Wu Zhoupeng: Prevention and treatment of VTE recurrence of venous thromboembolism in patients with malignant tumors

Venous thromboembolism (venous thromboembolism, VTE) is a common clinical disease, including pulmonary embolism (Pulmonary embolism, PE) and deep vein thrombosis (deep vein thrombosis, DVT), VTE chronic period prone to recurrence.
recently held a related academic conference, Dr. Wu Zhoupeng, from Vascular Surgery at Huaxi Hospital of Sichuan University, elaborated on how to carry out effective anticoagulant therapy for combined recurrence of malignant tumors in clinical cases.
(female, 50 years old) First hospitalization record (June 2017): swelling pain in the upper left limb.
history: after breast cancer surgery, intravenous intravenous fluid port implantation, regular chemotherapy for more than a year.
ultrasound: blood filling defects at the intravenous infusion port of the left neck and at the low echo, considering thrombosis, there is no abnormality in the veins in the right neck.
Coagulation: APTT 39.2 s, FIB 3.36 g/L, TT 16.9 s, D-Diajuly (ELISA) 2089 μg/L Treatment: Transvascular Surgery, 7 days in hospital, regular anticoagulant, left upper limb pain and swelling significantly reduced, discharged with the drug Inoparin (6000 IU, Bid).
re-hospitalization record (July 2017): "The patient's left upper limb swelling pain increased and he was admitted again."
ultrasound: After the implantation of the intravenous port in the left neck, thrombosis (new thrombosis may be) 0.64×0.28 cm, there was no abnormality in the right neck vein.
treatment: 10 days in hospital, during which regular anticoagulant, swelling pain control is good, discharge law anticoagulant, with the drug inoparin (6000 IU, Bid).
because the patient's compliance is not high, still once a day injection.
third hospitalization record (August 2017): "The patient's swelling pain in the left upper limb did not improve and he was admitted to the hospital again."
ultrasound: 2.01 cm for venous thrombosis in the left × 1.04 cm.
: Adequate devasalban treatment, 15 mg for the first 3 weeks, Bid, 20 mg after 3 weeks, Qd.
the results of the hospital on the 10th day of the patient's self-report left neck swelling pain disappeared, left neck and left upper limb vascular ultrasound review were no blood clots.
examination: the left neck shallow blood vessels did not see abnormalities, the left upper limb no edema.
blood routine: white blood cells 4.24×109/L, hemoglobin 89 g/L, plateplate 152×109/L, neutral granulocyte count 2.68×109/L.
Blood Coagulation Series: APTT 38.2 s, FIB 3.53 g/L, PT 13.1 s, TT 17.3 s, D-D-Djumer (ELISA) 1530 μg/L Q:VTE Recurrence? Indirect cause: Malignant tumor is an important risk factor for VTE recurrence.
malignant tumor cells and their products interact with the host cells to produce a high coagulation state, which causes the body's function to defend against thrombosis is reduced.
Patients with malignant tumors have abnormal coagulation mechanisms, and laboratory examinations show that fibrin degradation products (FDP) increase, plates increase, plateplate aggregation function is increased, fibrin dissolution is low and hyperfibrinogenemia is found.
risk of developing VTE was at least 4 to 6 times higher in patients with cancer than in non-tumor patients, resulting in a significant decrease in survival.
, patients with malignant tumors, such as the application of chemotherapy, are prone to toxic reactions and damage to endotrical cells in blood vessels (Figure 1).
the mechanism by which Figure 1 malignant tumors cause VTE recurrence: insufficient anticoagulant dose.
patients in June heparin anticoagulant dose is insufficient, in July changed to Bid injection after the patient's compliance is not high, still once a day injection, resulting in increased thrombosis.
An international multi-center, forward-looking, observational registration study, RIETE, included 1,635 VTE patients, a retrospective analysis of the registration data of this population, the results showed that at least 14% of patients with insufficient anticoagulant dose, anticoagulant dose significantly increased the risk of VTE recurrence (increased by about 10 times).
of people with insufficient anticoagulant dose mainly include age >70 years old, weight <60 kg, combined tumor, CrCl<30 ml/min and other 4 categories.
Q: How should VTE recurrence be prevented? Early treatment: including anticoagulant, thrombosis, surgical hydrant, lower cavity venous filter, etc.
-term treatment is mainly anticoagulant therapy, multi-application of vitamin K antagonists (e.g. warfarin), direct X.a factor inhibitors (e.g. devasalban) and other effective drugs to prevent recurrence.
is the basic treatment of VTE, long-term anticoagulant is particularly critical.
anticoagulants: divided into injectable anticoagulants and oral anticoagulants.
, injection anticoagulants have low molecular heparin, sulfonda liver sunflower sodium, etc. , which is characterized by quick effect, but can cause plate reduction, higher risk of bleeding.
Oral anticoagulants, including huafalin, dabiga group, devasaban, etc., will not occur heparin-induced plate reduction;
10th edition of the Guidelines for Anti-Thrombosis (VTE) Anti-Thrombosis Treatment, published by the American College of Thoracic Physicians (ACCP), recommends that VTE recurrence is rare under anticoagulant therapy at therapeutic doses.
In the event of a thrombosis, the following assessments should be made quickly: (1) reassessing whether VTE relapses, (2) assessing compliance with anticoagulant therapy, and (3) considering the presence of malignant tumors.
If thrombosis is confirmed to be associated with relapsed VTE, specific therapeutic factors need to be assessed and managed, including: (1) whether patients with low molecular weight heparin (LMWH) ;(2) are dependent; VKA) whether the dose is insufficient, (4) whether the prescription for anticoagulant therapy is correct, (5) whether the patient is taking a new oral anticoagulant (NOACs) at the same time - a drug that reduces anticoagulant efficacy, and (6) whether the anticoagulant dose is reduced (non-VKA drugs).
guidelines also indicate that DVT/PE can be treated with devassalban.
for special populations, standard dose devasalban significantly reduced the risk of haemorrhage.
the clinical benefits of long-term anticoagulant therapy with VTE were mainly carried out from three aspects: efficacy, safety and compliance.
efficacy and safety are two of the primary indicators for assessing the clinical benefits of the drug, and patient compliance needs to be considered for long-term administration.
considered, LMWH is the best choice: NOACs are better than VKA for patients without tumors, VKA is better than LMWH for patients who do not receive NOACs, LMWH is better than VKA and NOACs for patients with combined tumors, and for patients who do not receive LMWH, NOACs are recommended in no particular order.
tumor is an important risk factor for VTE recurrence.
traditional anticoagulant therapy patients with poor compliance and insufficient anticoagulant dose significantly increased the risk of VTE recurrence.
VTE long-term anticoagulant needs to weigh efficacy, safety and patient compliance, Devasalban has an advantage.
the effectiveness of devassalban in long-term treatment of VTE is accurate, significantly reducing VTE recurrence, its safety is comparable to traditional therapy.
devassalban oral dosage, long-term use once a day, significantly improve patient satisfaction, compliance is better, more easily meet the requirements of full dose anticoagulant.
devassalban has a higher clinical net benefit for the prevention and treatment of malignant tumors combined with relapsed VTE.
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