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ANTICOAGULATION

Choosing the Appropriate Antithrombotic Agent for the Prevention and Treatment of VTE: A Case-Based Approach

Clinical Associate Professor; Director, Antithrombosis Center, Department of Pharmacy Practice, College of Pharmacy, The University of Illinois at Chicago, Chicago, IL

Ann K Wittkowsky, PharmD CACP FASHP FCCP

Clinical Professor, University of Washington School of Pharmacy; Director of Anticoagulation Services, University of Washington Medical Center, Seattle, WA

Paul P Dobesh, PharmD FCCP BCPS

Associate Professor of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE

David W Hawkins, PharmD

Senior Associate Dean and Professor and Chair of Pharmacy Practice, South University School of Pharmacy, Savannah, GA

William E Dager, PharmD FCSHP

Pharmacist Specialist, Department of Pharmaceutical Services, The University of California Davis Medical Center, Sacramento, CA; Clinical Professor of Pharmacy, School of Pharmacy, University of California at San Francisco, San Francisco, CA

Reprints: Dr. Nutescu, College of Pharmacy, The University of Illinois at Chicago, 833 S. Wood St., MC 886, Rm. 164, Chicago, IL 60612-7230, fax 312/413-4805, enutescu{at}uic.edu

OBJECTIVE: To review the risk of venous thromboembolism (VTE) in various patient populations and evaluate the agents available for the prevention and treatment of VTE using a case-based approach.

DATA SOURCES: A MEDLINE search (1995-July 2006) was conducted to identify relevant literature. Additional references were reviewed from selected articles.

STUDY SELECTION AND DATA EXTRACTION: Articles related to the prevention of VTE in orthopedic surgery, general surgery, and medically ill patients, as well as the treatment of VTE, were reviewed.

DATA SYNTHESIS: Pharmacologic options for the prevention and treatment of VTE include warfarin, unfractionated heparin (UFH), low-molecular-weight heparins (LMWH), and fondaparinux. Current guidelines support the use of warfarin, LMWH, or fondaparinux for VTE prophylaxis following lower limb major orthopedic surgery. For VTE prophylaxis in hospitalized medical patients or patients undergoing general surgery, use of UFH and LMWH is supported; however, recent data on fondaparinux suggest that it is also effective in these patient populations. The use of UFH or LMWH (both in conjunction with warfarin) for treatment of acute deep venous thrombosis or nonmassive pulmonary embolism is recommended. Recent data suggest that fondaparinux (in conjunction with warfarin) is also effective for the treatment of VTE. A variety of pharmacokinetic, pharmacodynamic, and pharmacoeconomic factors differentiate each agent for the various indications.

CONCLUSIONS: Currently, a "one-size-fits-all" anticoagulant is not available for treatment of VTE. A variety of patient factors, including type of surgery, medical indication, thrombotic risk factors, bleeding risk, history of heparin-induced thrombocytopenia, and a variety of comorbid conditions can affect the safety, efficacy, and selection of appropriate VTE therapy.

Key Words: anticoagulants, direct thrombin inhibitors, factor-Xa inhibitors, heparin, low-molecular-weight heparin, venous thromboembolism, warfarin

Published Online, August 15, 2006. www.theannals.com, DOI 10.1345/aph.1G577

THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-06-021-H01