Venous thromboembolism (VTE) is a condition that, despite being mostly preventable, is a significant source of morbidity and mortality among hospitalised patients (Popoola et al, 2016). Symptoms include localised pain, swelling and erythema (Andras et al, 2017). Anticoagulation therapy is used to treat symptomatic VTE, since the goal is to prevent reoccurrence, with vitamin K antagonists (VKA) being the prevailing drugs of choice. However, it can be challenging to reach therapeutic levels of VKAs in many patients, and this places them at an increased risk for bleeding (Andras et al, 2017). In order to provide optimal VTE management and prophylaxis, risk-appropriate treatment plans delivered in a patient-centred environment are key (Streiff et al, 2016).
It has been found that nearly 50% of patients forego one or more prescribed doses of VKAs, and patient refusal is most often the reason documented for this (Popoola et al, 2016). Studies have shown that these omitted doses result in avoidable patient harm, as they are related to VTE events (Popoola et al, 2016). Low-molecular-weight heparin (LMWH) may be a possible alternative to VKAs (Andras et al, 2017), as it does not require laboratory tests to establish therapeutic levels, can be used in patients with contraindications to VKAs and minimises the risk of complications associated with bleeding. However, it needs to be established that its safety and efficacy are equivalent to those of VKAs.
Patient acceptance of the treatment plan is a crucial step in adequate VTE prevention. Educating patients and families about all their options places them at the centre of their own care and engages them to make the best, informed decisions around their healthcare needs. By engaging patients and families in care, the rate of refusal for anticoagulation therapy can be reduced, compliance can be improved and needless patient harm could be reduced (Popoola et al, 2016).
Objectives
The purpose of Andras et al's (2017) review was to appraise trials that randomly assigned participants to long-term anticoagulation therapy with VKAs or LMWH for treatment of symptomatic VTE. The specific aim was to assess the safety and efficacy of LMWH against VKAs in the long-term treatment of symptomatic VTE. Over the course of the 3-month treatment period, the outcomes measured included episodes of major bleeding complications, frequency of recurrent symptomatic VTE and mortality.
Intervention/methods
In accordance with clinical standards for symptomatic VTE, traditional practice includes administration of VKAs. The course of treatment is a minimum of 3 months, with a goal of achieving an international normalised ratio (INR) of 2.0–3.0. Although prevention of recurrent symptomatic VTE can also be achieved with adjusted subcutaneous unfractionated heparin, regular laboratory monitoring is required with this treatment method. LMWH is associated with fewer complications than VKAs and unfractionated heparin; therefore, LMWH should be evaluated to determine whether it is a safer, patient-friendly alternative for long-term treatment (at least 3 months) of symptomatic VTE.
The Cochrane Vascular Specialized Register, which comprises studies from MEDLINE Ovid, AMED, CINAHL and Embase Ovid databases, as well as manual searches of applicable journals, was used to search for relevant trials. In addition, the following trial registries were explored: ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform and ISRCTN Register. Trials that were included compared VKAs to LMWH for long-term treatment of symptomatic VTE and randomly allocated the participants. There were no restrictions with regard to publication status or language.
Results
This review of 16 trials and 3299 patients found no evidence that LMWH was more efficacious that VKAs in the long-term treatment of symptomatic VTE (Andras et al, 2017). The findings showed no distinct differences between the treatment groups for recurrent symptomatic VTE and mortality. However, analyses revealed an advantageous difference for LMWH regarding major bleeding complications. Thus, the authors concluded that, with no discernible distinction related to reoccurrence of symptomatic VTE or mortality and a favourable difference associated with major bleeding complications, LMWH may be a safer alternative to VKAs (Andras et al, 2017).
Conclusions
A favourable difference, supporting LMWH, related to major bleeding was noted in Andras et al's (2017) review, although the evidence was graded as being of low quality. However, high-quality evidence from the review suggested no clear difference related to major bleeding complications between VKAs and LMWH. Further, moderate-and high-quality evidence demonstrated no obvious difference between VKAs and LMWH related to symptomatic VTE recurrence, major bleeding complications or mortality. Nonetheless, even if an increase in patient safety cannot been clearly delineated, it is possible that LMWH provides benefits that could promote patient safety and enhance patient experience, although the evidence is uncertain due to its low quality.
For patients who have a contraindication to VKAs, have difficulty achieving a therapeutic INR, are concerned about bleeding complications or are hesitant to commit to regular laboratory testing, LMWH as an alternative treatment might result in a positive experience and promote compliance with long-term anticoagulation therapy for symptomatic VTE. If the number of missed doses that have been linked to VTE events can be reduced, it is feasible that patient harm can be reduced and patient safety increased.
Implications for practice
In the US, VTE-related events are a Joint Commission priority and are reflected in the National Patient Safety Goals (NPSGs). Andras et al (2017) is relevant to NPSG.03.05.01 (reduce the likelihood of patient harm associated with the use of anticoagulant therapy) and presents LMWH as a possible alternative to VKAs for long-term treatment of symptomatic VTE.
Nurses are instrumental in promoting patient-centred care due to their essential role in patient education. Andras et al's (2017) review provides nurses with pertinent information regarding LMWH for patient education, as this possible alternative to VKAs could potentially increase compliance and reduce avoidable patient harm. Further research is needed to gain a better understanding of why patient refusal is the primary reason for missed doses.