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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 66-year-old woman is seen in follow-up for breast cancer management. She was diagnosed with breast cancer metastatic to bone 1 month ago. A deep venous thrombosis in the left lower extremity was discovered at the time of her breast cancer diagnosis, and she has been treated with a low-molecular-weight heparin since then. She recently started systemic chemotherapy for treatment of her breast cancer. Medical history is otherwise unremarkable. Medications are docetaxel and therapeutic enoxaparin.

On physical examination, temperature is 37.2 °C (99.0 °F) and blood pressure is 110/76 mm Hg; pulse and respiration rates are normal. Cutaneous tumor nodules are noted above the right breast mastectomy scar. The left calf is slightly larger than the right. No petechia or bruising is present.

Laboratory studies are significant for a platelet count of 30,000/μL (30 x 109/L).

Q.

WWhich of the following is the most appropriate management of her venous thrombosis?

This patient's enoxaparin dose should be reduced. The International Society of Thrombosis and Haemostasis (ISTH) recently published guidelines on the management of patients with cancer-associated thrombosis (CAT). This is a challenging patient population with unique and often difficult-to-manage issues associated with thrombosis treatment, such as in this patient. Although many of these specific situations lack evidence from clinical trials to guide management, the ISTH guidelines provide recommendations based on the available evidence, biological rationale, and expert opinion. In this patient with CAT and thrombocytopenia, the need for thrombosis treatment must be balanced against the increased risk of bleeding from chemotherapy-induced thrombocytopenia. Biologically, the risk of recurrent thrombosis is greatest in the acute phase of thrombosis, or the first month after the event. During this time, full therapeutic anticoagulation and platelet transfusion (to a platelet count of ≥50,000/μL [50 x 109/L]) to minimize bleeding risk is preferred. After this time, the thrombosis is considered subacute and it is recommended that the anticoagulant dose be reduced to 50% of the full therapeutic dose or to a prophylactic dose to minimize the risk of bleeding provided the platelet count remains between 25,000 and 50,000/μL (25-50 x 109/L) while thrombosis treatment is continued. It is also recommended that anticoagulation be withheld completely in patients with subacute thrombosis and platelet counts less than 15,000/μL (15 x 109/L).

Continuing enoxaparin at the therapeutic dose would not be appropriate because of the increased risk of bleeding associated with thrombocytopenia. Additionally, neither fondaparinux nor rivaroxaban has been adequately studied in the management of CAT, and neither has been shown to be safer than or superior to a low-molecular-weight heparin. Therefore, substituting theses agents for enoxaparin is not recommended.

Key Point

  • In patients with subacute cancer-associated thrombosis, the low-molecular-weight heparin dose should be reduced by 50% from the therapeutic dose or to a prophylactic dose when the platelet count is between 25,000 and 50,000/μL (25-50 x 109/L).
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