Thromboembolism Are Similarly Effective.
Thomas L. Schwenk, MD reviewing Castellucci LA et al. JAMA 2014 Sep 17.
Rivaroxaban and apixaban probably confer the lowest risks for major bleeding.For many years,
unfractionated heparin (UFH) followed by
vitamin K antagonists was the standard treatment for patients with deep venous thrombosis or pulmonary embolism. More recently,
low-molecular-weight heparin (LMWH) combined with
vitamin K antagonists has become the most common choice, but other options include
fondaparinux plus a
vitamin K antagonist; edoxaban (submitted to the FDA, but not yet approved) or
dabigatran (Pradaxa) combined with
LMWH; or
rivaroxaban (Xarelto),
apixaban (Eliquis), or
LMWH alone.
In a systematic review, researchers examined the safety and efficacy of these treatment strategies in 45 randomized controlled trials (durations, generally 3–6 months) with nearly 45,000 patients. Network meta-analysis techniques were used to compare all regimens with the LMWH–vitamin K antagonist combination. All treatment options, except the UFH–vitamin K antagonist combination, were similarly effective: The UFH–vitamin K antagonist combination was associated with about 40% greater relative risk for venous thromboembolism (VTE) recurrence (1.8% vs. 1.3%). Incidences of major bleeding were 0.5% and 0.3% with rivaroxaban and apixaban, respectively, compared with 0.9% for the LMWH–vitamin K antagonist combination.
COMMENT
These results are a starting point for making clinical decisions about the best treatment strategy for patients with VTE.
However, many factors, including cost, monitoring, and patient comorbidities (such as severe renal failure) must be weighed.CITATION(S):
Castellucci LA et al. Clinical and safety outcomes associated with treatment of acute venous thromboembolism: A systematic review and meta-analysis. JAMA 2014 Sep 17; 312:1122. (Δεν είναι ορατοί οι σύνδεσμοι (links).
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