DVT guidelines address travel and other issues

According to the American Heart Association, between 600,000 and one million Americans are affected by deep vein thrombosis (DVT) annually. As many as 200,000 will die of pulmonary embolism (PE), which is more than from breast cancer and AIDS combined.

New guidelines from the Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy recommend fondaparinux (Arixtra, GlaxoSmithKline) as an alternative to low molecular weight heparin (LMWH) and give the drug three of the strongest recommendations for use during knee and hip arthroplasty. In addition, for the first time, the guidelines offer formal recommendations on how long-distance travelers can avoid thrombotic events. The updated document was published as a supplement to the September 2004 issue of the journal Chest. The guidelines were last revised in 2001.

"This represents an extensive update to the guidelines," said Jack Hirsh, M.D., a co-chair of the ACCP panel that developed the guidelines and professor emeritus at McMaster University in Hamilton, Ontario, Canada. "We were much more rigorous in our literature search and more transparent in linking evidence to our recommendations."

The recommendations for preventing DVT during long-distance travel have probably received the most attention from the press, Hirsh said. He explained much speculation has occurred about the prevention and treatment of DVT in those spending several hours on a plane. Those at increased risk for VTE may benefit from a dose of LMWH or fondaparinux prior to departure. Aspirin is not recommended for the prevention of travel-related VTE, however.

"Since 1995, the ACCP guidelines have recommended that every institution should have a written policy in place to stratify patients for their risk of VTE," said Henry Bussey, Pharm.D., a member of the ACCP panel and a professor of pharmacotherapy at the University of Texas at Austin College of Pharmacy. "The role of pharmacists in developing and implementing such policies depends on the individual institution," added Bussey, who is also president and senior editor of ClotCare Online Resource (at http://www.clotcare.com/). He suggested that pharmacists work with the appropriate committee at their institution, such as the pharmacy and therapeutics committee or risk management committee, on this issue.

It is worth noting that the National Quality Forum (NQF) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently announced a joint project to develop and standardize performance measures for the prevention and treatment of DVT. NQF will oversee the project and assume responsibility for those aspects of the project relevant to the development of organizational policies and procedures, care practices, and appropriate improvement interventions. NQF will subcontract to JCAHO the actual creation of the DVT performance measure set, in addition to the specification and testing of these measures. In a recent press release, the Coalition to Prevent Deep Vein Thrombosis expressed its support of the NQF/JCAHO partnership.

http://Clotcare.com/ can serve as a practical resource for pharmacists wishing to ensure that their patients at increased risk for VTE are identified and receive appropriate care. Bussey said that Web site hosts a listserv of approximately 1,000 people, of whom about 80% are healthcare professionals. He also said that the site is interactive. If visitors to clotcare. com cannot find what they are looking for by searching the database, they can submit a question and receive an answer from the editorial board.

Bussey said that the site sends out e-mail alerts that contain new information about the prevention and treatment of VTE two or three times per month. The site also provides links to other relevant sites, including a link to the Chest Web site, http://www.chestjournal.org/ .

"This is an exciting time in the field of thrombosis," concluded Hirsh. "The new ACCP guidelines not only offer an update of recommendations from previous years, but they also provide a look at new therapies that are now available and a preview of therapies still in development."