St. Emlyn´s - December 17, 2016 - By Dan
"This weekend, the results from the multi centre POT-CAST Dutch study were presented at the American Society of Haematology and simultaneously published in the New England Journal of Medicine. At long last, a prospective randomised controlled trial on the topic, of a decent size, in a high impact journal...
CLINICAL BOTTOM LINE
Well, if pushed I think I would stick to our previous position. Low risk patients with temporary imombilisation following lower limb injury seem to have a low VTE event rate and would seem not to benefit from thromboprophylaxis. The GEMNET guidance has always been clear on this. However, high risk folk are still a concern. As such a discussion of risk at the bedside and a shared decision making process is essential.
How much risk is ‘high risk’? Well, this paper does move things on a bit, suggesting that in a mixed cohort of patients with active cancer, obesity, family history of VTE and smokers that thromboprophylaxis seems to be of limited benefit. Perhaps ‘high risk’, is actually much higher than we thought when we wrote the GEMNET guidelines. Perhaps predicting which patients in immobilisation are at risk of a subsequent VTE is impossible, as not all risk factors can be prospectively characterised. We shall see. No doubt there will be meta-analyses and logistic regression to follow from recent evidence. Until then, I intend to keep having the conversation.
For those patients in low and middle ground of VTE risk I suspect I will dwell less on the equipoise and more on the low event rate. Therefore I would expect to be giving out less LMWH overall to these patients. But that’s just me – I’m always interested to hear what you all do about the risk for clots in pots, and whether this paper will impact on your practice."