Overtreatment of PEs is common, says study

What to tell patients about the pros and cons of anticoagulation treatment

A retrospective analysis of treatment patterns of isolated subsegmental pulmonary embolism (SSPEs) at one tertiary care hospital found that almost all isolated SSPEs were anticoagulated at a similar frequency to more proximal embolisms (87% vs. 94%), and this treatment was associated with harm in some patients (e.g., decreases in hemoglobin or receipt of a blood transfusion).

“Owing to fear of complications, physicians are likely reticent to leave a pulmonary embolism (PE) untreated, even if it may represent imaging artifact or is discovered incidentally,” wrote study author Emily G. McDonald, MD, MSc, assistant professor of medicine at the McGill University in Montreal, Quebec. In an accompanying commentary, Lisa K. Moores, MD, FCCP, MACP, professor of medicine at the Edward Hebert School of Medicine in Bethesda, MD, noted that the current data highlight the issue of overtreatment of SSPEs, and that at a minimum, practitioners should have a conversation with patients about the advantages and disadvantages of anticoagulation treatment for SSPEs.  

“Deciding on treatment versus clinical surveillance is a matter of weighing the harms and benefits of the therapy, balanced against the risks of surveillance alone,” said McDonald. Pharmacists can begin by asking the simple question: “Is this an isolated SSPE?” She noted that patients with a single SSPE in the absence of a deep vein thrombosis (DVT) in the legs are candidates for clinical surveillance. “Pharmacists are optimally positioned to initiate a discussion surrounding the update to the CHEST guidelines that suggest that clinicians may opt for clinical surveillance in many of these cases.” 

She noted that pharmacists can identify which patients are at high risk of bleeding, such as patients on hemodialysis or with end-stage kidney disease, those with cirrhosis (especially if they are known to have varices), and those who are currently on single or dual antiplatelet therapy, in whom therapy cannot be safely withheld while they are started on therapeutic anticoagulation (e.g., patients with a drug eluting stent placed in the prior 6–12 months).

McDonald suggested treatment for patients whose embolism has been confirmed by a staff radiologist and who have one of the following:

  • Risk factors for propagation of clot or recurrence (e.g., hospitalized patients and those with an active malignancy).
  • Poor cardiopulmonary reserve, as there is a risk these patients would poorly tolerate a PE if it occurred during clinical surveillance.

“From a provider standpoint, the guidelines recommend that we assess the likelihood that the clot is real, determine if there is a concomitant DVT, and assess the risk of bleeding,” said Moores. “These determinations should drive the decision about whether patients should be anticoagulated or not. I think from a pharmacist's perspective, reminding the team to assess bleeding risk is always helpful.  In particular, bringing up any drug interactions that might affect that bleeding risk is also very helpful.”

For the full article, please visit www.pharmacytoday.org for the November 2018 issue of Pharmacy Today.