Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT.
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
Blood Adv. 2018 Nov 27;2(22):3257-3291. doi: 10.1182/bloodadvances.2018024893.
BACKGROUND: Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS: The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS: Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
背景:临床医生在优化抗凝剂的使用以治疗静脉血栓栓塞症(VTE)时会面临许多实际问题。
目的:这些美国血液学会(ASH)的循证指南旨在帮助患者、临床医生和其他医疗保健专业人员在 VTE 管理中使用抗凝剂的决策。这些指南假设已经选择了抗凝剂。
方法:ASH 成立了一个多学科指南小组,以平衡最小化潜在的利益冲突偏见。麦克马斯特大学 GRADE 中心支持指南制定过程,包括更新或进行系统的证据审查。小组根据对临床医生和患者的重要性对临床问题和结果进行了优先级排序。使用 Grading of Recommendations Assessment, Development and Evaluation(GRADE)方法评估证据并提出建议,这些建议将接受公众意见。
结果:小组就优化接受抗凝剂治疗的患者管理达成了 25 项建议和 2 项良好实践声明。
结论:强烈建议包括使用患者自我管理国际标准化比值(INR)和家庭即时检测 INR 监测来进行维生素 K 拮抗剂治疗,并反对使用围手术期低分子量肝素(LMWH)桥接治疗。有条件的建议包括根据实际体重确定 LMWH 的治疗剂量、不使用抗因子 Xa 监测来指导 LMWH 剂量、使用专门的抗凝管理服务,以及在危及生命的出血发作后恢复抗凝治疗。
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