Treatment strategies for acute pulmonary embolism
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Background: Acute pulmonary embolism (PE) is a life-threatening condition that has been treated with anticoagulation for almost 50 years. Objectives: To review the current treatment options for PE and discuss recently published new features. Methods: We reviewed literature involving the treatment strategies for venous thromboembolism (VTE) and in particular pulmonary embolism. Specific attention was drawn towards the evidence of the present treatment and of drugs being studied in Phase III trials. Results/conclusions: Treatment of acute PE consists of parenteral administration of heparin, low-molecular-weight heparin or fondaparinux overlapped and followed by oral vitamin K antagonists for a minimum of 3 months. Contemporary features include the emergence of new anticoagulant drugs such as oral synthetic inhibitors of thrombin or factor Xa. The duration of anticoagulation for unprovoked VTE remains highly debated.Keywords:
Fondaparinux
Fondaparinux
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Fondaparinux
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Direct thrombin inhibitor
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【はじめに】静脈血栓塞栓症（VTE）の治療として，エドキサバンとリバーロキサバンの当院における使用経験を報告する．【対象と方法】2014年11月～2016年9月までにVTEに対しエドキサバンとリバーロキサバンで治療した患者を後向きに検討した．【結果】患者背景において，エドキサバン群は外傷や術後安静等の一過性リスクに多く使用され，リバーロキサバン群は悪性腫瘍群に多く使用されていた．有効性の評価として，血栓塞栓症イベントはエドキサバン群（5.6%） vs. リバーロキサバン群（0%）であったが，統計学的に有意差はなかった（P=0.362）．安全性の評価としての出血性合併症は，エドキサバン群（14.1%） vs. リバーロキサバン群（9.5%）で，両群に有意差（P=0.719）はなかった．経過観察中（平均観察期間148日）の死亡はエドキサバン群（8.0%） vs. リバーロキサバン群（4.6%）と有意差（P=0.271）はなく，死因は全て癌死であり，VTE関連の死亡は両群ともなかった．【結語】患者背景の相違はあるが，本検討でエドキサバンとリバーロキサバンのVTE治療成績は，安全性，有効性ともほぼ同等であった．
Edoxaban
Oral anticoagulant
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To compare the clinical efficacy of fondaparinux and LMWH and provide clinical evidence for the effectiveness of fondaparinux in the treatment of recurrent spontaneous abortion caused by PTS.A retrospective analysis was conducted for 120 patients diagnosed with a recurrent spontaneous abortion caused by PTS in Qingdao Jinhua Women's Hospital from March 2019 to April 2020. The patients were divided into two groups: 68 cases in the control group, treated with LMWH, 52 cases in the observational group, treated with fondaparinux. The pregnancy outcomes and adverse reactions between the two groups of recurrent miscarriage patients were compared.No significant difference was detected in the general data between the two groups of patients before treatment (P>0.05). In the observational group, the R value was increased, and the α and MA values were decreased after three months of treatment compared to those before treatment (P<0.05). In the control group, the R value was increased, and the MA value was decreased after three months of treatment compared to those before treatment (P<0.05). After treatment, no significant difference was observed in the pregnancy outcome between the two groups (P>0.05). The total adverse reaction rate of the fondaparinux group was lower than that of the LMWH group (P<0.05).In this study, no significant difference was detected in the pregnancy outcome between fondaparinux and LMWH in the treatment of recurrent spontaneous abortion caused by PTS, but fondaparinux had a low occurrence rate of adverse reactions and high safety.
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Venous thromboembolic events (VTEs) are common and potentially fatal complications in cancer patients, and they are responsible for the second most common cause of death. Low molecular weight heparin (LMWH) is the gold-standard treatment, but the costs involved limit its use, especially in developing countries. Recently, the oral anticoagulant rivaroxaban, which directly inhibits factor Xa, was approved for VTE treatment.We conducted a retrospective analysis from January 2009 to February 2014 with patients who had cancer and VTE who were receiving rivaroxaban. We compared the efficacy, safety, and cost of rivaroxaban and low molecular weight heparin (LMWH) alone or followed by vitamin K antagonists.Forty-one patients were identified, with a median age of 62.5 years. The most frequent tumor histology was adenocarcinoma (78%), which was most often found in the colon (26.8%). Most participants had advanced disease and an implanted central venous catheter. Patients' VTE risk-assessment scores were low (12.5%), intermediate (50%), and high (35.5%). Pulmonary thromboembolism was reported in 41.4% of patients, but inferior limb thrombosis was reported only in 14.6%; 43.9% of patients received enoxaparin before starting rivaroxaban. Rivaroxaban was used for a median time of 5.5 months. Nonmajor bleeding was reported in 12.2% of patients, and rethrombosis was reported in 12.2%. In our study, rivaroxaban was as safe and effective as enoxaparin/vitamin K antagonists (P = .54 and P = .25, respectively) or LMWH (P = .46 and P = .29, respectively).Although our study was a retrospective analysis, our results suggest that in this cohort of oncologic patients, rivaroxaban was safe and effective. Its oral route and lower cost make it an attractive alternative to LMWH, improving management of patients with cancer in low-income countries. Additional studies are necessary to confirm our data.
Vitamin K antagonist
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Venous thromboembolism presents a major public health concern in the UK, and increases morbidity and mortality in hospitalized patients. With the development of two new classes of oral anticoagulants, direct thrombin inhibitors (dabigatran) and direct factor Xa inhibitors (rivaroxaban), there could be a paradigm shift in the management of acute venous thromboembolism.
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Rivaroxaban is an oral, direct Factor Xa (FXa) inhibitor in advanced clinical development for the prevention and treatment of venous thromboembolism1 Unlike the indirect, subcutaneously administered FXa inhibitor fondaparinux, the mechanism of action of rivaroxaban is antithrombin independent1 There is no need for routine monitoring of coagulation parameters with rivaroxaban – Rivaroxaban has predictable pharmacokinetics and pharmacodynamics2,3 – Rivaroxaban has a low propensity for drug–drug interactions3–6 – Dietary restrictions are not necessary in patients receiving rivaroxaban7 An optimum clotting assay might be valuable if a physician wants to measure the pharmacodynamic effects of rivaroxaban
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Introduction and Objectives: Although low-molecular-weight heparin (LMWH) remains the standard treatment for venous thromboembolism (VTE) in patients with active cancer, a factor Xa inhibitor such as rivaroxaban is increasingly used without clinical evidence. We compared the incidence of bleeding and other treatment outcomes using rivaroxaban and LMWH for the treatment of VTE in patients with gastrointestinal and pancreatobiliary cancer (GI cancer). Methods: This single-center retrospective analysis included patients with VTE associated with GI cancer, who were treated with either rivaroxaban or LMWH. The primary end-point was the incidence of clinically relevant bleeding. Secondary outcomes included the incidence of major bleeding, recurrent VTE, and mortality. Results: Of 281 patients, 78 received rivaroxaban and 203 received LMWH. Clinically relevant bleeding occurred in 20 patients (26%) in the rivaroxaban group and 31 (15%) in the LMWH group (P=0.043). There was no statistically significant difference in the VTE recurrence rate (4% with rivaroxaban vs. 4% with LMWH, P>0.999) or incidence of major bleeding (5% with rivaroxaban vs. 9% with LMWH, P=0.296). Multivariate Cox proportional hazards analysis for cancer type, stage, chemotherapy history, and Eastern Cooperative Oncology Group performance status showed a 1.904-fold higher risk of bleeding with rivaroxaban (1.031 to 3.516, P=0.040). Rivaroxaban use was not associated with a higher hazard ratio than LMWH use for all-cause mortality (HR 1.00, P=0.999). Conclusions: Rivaroxaban use was associated with more bleeding than LMWH use in GI cancer patients.
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Fondaparinux
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