Venous Thromboembolism background

Background

Venous Thromboembolism (VTE) is potentially life threatening. Frequently VTEs are asymptomatic, however pulmonary embolism may cause acute and chronic respiratory distress and peripheraldeep vein thrombosis may be uncomfortable and lead to skin breakdown and ulceration.

Up to 15% of patients with cancer are thought to develop symptomatic VTE (See reference 1). The risk varies by cancer type, and is especially high among patients with malignant brain tumors and adenocarcinoma of the ovary, pancreas, colon, stomach, lung, prostate, and kidney. Direct alterations to the coagulation cascade caused by the malignancy can cause a hypercoagulable state, which will continue until the end of a patient’s life. Previous randomized controlled trials have demonstrated that primary thromboprophylaxis can significantly reduce the incidence of VTE in immobile cancer patients (See references 2,3).

Specific risk estimates of VTE by cancer type, stage, and treatment approaches are still largely unknown. Further increases in risk can be caused by a wide range of factors which have been well described in the general population, many of which are common in palliative care patients. The impact of a background of malignancy on the risk stratification is unclear.

Evidence around VTE in palliative non-cancer patients is lacking, and guidelines have largely been based on group consensus and extrapolation of studies evaluating hospitalized acute medical patients. Although several RCTs (MEDENOX, PREVENT, ARTEMIS) have shown that treatment with LMWH in hospitalized general medical patients improves survival and reduces VTE, the LIFENOX trial suggests that the use of LMWH with graduated compression stockings, versus graduated compression stockings alone, was not associated with a reduction in mortality from any cause in hospitalized, acute medical patients (See reference 4).

Limited research into primary thromboprophylaxis in the palliative care setting has focused on current practice around thromboprophylaxis in SPC units (See references 5,7), and the acceptability of thromboprophylaxis amongst patients and palliative care professionals (See references 8,9). No evidence exists to support or refute the routine use of primary thromboprophylaxis in this setting (See reference 6).

Studies of mechanical thromboprophylaxis have focused on surgical patients and have not shown benefit in medical or stroke (See reference 12) patients. Incorrect use of anti-embolism stockings may increase DVT risk and is less acceptable to palliative care patients than pharmacological measures (See reference 10).

Novel oral anticoagulant agents such as oral rivaroxaban and dabigatran have shown to be an effective method of thromboprophylaxis following elective orthopedic surgery. However, their role has not been examined in the palliative care setting (See reference 17).

NICE Clinical Guidance 9212 (published in January 2010) highlighted the need for a balanced approach to management of thromboprophylaxis in patients with a palliative diagnosis (See reference 13).

Disclaimer (SPAGG - Rewrite)

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.