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Dietary and Pharmacologic Management to Prevent Recurrent Nephrolithiasis in Adults

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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 63-year-old woman is seen for a swollen right calf of 12 hours' duration. Medical history is notable for a recent diagnosis of multiple myeloma being treated with chemotherapy. Medications are bortezomib, cyclophosphamide, dexamethasone, and zoledronic acid.

On physical examination, temperature is 36.7°C (98.0°F), blood pressure is 110/78 mm Hg, pulse rate is 77/min, and respiration rate is 12/min. The right calf is diffusely tender to palpation, with an increased circumference relative to the left leg measured at mid calf. The remainder of the physical examination is normal.

Laboratory studies show a platelet count of 18,000/μL (18 x 109/L).

Duplex ultrasonography shows thrombosis in the right common femoral vein.

Q.

Which of the following is the most appropriate management of this patient?

This patient should be treated with a therapeutic dose of low-molecular-weight heparin (LMWH) and platelet transfusion, with a target platelet count of 50,000/μL (50 x 109/L) or more. In situations in which anticoagulation is indicated but bleeding risk is increased because of other conditions, such as in this patient with cancer-associated thrombosis (CAT) and thrombocytopenia, management decisions must be made by considering the relative risks and benefits of treatment. Despite the lack of high-quality clinical studies to guide decision making, the International Society of Thrombosis and Haemostasis (ISTH) recently published practice recommendations for managing CAT in patients with challenging clinical circumstances. In CAT, the risk of clot recurrence is highest in the time period immediately following the initial episode. Therefore, therapeutic anticoagulation in the acute phase of thrombosis (generally considered the initial 4 weeks) is highly desirable. However, platelet counts less than approximately 50,000/μL (50 x 109/L) significantly increase the risk of bleeding. To attempt to balance benefits and risks, the recommendations indicate providing therapeutic anticoagulation and platelet transfusion to maintain a platelet count of 50,000/μL (50 x 109/L) or more.

Inferior vena cava filter placement may be appropriate if platelet transfusions are not possible or are contraindicated; however, therapeutic-dose anticoagulation is the preferred therapy if platelet support can be given.

Prophylactic-dose LMWH is considered acceptable therapy only if the cancer-related thrombosis is beyond the acute phase with platelet counts less than 50,000/μL (50 x 109/L), but it would not be indicated initially with or without platelet transfusion.

Key Point

  • In patients with acute cancer-associated thrombosis and thrombocytopenia, therapeutic-dose anticoagulation with low-molecular-weight heparin and platelet transfusion to 50,000/μL (50 x 109/L) or more is the recommended treatment approach.
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