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New Guidance Statements on Management of Venous Thromboembolism

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New Guidance Statements on Management of Venous Thromboembolism

Feb 09, 2016

For the first time, the Anticoagulation Forum has published clinical guidance statements for managing blood clots in the veins, or venous thromboembolism. Dan Witt, PharmD, Professor of Pharmacotherapy at the University of Utah, is a lead author on statements regarding warfarin management. He explains what prompted the new set of guidance statements, how they differ from existing guidelines, and why they will be of value to practitioners who encounter this condition.

Episode Transcript

Interviewer: Clinical guidance statements on treatment of blood clots or venous thromboembolism, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Dan Witt, Clinical Professor of Pharmacotherapy at the University of Utah. He's one of a group of leading experts assembled by the Anticoagulation Forum to generate a series of clinical guidance statements on treatment of blood clots or venous thromboembolism. Doctor Witt, why now?

Dr. Witt: So the Anticoagulation Forum is a professional organization that is comprised mostly of front-lying anticoagulation providers. So these would be pharmacists, nurses, nurse practitioners, physician's assistants and physicians who spend most of their time working with patients who are taking blood-thinning medications or anticoagulants for treatment or prevention of blood clots.

The Anticoagulation Forum was interested in producing this document for a couple of reasons. One is that there have traditionally been guidelines produced by a group called the American College of Chest Physicians. Recently, it was rumored that maybe those weren't going to be coming out on such a regular basis. So one attempt was to try to fill a void that was going to be created by not having the regular release of these guidelines coming out.

The second one was that the evidence-based guidelines, like the American College of Chest Physicians puts out, sometimes don't resonate with frontline providers as much because they are so heavily based on what the evidence says that sometimes they can't make concrete statements about things that providers caring for patients really wonder about. So there has to blend of sort of expert advice that isn't necessarily backed up 100% by the evidence and also relying on evidence as well.

So what the Anticoagulation Forum was trying to do is provide a series of documents that really capitalized on the expertise of the people that were writing the chapters, but at the same time keeping at least one foot in that evidence-based medicine realm.

Interviewer: On the first hearing, it might sound like giving advice that is not based on evidence might sound a little scary. But you gave me an example that illustrates that idea very well.

Dr. Witt: Yeah, so one example of that was that when patients begin taking these blood-thinning medications, they have dramatic effects on their lifestyle. For some of the medicines, even the food that they eat can interact with these medicines and they have to be careful of the activities that they're engaging in. There are just a lot that you have to be aware of.

And so providing a lot of education up front is something that anticoagulation providers just do as a course of business. The evidence-based guidelines went out and tried to find evidence, studies in the literature, that would back that up and say, "Well, education improved outcomes. So reduced the risk of bleed, reduced the risk of blood clots, reduced the risk of death."

And you can imagine that those kinds of studies would be very difficult to do. So there wasn't any "evidence" to substantiate that. And so the guideline committee is then sort of faced with this decision to say either nothing or to accurately say what the evidence says, that there is no evidence to support that this is beneficial. So you really can't make a recommendation and say, "We don't recommend that you educate your patients about that."

And so it's situations like that where it makes sense that a course of action would be warranted, but you can't back it up with "evidence."

Interviewer: Right, and also based on the collective experience of your experts, you can make some of those recommendations.

Dr. Witt: Absolutely.

Interviewer: It seems like these statements, a lot of them are just centered on very practical situations. "This is what I see with my patient. How do I go about evaluating what to do next?"

Dr. Witt: That is right. Each of the panels as they got together, they first came up with a list of about 10 or so questions that they felt like, "Well, here are the common things that we see coming up when we're managing patients." And so then, they worked off of that list of questions to design the guidance statements. So I think it was a real practical, everyday sort of helpful way to approach the recommendations.

Interviewer: And maybe a little different than what's been done before?

Dr. Witt: Yeah, I think it is. We just learned also that the American College of Chest Physicians has published some updated guidelines on venous thromboembolism and those are extremely helpful. But I think the Anticoagulation Forum's documents stand on their own as well because they take a slightly different take on it. And I think that using the two documents complementary together can really provide clinicians with the information that they need to know to take good care of the patients.

Interviewer: You know, it seems like one of the things that are changing in managing venous thromboembolism is the treatment. Is that part of what these guidelines are about?

Dr. Witt: Yeah, that's a great question. And up until 2012, there was really only one option for the long-term treatment of venous thromboembolism, an oral medication, and that was warfarin or Coumadin.

And warfarin is sort of an interesting drug. It got its start as rat poison. And so many people still know it was used as rat poison and as they begin to take it, they'll often ask you, "Well, what is this medicine that I'm taking?"

Well, it's a very effective medicine, but it's a difficult medicine to manage because the dose is different for every patient. And then, Warfarin can be affected by hundreds and hundreds of different drugs. The food that you eat in your diet can affect how the drug works. And so, it really needs to be managed carefully.

And so, in 2012, the first of a series of new drugs called direct oral anticoagulants came out that produce the same effect of warfarin but don't require the same type of intensive monitoring that is required with warfarin therapy.

And so practitioners are now trying to figure out, "Well, how do I incorporate these new treatment options into the management of the patients that I'm seeing with venous thromboembolism?" And that was one of the things that these guideline statements were really intended to address.

Interviewer: And so what is your hope in getting this information out there?

Dr. Witt: My hope, and I think the hope of the people who were behind this project, is to get information that's practical and usable at the bedside into the hands of the people that are taking care of these patients. We tried to make it so that it was easier to read. The information is written in a very straightforward manner. We tried to summarize all the recommendations so that they're easy to find. Our hope is that it just elevates the care that patients that are requiring these medications would receive. And that will, in turn, lead to better outcomes.

Interviewer: Where should someone go to find out more?

Dr. Witt: One of the things that I think is great about these guidelines is they have been published in the Journal of Thrombosis and Thrombolysis and they are open access. So if you go to the journal's web page, you can actually click on the journal edition and any of those articles can be accessed and downloaded for free.

Announcer: Interesting, informative and all in the name of better health. This is The Scope Health Sciences Radio.