Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast is Narrator - ? 00:12 provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 136 I'm your co host, Dr. Kane, Speaker 1 00:35 and I'm Dr. Patel, and the topic of today's podcast is major recommendations from the 2021 chest anticoagulation for VTE disease guidelines. I am so excited that we're going to discuss this second update to the ninth edition. The ninth edition was originally published in 2012 they did their first update to that guideline in 2016 and so just recently, online only publication made available in July, end of July of this year was their second update to this ninth edition. And Dr. Kane, you know, you and I both work with anticoagulation patients, you know, in different capacities, but you know, you see your inpatient anticoagulation issues, and I see my outpatient related anticoagulation issues. So this topic was very pertinent and interesting to both of us, and I'm excited to talk about that Dr. Sean Kane 01:28 for sure. And you know, just for the audience's benefit, we do have a link to the pre print of the executive summary of these guideline updates at our website. So go to HelixTalk.com episode 136 what you'll see in that that document is 17 pico style questions. So pico stands for patient, intervention, competitors and outcomes. It's the format that they're using, and they basically have 29 recommendations out of those 17 PICO questions. Four of those are completely new, and eight of those were substantially modified from the original 2012 chess guidelines. So we don't have time to go through all of those guideline recommendations during this episode, but Dr. Patel and I have kind of highlighted some of the ones that we think are most pertinent or most interesting. But if you want the full thing, you're going to have to go to those guidelines and take a peek for yourself. Speaker 1 02:17 And Dr. Kane, something that this update did was kind of defining different categories. I think it's important that we we kind of provide those definitions to orient our audience. And one of the definition category was defining phases of the treatment. And so they're calling an initiation phase, which is anywhere between five to 21 days of having diagnosed with the VTE that's, you know, that's one phase to define or initiate anti COA regimen. The next phase is the treatment phase, and that's up to three months. That's where the patient will complete the acute VTE treatment. And the extended phase is anywhere from three months to maybe indefinite therapy, or there is no planned stop date, and this is where we are using either full dose or reduced dose anticoagulation for secondary prevention. This is no longer a treatment, but it's more of preventing second occurrences, and Dr. Sean Kane 03:17 that extended phases we'll talk about gets confusing, because you do use similar or the same drugs to prevent the VTE that you used for the treatment phase. Sometimes the doses are different. We'll talk about that, but that's where some of the confusion comes in with respect to that extended phase. Speaker 1 03:34 And the other definition they provided were risk factors. And now you know, we know that VTE could be provoked or unprovoked, but under the provoked VTE category, they've kind of redefined major transient risk factors. These are risk factors present within three months of having a VTE. Some of the examples of the major risk factors include maybe patient undergoing surgery with general anesthesia that's lasting more than 30 minutes. Maybe they're confined to their beds or in the hospital for at least three days, so immobility and then if they have major trauma. So these risk factors are still kind of think about your wardrobes. TRIAD type factors at play. Dr. Sean Kane 04:19 Here they also outlined some minor risk factors for whatever reason they picked within two months instead of three months of the VTE. And examples of a minor risk factor would be, you know, oral contraceptives or estrogen therapy, being pregnant, having some leg injury where you have reduced mobility for at least three days, prolonged car air travel again, these are minor risk factors, and you would associate these risk factors with the VTE as a provoked vte, if the patient had any of these within a two month time period of having that VTE. Speaker 1 04:50 And then we have the persistent risk factors. And these are conditions or situations that are non modifiable, such as. Genetic predispositions, or they have genetic thrombophilia or antiphospholipid syndrome or even other health conditions such as, you know, active cancer. Dr. Sean Kane 05:09 And then, of course, those are provoked where there's a clear, or hopefully a clear reason why they had a blood clot. The other category is an unprovoked vte, where there's no clear risk factor of why the patient had a DVT or a PE we called those patients unprovoked VTEs. Speaker 1 05:25 And the recommendations for, you know, treatment and stuff for those who have unprovoked VTE are slightly different than those who've had provoked VTE. And those are previously outlined, and, you know, existing additions and updates of the chest guidelines. Dr. Sean Kane 05:40 Other things that you'll see in the guidelines is that they indicate magnitude using arrows so horizontal, upward or downward, arrows to describe the magnitude of benefit or harm with different recommendations and therapies. Speaker 1 05:53 And I think one thing that I saw Dr. Kane that did it nice, is to understand the magnitude they did, everything per 1000 patients. If there was an event, they said X events out of, you know, 1000 patient cases. That way it's easier to compare, because obviously these studies have different number of patients included, so it's already calculated for us, so it makes the comparison easier. And obviously, in order to look at the strength of the evidence or certainty of the evidence. They use the grade method, which is grading up, recommendation, assessment, development and evaluation, and define these as high, moderate, low or very low certainty evidence. Dr. Sean Kane 06:36 So in terms of the guidelines, you know, Dr. Patel, as we mentioned, they came up with a handful of, or several handfuls of recommendations, and we've picked out some of the most pertinent ones. And you know, you and I talked beforehand, I think we both felt that one of the most pertinent ones was the new recommendation related to cancer associated vte, so patients that have active cancer, that now have a DVT or PE, the recommendations have changed for what are the preferred therapies in that group Speaker 1 07:02 to provide the background up until now for cancer associated vte, we used to think low molecular weight heparin therapy for six months was like that staple, but we do have new evidence. We know that patients who have cancer, they're at higher risk of thrombosis, and their bleeding risk is higher as well, especially when they have a vte, then patients who have VTE but they don't have cancer, so kind of comparing to the same VTE population with or without cancer. And you know, the trial that established the utility of low molecular weight heparin over warfarin was that CLOT trial, but there is more data with DOACs being available and used, and that's where the recommendation is changing. Dr. Sean Kane 07:47 And that new recommendation is essentially that doacs are recommended as the preferred therapy over low molecular weight heparins, and really over warfarin. By by extension, this is a strong, moderate certainty recommendation they do appropriately make kind of an asterisk here. So doacs are preferred for the treatment of VTE and cancer associated vte, but in patients that have GI cancers, you might prefer apixaban or a low molecular weight heparin. So only one of the four doacs on the market, and you would potentially not prefer rivaroxaban or edoxaban in those patients with active GI cancer. So this is colorectal cancer, stomach cancers, things like that. And the reason is that among patients with those GI cancers, in the trial of rivaroxaban and edoxaban, those patients actually had dramatically higher risks of major bleeding compared to a low molecular weight heparin. So again, in those with GI cancers, you're going to prefer low molecular weight heparin or apixaban, and not those other doacs. Speaker 1 08:49 But if they have another type of cancer where GI cancer is not an issue or not involved, then they could equally use edoxaban or rivaroxaban or apixaban for the treatment over a low molecular weight heparin. Dr. Sean Kane 09:03 And you know one advantage at low molecular two advantages that low molecular weight heparins have is that you can more easily adjust a dose if you need to. So for example, with thrombocytopenia or with renal impairment, you can easily titrate the dose to whatever you want. And also it's injectable. So although that's a downside, because most patients don't want to inject themselves. It can be an upside if they have difficulty swallowing, or they can't keep food down because they're too nauseated, things like that. So you do have an alternative route as a potential benefit, in addition to kind of an annoyance for certain patients. Speaker 1 09:36 And the second recommendation that was striking to me, Dr. Kane, because I do see patients with this particular syndrome is anticoagulant agent of choice in those patients who have antiphospholipid syndrome. This antiphospholipid syndrome is commonly seen in patients who have other inflammatory conditions like lupus. And so far, you know, we've we've kind of used warfarin, but the the introduction of doac, the use of doac has been seen. I've seen that one off, and I've always questioned, what's the evidence of doac in this particular patient? We kind of define antiphospholipid syndrome as being that persistent risk factors for provoked VTE. And so the guidelines came out with more of a put my foot down. Type of recommendation say that, you know, Vitamin K, antagonist therapy, warfarin therapy, with the INR Range of two to three is actually preferred over using doac for the treatment phase. Now this recommendation, the type of evidence that's available is weak, but they're still saying they're supporting vka therapy over direct therapy. And the expert panel actually went one step ahead and said that if your patients with APS, the anti phospholipid syndrome have are triple positive, meaning they have lupus anticoagulant, anti‑cardiolipin antibodies and anti‑beta2‑glycoprotein‑1 antibodies. These patients are called basically triple positive, then definitely we want to avoid doacs and prefer warfarin therapy and Dr. Sean Kane 11:16 Dr. Patel. What's so interesting about this is that we, as time has gone on, we've seen fewer and fewer recommendations for warfarin for a variety of different indications and patient populations. So it's interesting that now we have a recommendation favoring warfarin, as opposed to any of the other therapies, in this case, with in patients who have anti phospholipid syndrome. Speaker 1 11:37 Yeah, and Dr. Kane, I love to see that Warfarin still is in business for these patients. However, what's kinda related is the presence of lupus anticoagulant throws off INR. It just reacts to the reagent that draws INR in the lab. And so really INR becomes kind of like this. Do we really trust the INR to measure warfarin, anticoagulant activity at that point, and then you have to go out and do Chromogenic factor x assay, which is not routinely done, takes a few days to come around. Who knows how to interpret it. So it's not easy and straightforward, but the recommendation is still to use Warfarin and monitor INRS and keep it between two and three. Dr. Sean Kane 12:17 Dr. Patel, you've taken me down a rabbit hole. I was not aware of that APS would impact your INR and that you'd have to get these alternatives, send out labs and things like that. Sounds like there's a lot more under the covers of this recommendation than what you might appreciate from just reading the guideline document Correct. Well, our next recommendation is clarifying during the extended phase, so once a patient has had three months of treatment of their VTE if they qualify for extended therapy or extended prophylaxis. How do you dose it? The recommendation is that you should use a reduced dose of an anticoagulant as opposed to the full dose of the anticoagulant. So for example, if a patient was taking apixaban five milligrams twice a day, which is the normal treatment dose of apixaban, that during that extended phase, you would cut that down to two and a half milligrams twice a day. So same would be true with ribaxaban. They have an alternative extended therapy dose of 10 milligrams a day, as opposed to 15 milligrams a day. Obviously, things like renal function, BMI, adherence, cost, all that is going to play a role. But if you're going to do the extended therapy, you should be favoring the lower dose over the normal treatment dose during that phase, Speaker 1 13:29 you know. And this is something that gets overlooked, because patients who are on doac are no longer with quote, unquote, anticoagulation clinics where, you know, patients not coming back for frequent monitoring. And so really, that time period of when patient moves from that treatment phase to the extended treatment phase is hard to keep up with routine primary care practice, and so it's important to catch the dosing and decide whether we need to de escalate and reduce the dose for this extended phase therapy. Interestingly enough, the guidelines also added that for whatever reason, we decide that an anticoagulant is a no go going forward for the extended phase therapy, they're recommending aspirin, which is an anti platelet therapy, over no therapy whatsoever, so some oversight and keeping the disease process in check is still recommended. Then no anti platelet or no anticoagulant therapy Dr. Sean Kane 14:31 at all. And what's interesting about that Dr. Patel is that aspirin, it has been studied in terms of this extended phase, and it is effective is just not nearly as effective as the doacs. So in someone who's at a higher risk, you should probably pick a doac for extended phase. But if for whatever reason you don't want to do that, it does make sense to choose aspirin, assuming that you wouldn't already be on it for some other indication. Speaker 1 14:55 And that leads, you know, definitely, to the recommendation this update has made is the use of aspirin for the extended VTE treatment. And so, like you said, Dr. Kane, you know, use of reduced dose, direct therapy is recommended over use of aspirin or no therapy for the extended phase treatment. Here, the more evidence, you know, lies with the rivaroxaban and aspirin. That's, you know, coming from the randomized control trials. But for this reason, they're extending this recommendation to other DOACs as well, to be used for that secondary prevention. Dr. Sean Kane 15:31 And they do comment that for an unprovoked vte, if you're planning to kind of stop therapy, you could certainly consider aspirin for those unprovoked VTE patients, as opposed to doing nothing, because, again, it is still effective. This is not as effective as doex, obviously, primarily cost, but also bleeding risk is going to be lower with aspirin than a doac, but efficacy isn't going to be as good. Speaker 1 15:56 And then, you know, these were kind of like the top important recommendations from our viewpoints and perspectives, but their guidelines kind of goes on and makes other recommendations for initiation of therapy and various different type of VTE. So one of the recommendation kind of lies around is for an isolated, distal, acute DVT, acronym they have used as Id DVT, whether we start the anticoagulation or not. Now, these ID DVTs, as the word says isolated, distal. They're located in veins that are distal to the popliteal vein, so below knee. And the current management is, you know, either to offer anticoagulation or just to simply do like a repeat or serial ultrasound monitoring, and then only offer anticoagulation if the the ultrasound monitoring shows that the clot is like, slowly but surely moving upwards past the knee. There's some risk factors that we can look out for for such extension or, you know, the clot traveling upwards. And those are, usually, you know, the clot burden, meaning how big the clot is, some other persistent risk factors that are present, such as cancer or thrombophilic conditions or history of other VTEs in past, or patients in mobile because they're in the hospital or, you know, inpatient in general. And so these are the factors that we have considered in past, and that's why the recommendation is either offering anticoagulation or just monitor using ultrasound. But this guideline is kind of making a recommendation for us. Dr. Sean Kane 17:35 And Dr. Patel, just to provide a little more context, most DVTs are in the leg, and most leg DVTs are above the knees. We call those proximal DVTs. The reason we weren't sure about distal DVTs is that they're not as common, so it's kind of like more of a zebra versus a horse in terms of its incidence rate. But also the distal DVTs tend to not be as symptomatic, especially longer term. They're also less likely to embolize and turn into a PE so the guidelines did weigh in on this, and they said, if you have this distal acute DVT and you have severe symptoms, or some of those risk factors that tell that you went through, probably you should consider anticoagulation. That was a weak, low certainty recommendation. But if you're kind of in the majority of patients, which would be that you don't have severe symptoms, you don't have risk factors for that clot extending. The recommendation is that you could consider two weeks serial imaging, so ultrasound, as opposed to anticoagulating. And if over that two week period, the thrombus doesn't change at all, don't anticoagulate. So you save yourself that three months of anticoagulation. If it does extend, but it doesn't get proximal, so it doesn't cross the knee. Then consider anticoagulation. It's a weak, very low certainty recommendation. And then, of course, if it does extend where that clot in your calf goes up past your knee and it turns into a proximal DVT, you would treat it like a normal proximal DVT, which would be you initiate anticoagulation for at least three months. That's a strong, moderate certainty recommendation, right? Speaker 1 19:06 And another such recommendation they produce was these isolated sub segmental PE. So now we're not talking about, you know, lower extremity VTEs, like DVTs. We're talking about PE. And these are isolated sub segmental kind of occurring in more of the branches of the lungs. And then question is whether we start anticoagulation treatment or not. Now the sub segmental PEs are really small clots, and small clots also means there is a high false positive rate. It sometimes becomes more of an incidental finding in cancer patients when they're going under CT therapies and stuff, and some of the times these smaller clots may resolve without the need for systemic anticoagulation, and they may not end up causing hemodynamic instability, or, you know, vast symptoms that you would normally. Normally expect with the PE such shortness of breath or difficulty breathing and things like that, but we do know that isolated subsegmental pes are associated with DVT. So it's important to still rule out and make sure a patient didn't have a DVT that ended up causing these subsegmental pes Dr. Sean Kane 20:20 so really, then the clinical question is that, if you're doing a CT chest because a patient has cancer, and you happen to find this fairly small pulmonary embolism, how important is it to treat that patient? So the guidelines weigh in here, and they say that you should definitely check for DVT, because the clot got there somewhere. But if you don't find a proximal DVT, and they have low risk factors for recurrent VTE, then clinical surveillance is recommended, as opposed to anticoagulating the patient. And that's a weak, low certainty recommendation. Obviously, a patient has a PE, so you're going to have to tell them about their PE and educate them on signs and symptoms of that PE getting worse. So for example, increasing dyspnea, chest pain, difficulty, breathing, stuff like that. And obviously they need to report to their provider, even go to the ER if those things appear to be worsening, Speaker 1 21:12 and if they have again, we checked and they don't have any proximal DVT, but they do have high risk factors for recurrent VTE, then we're going to initiate the anticoagulation rather than just doing clinical surveillance. It's a weak recommendation, but I think that makes sense. You know, their risk factors present, they already have a clot, then why not just start the anticoagulation? Dr. Sean Kane 21:36 The next one that comes to my mind is intervention. So for DVTs and PES there are physical interventions that can occur, either Thrombolytic Therapies, mechanical therapies, or a combination of pharmacomechanical therapies. Basically, this means that you do a procedure where you go after the clot. You either break up the clot, you put a catheter in the clot to help dissolve it, or you literally suck the clot out of a patient. And really the questions that the guidelines addressed is, is it ever a good idea to do this more invasive, physical removal of a clot, or is it just better to do typically, anticoagulation for these patients? So in the case of an acute DVT, again, typically this is going to be in the leg, the recommendation is that anticoagulation alone is preferred over any of these interventions, these thrombolytic, mechanical, pharmacomechanical interventions, however, they do say that you might consider a catheter directed intervention, so one of these more invasive procedures in patients that have a limb threatening DVT, typically that would be that you have such high burden that you aren't able to drain blood through the venous system out of your leg, for example, and that could cause swelling and impair pulses, and then could be limb threatening. So in those cases, maybe. But for the run of the mill patient, they do not recommend catheter directed thrombolysis or other interventions. They just prefer run of the mill normal anticoagulation for those DVTs. Speaker 1 23:01 And then if we switch sides and talk about interventional therapy for patients who have acute PE for those patients, it's not as straightforward. We're going to have to look and see their hemodynamic stability. And so that's where blood pressure comes into play, and the recommendations kind of divided based on the presence of hypotension or not. So if the patient has hypotension, which is defined as blood pressure below 90, and the patient's bleeding risk is not high, again, these are some of the factors to consider, and it could be contraindication for a systemic thrombolytic therapy, for example, using TPA or alteplase. So in patients who have hypotension but their bleeding risk is not high, the TPA style therapy is preferred over no therapy. Again, this recommendation is weak and because, you know, there are various different studies using different agents and different doses, the panel could not come up with a single agent in a dosing strategy, but TPA, alteplase type of thrombolytic therapy is recommended. Dr. Sean Kane 24:10 And Dr. Patel, we would call those patients massive PE. So massive doesn't necessarily mean the size of the clot. It means that they are hypotensive and have a PE, and their mortality rates are actually quite high, like 50% so that's why we're not just anticoagulating them, but giving them literally thrombolytic therapy with TPA or alteplase. But their Speaker 1 24:30 risk is a little bit lower if they don't have that hemodynamic instability, right, so they have no hypotension, then the guidelines recommending don't do that invasive, you know, systemic thrombolytic therapy, but in cases of patients who have worsening PE So, we are seeing, you know, that blood pressure is dropping, the heart rate is increasing, patients not able to maintain a good gas exchange, we are seeing poor signs of perfusion. In we're seeing, you know, worsening the right ventricular function and other cardio biomarkers are kind of worsening in those patients after starting the anticoagulation. If there is no hypotension present, again, we have to make sure and leading risk is acceptable again. These are patients who have sort of like a massive PE, they don't have these signs, but they're worsening. In that case, there are supporting use of systemic thermolytic therapy over doing nothing. Dr. Sean Kane 25:32 And that is a weak, low certainty recommendation, because the body of literature for this patient group, which are called intermediate risk PE, it is fairly controversial. Again, we just to summarize. So the guidelines say for massive PE, where your blood pressure is low, you get a thrombolytic like TPA. If you are not hypotensive and you don't have any signs or symptoms of basically poor right ventricular filling, you just anticoagulate. You don't give TPA. But if you're kind of in the middle, and they call that the intermediate risk PE patient, then you can consider thrombolytics. But again, the level of evidence is not nearly as good as what you would like it to be, and the reason for that is that is controversial in terms of the body of literature supporting that. So Dr. Patel, the next recommendation was IVC filters, and these are either permanent or retrievable filters that can be given in patients that have an acute PE and for the audience, if you're not familiar with it, an IVC filter is basically a device that catches clots on their way to the lung from the legs. So if you have a DVT, a clot in your leg that embolizes, where that clot is traveling through your bloodstream, it's going to go to the right side of the heart and then up into the pulmonary artery. We call that a PE. So the IVC filter is literally like a net that is going to catch that clot before it gets to the right side of the heart, so that that DVT that embolizes does not turn into a PE. Speaker 1 27:00 And really, the panel weighed in on this recommendation, because, honestly, there's just a wide variation in practice the use of IVC filter, and the panel also thinks that some of the IVC filters were inappropriately used or placed, and so they came out and made a recommendation that in the case of acute DVT, you do not have to use an IVC filter in addition to your normal anticoagulation therapy. This is they were so certain about this, and obviously based on the evidence too, that this was a strong, moderate certainty evidence. However, if the patient has proximal DVT and they have contraindication to anticoagulation therapy, meaning we cannot start an anticoagulant, then you can justify the use of IVC, and then those patients IVC filter placement is recommended, but know that, you know it doesn't prevent more DVTs from occurring, because obviously it's just blocking the clot from traveling and turning into a PE. So really, Dr. Sean Kane 28:02 the next recommendation, which I found interesting, because I never see these patients in my clinical practice, is basically they're giving the green light for selected patients that have an acute pulmonary embolism, that they may be appropriate for outpatient therapy and may not have to be hospitalized. And when I think about PES I think about pretty severe disease burden and, you know, risk of death and things like that. So this one kind of caught me off guard a little bit, but they do have quite a few kind of nuances or asterisks that are are worth mentioning. Speaker 1 28:35 Yeah, Dr. Kane, I was also very delighted to see this recommendation, and they're obviously not those massive PE patient that we discussed earlier, who you know need thrombolytic therapy, for example, but these are your low risk PE patient. The recommendation is to treat them outpatient over hospitalization, but making sure that they do get started on the right therapy as needed, and there they do have adequate home circumstances, such as, you know, support in case they need to, you know, they the PE worsens, they need to reach out to the doctor or go to the hospital. They have the right support and tools to do that. So, Dr. Kane, you know, it's hard to kind of say who deserves the inpatient therapy versus outpatient therapy. So the guideline kind of delineates that we could consider outpatient therapy in patients who have good cardiopulmonary reserve, meaning they are not, you know, hemodynamically unstable. They're stable, no other contraindications, such as, you know, they've had a recent bleeding or renal disease or liver disease or severe thrombocytopenia, defined as less than 50,000 platelets, because these patients may need, you know, more of a closer monitoring after starting the anticoagulation, rather than doing in, you know, at home, outpatient monitoring, and we need to also make sure that the patient. It's going to understand the treatment and be compliant to the treatment, and then patients generally feeling well enough to be treated at home. So again, this, this is probably a shared decision making as well, and not just one and done decision. Dr. Sean Kane 30:13 And I would say that this is not going to impact a ton of patients, because I think providers are fairly used to admitting the PE type patient for fear that they could get clinically worse, or that they will not have the appropriate outpatient treatment, or that they'll delay therapy, or something like that. So I think this is more of a exception versus the rule, but it's interesting that they've kind of given the green light for that, and Speaker 1 30:39 another recommendation they rated on, which was actually weighed on in the previous update since the availability of the DOAC app, but it became a stronger recommendation in this particular edition, is what agent to choose for the treatment phase of anticoagulation, which is that acute first three months of treatment since the development of DVT or VTE, and the recommendation has become stronger with moderate‑certainty evidence for the use of a DOAC over warfarin for that first three months of treatment. Again, we're going to look at patient‑specific factors, you know, renal function, whether the patient can afford the copay, does the insurance cover it or not, bleeding risk, compliance, etc. If they have poor renal function, or again, as we talked about, they have presence of thrombophilia such as antiphospholipid syndrome, then warfarin will be better for them. But for your most general population patients, a DOAC is preferred Dr. Sean Kane 31:42 over Warfarin and Dr. Patel. I can tell you that over the last five years, I've seen more and more and more patients moving to the doacs, primarily for the convenience reason. Most of the data didn't support necessarily an efficacy benefit or a safety benefit. For vte, we saw different data for afib, but the convenience factor here is by far the biggest driver at the risk of cost, right? So there is this balance here, but most patients that can afford it are preferring the doacs because of the convenience of it, absolutely. Speaker 1 32:14 And some of these patients are going to be on therapy for longer, as we talked about, the extended phase, too. So you got to have to look at that convenience and you know, diligence and following recommendations, especially with Warfarin and monitoring burden. But that means that duration of anticoagulation therapy was kind of weighed in in this particular update as well. And so patients who have acute VTE but no contraindications to anticoagulation, three months of anticoagulation is recommended with a strong, moderate certainty recommendation; they have transient risk factors, then they're recommending against going more than the three months, or like extending the anticoagulation treatment. This is a little bit of a weaker recommendation. And obviously, you know, patient individualized, patient, shared decision making will be employed here. Dr. Sean Kane 33:06 And you know, for those that don't have a transient risk factor, so those either that had an unprovoked vte, where we don't know why they had a clot, or those that had a clot that have a risk factor that persists, so like active cancer or some genetic predisposition. The recommendation is that you would do the extended phase anticoagulation with the doac if the doac is contraindicated. Interestingly, they recommend a warfarin, which I'm not aware of. A lot of data supporting that. So they give it a weak recommendation, moderate certainty, and they acknowledge that you really should be taking into account patient preference and future VTE risk when doing this extended therapy approach or extended phase approach. And every year, if you're going to do it every year, you should be reevaluating, basically, the pros and cons of continuing that extended phase. So reevaluating bleeding risk, the burden of therapy, cost changes in patient preference, things like that. This is not a lifelong therapy. It's an every year reassess kind of therapy. Speaker 1 34:05 And I think I love that particular caveat the panel has put in this particular update. Dr. Kane is because I I do have patients that I follow, and they're older patients, and a lot of things are changing. You know, their falls risk, for example, as they age, are increasing, and so then you definitely have to pitch your anticoagulation against that risk benefit analysis and say, is it worth for me to keep pushing anticoagulation? The patient has been clot free for the last 15 years, but here they're falling or they're having bleeding events. So it really is it necessary for me to continue treating this patient with anticoagulation. So I love yearly reevaluation recommendation the panel has put in. Dr. Sean Kane 34:51 And I think Dr. Patel, it's so important to realize or reiterate that all anticoagulants are, you know, high risk therapies. They literally. They kill people every year because of major bleeding. This is something that we need to be aware of, and also, from a provider standpoint, huge opportunity for prescribing error or not readdressing it appropriately. So in my mind, this is a huge opportunity for pharmacy to play a role in terms of improving the safety of these very important but still dangerous medications. Speaker 1 35:24 And last, but not the least, I do want to talk about how the guidelines did mention use of compression stockings, especially in the prevention therapy for post-thrombotic syndrome. Post-thrombotic syndrome is usually accompanied by, you know, swelling in the leg pain. This is obviously happening because patient had a DVT. It's common. 20 to 40% of DVT patients end up having this post-thrombotic syndrome despite having gone through the right treatment and duration of anticoagulation. And so used to use these compression stockings, which are basically, you know, pressurized socks that helps the swelling down, helps move the blood flow in the right direction and stuff. And the recommendation, in particular for prevention, the guidelines recommended that they're not recommended for PTS prevention post-thrombotic syndrome prevention in the situation of acute DVT, the treatment data so in there, if you're treating post-thrombotic syndrome, yes, go ahead and use it, but it's not going to prevent the PTS from happening in the situation of acute DVT. Again, these compression stockings also do not reduce the risk of recurrent VTE or DVT. So again, non invasive treatment or therapy, but we need to make sure that we are still using evidence behind use of the compression stocking when prescribing one. Dr. Sean Kane 37:03 Well, Dr, tell you know, we've gone through a number of recommendations that we kind of hand picked, but as we mentioned at the beginning of the episode, there's more in there. So for any listener that wants to see more information, we do have a link in our show notes at HelixTalk.com this is episode 136 where you can see all of the other recommendations, the evidence behind it. There's a ton in that document, and if you want to know more about any of these that obviously the document is going to go into more detail. So I'd encourage your listeners to take a look at that, to get all of the guideline glory, not just kind of the key points that we've gleaned from the document itself. So with that, we're going to wrap it up. So if you want to see us on Twitter, we're at HelixTalk, and we release some clinical pearls fairly frequently. So follow us on Twitter. We love the five star reviews in iTunes, we also have a mailing list, so if you want to get an email every time an episode comes out, you can provide us with your email address, and you'll get an email in your inbox every three weeks when these new episodes post on a Tuesday. So with that, I'm Dr. Kane and I'm Unknown Speaker 38:03 Dr. Patel, and as always, study hard. Narrator - Dr. Abel 38:07 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there to Narrator - ? 38:18 suggest an episode or contact us or online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.