Oral Warfarin Remains An Effective Treatment Option in the Extended Prophylaxis of VTE for Patients with Cancer: The Effectiveness of the CancerCare Manitoba (CCMB) Anticoagulation Clinic (ACC).
Notice bibliographique
Résumé
Abstract Venothromboembolism (VTE) in patients with active malignancy is associated with adverse outcomes and effective anticoagulation for extended duration with either oral vitamin K antagonist (VKA) or low molecular weight heparin (LMWH) is indicated for as long as the cancer is active. Although current literature suggests that LMWH is more efficacious in reducing VTE recurrence in patients with cancer when compared with oral VKA1, the need for daily injection and high drug cost are major drawbacks to the upfront use of LMWH in this setting. At our institution in Manitoba (Canada), we treat all patients with first line VKA, managed by a specialized pharmacist-run anticoagulation clinic (CCMB ACC), switching to LMWH if thrombosis recurs despite VKA. The aim of this retrospective review is to access the efficacy and safety of this approach, comparing outcomes between patients with cancer to a convenience cohort (controls) on VKA managed by the same ACC and to that of the literature. We hypothesize that appropriate anticoagulation with an oral VKA can be achieved through ACC and its use as first line therapy for extended VTE prophylaxis in cancer patients is not associated with significant increase in VTE recurrence or major bleeding episodes. Methods: We analyzed retrospectively all patients receiving oral VKA who were monitored by the CCMB ACC from July 23, 2002 to August 9, 2007, using the ACC database and CCMB electronic charts. Primary outcome is the time spent within the target INR range (%TSTR) which is defined as the proportion of patient-days for which the INR was between 2 and 3, and imputing daily values between INR tests by linear interpolation2. We limit this analysis to include only patients with at least 30 days of follow up to ensure adequate time for stabilization of INR. Secondary outcomes include rate of VTE recurrence, rate of major bleeding and rate of switching to LMWH for any reason. Multinomial logistic regression was performed to identify predictors for poor anticoagulation as well as cox regression to identify predictors of recurrence VTE or bleeding complications. Results: Although the quality of anticoagulation with oral VKA is inferior in patients with VTE and active cancer when compared to control patients (%TSTR 54% versus 64%, p<0.001), the rate of VTE recurrence and bleeding is similar. The TSTR in this cohort compared favourably with those obtained from the literature (%TSTR 54% vs 46% in the CLOT trial3) and the risk of VTE recurrence and bleeding is not excessive (10% and 5.3% respectively). However, patients with cancer are more likely to experience VKA failure (OR 7.22; 95% CI 1.47–35.5) and risk of death (OR 4.48; 95% CI 2.72–7.34) compared to control. No significant predictors were identified for recurrent VTE but those with poor INR control were more likely to suffer from bleeding complications. Conclusions: Oral VKA remains an effective option for anticoagulation for most patients and LMWH can be reserved for patients with additional risks for VKA failure and those with poor INR control due to increased risk of bleeding.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,006 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,001 | 0,003 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,001 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,001 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».