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NCCN Guidelines and Compendium Updated

NCCN Flash Updates™ sent February 15, 2013
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Venous Thromboembolic Disease. These NCCN Guidelines® are currently available as Version 1.2013.

  • Global Change
    • A new table of "Thrombolytic Agents" for deep vein thrombosis and pulmonary embolism was added (VTE-I). The following agents were included: alteplase for PE and for DVT; reteplase, tenecteplase for DVT only.
    • A new table of "Contraindications to Thrombolysis" was added (VTE-J).
  • Deep Vein Thrombosis (DVT) or Superficial Vein Thrombosis (SVT)
    • Diagnosis: The recommendation, "Detected radiographically in asymptomatic patients" changed to "Incidental DVT/SVT". (DVT-1)
    • Workup/Imaging: For venous ultrasound, a new footnote "b" was added that states, "In cases with high suspicion of DVT and no contraindications, consider initiating early anticoagulation while waiting for imaging results." (DVT-1)
    • Pelvic/iliac/IVC or Femoral/popliteal DVT or SVT
      • For patients who have a contraindication to anticoagulation placement, the recommendation "IVC filter" changed to "IVC filter (retrievable filter preferred)". Corresponding footnote "g" that states, "Consider permanent filters only for rare patients with permanent contraindications to anticoagulation or with chronic comorbidities," is new to the algorithm. (DVT-2)
    • Pulmonary Embolism (PE)
      • Workup: For chest x-ray, a new footnote "c" was added that states, "In cases with high suspicion of PE and no contraindications, consider initiating early anticoagulation while waiting for imaging results."  (PE-1)
  • Heparin Induced Thrombocytopenia (HIT)
    • Diagnosis and Treatment (HIT-2)
      • For patients who are HIT antibody negative, the recommendation to "Consider sending serotonin release assay (SRA)" was removed.  These patients still have the option to "Consider repeating HIT antibody test depending upon pre-test probability."
      • For patients who are HIT antibody positive or SRA positive, the duration of therapy was revised as follows:
        • "HIT without thrombosis: At least 4 weeks (in the absence of serious bleeding risk)." Previously the duration was at least 4-6 weeks.
        • "HIT with thrombosis: At least 3 months as indicated for thrombotic event."Previously the duration was at least 3-6 months.
  • Therapeutic Options for HIT
    • Lepirudin was removed from the list of direct thrombin inhibitors. (HIT-B 1 of 2)
    • Under warfarin, the recommendation changed to "Treat for at least 4 weeks (no thrombosis) or at least 3 months as dictated by thrombotic event." Previously it was "…or at least 3-6 months…" (HIT-B 2 of 2)
  • Contradindications to Prophylactic or Therapeutic Anticoagulation Treatment
    • Relative Contraindications (VTE-B)
      • The fifth bullet changed to "Underlying hemorrhagic coagulopathy".  The following bullets were removed:
        • Clotting factor abnormalities (eg, severe liver disease)
        • Elevated PT or aPTT (excluding lupus inhibitors)
    • The following sentence was added to the beginning of footnote 1: "Refer to institutional specific anesthesia practice guidelines, if available."
  • Inpatient/Outpatient Prophylactic Anticoagulation Treatment
    • The third bullet was revised as follows "Unfractionated heparin: 5,000 units subcutaneous 3 times daily every 8-12 hours (category 1 for inpatient)." (VTE-C)
  • Reversal of Anticoagulation in the Event of Life Threatening Bleeding or Emergent Surgery
    • The Reversal of Anticoagulation tables (VTE-E) were revised extensively, including the following:
      • Reversal of Anticoagulation: Management of Supratherapeutic INR
        • Under warfarin, the INR listings changed as follows:
          • "INR < 5" changed to "INR< 4.5"
          • "INR 5-9" changed to "INR 4.5-10"
          • "INR > 9" changed to "INR > 10"
      • Lepirudin was removed from the list of direct thrombin inhibitors and from the rest of the table.

 

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