CURATIVE Domaine 5: Discontinuing Flashcards
5.1 Discontinuation of antithrombotic agents
invasive procedures:
depend on the underlying risk factors for thrombosis and hemorrhage as well as the type of procedure
In procedures where hemorrhage may be catastrophic (eg, neurosurgery) or unable to be easily controlled (eg, percutaneous renal biopsy), discontinuation or alteration of therapy is prudent
For less‐invasive procedures:
Consideration for the risk of:
5.1 Discontinuation of antithrombotic agents
In patients at high risk for thrombosis, anticoagulation should NOT be discontinued for invasive procedures
In patients at low to moderate risk for thrombosis, consideration may be given for discontinuation of anticoagulation prior to invasive procedures
eg, dental extraction and truncal mass removal or those where hemorrhage may be addressed through tamponade (eg, surgery on a peripheral limb), anticoagulant therapy may continue through the procedure if there is a high risk of thrombosis without anticoagulation
rebound hypercoagulability should be given when planning complete or temporary cessation of therapy
5.2 Antiplatelet agent discontinuation 5–7 days prior to an elective procedure versus no discontinuation (high risk)
In addition, dual antiplatelet therapy:
We recommend that antiplatelet therapy with a single antiplatelet agent should be continued.
We recommend discontinuing 1 agent if animals are receiving dual antiplatelet therapy
We suggest that these patients are at increased risk of bleeding and that close attention be paid to surgical hemostasis
Delphi process: 13/13 panel members responding agreed (round 2).
No veterinary studies specifically addressed the relevant PICO question and hence multiple studies from human medicine (LOE 6, Fair) were extrapolated to generate this guideline. The guideline represents a balance of the increased risk of thrombosis associated with drug discontinuation in patients with high‐risk conditions or where multiple risk factors exist compared to the perceived lower risk of surgical hemorrhage that may result from ongoing platelet inhibition of hemorrhage
significantly more hemorrhage compared with antiplatelet monotherapy
5.3 Antiplatelet agent discontinuation 5–7 days prior to an elective procedure versus no discontinuation (low/moderate risk)
We recommend that antiplatelet agents should be discontinued prior to the planned procedure.
Delphi process: 13/13 panel members responding agreed
5.4 UFH/LMWH discontinuation 24 hours prior to an elective procedure versus no discontinuation (high risk)
We recommend that heparin therapy should not be discontinued.
We recommend that surgery be planned to occur at nadir of anticoagulant effect (approximately 6–8 hours after prior dose if given by subcutaneous injection).
We suggest that these patients are at increased risk of bleeding and that close attention be paid to surgical hemostasis.
Delphi process: 12/12 panel members responding agreed (round 3).
No veterinary studies specifically addressed the relevant PICO question and hence multiple studies from human medicine (LOE 6, Good) were extrapolated to generate this guideline.314-328 Patients at high risk of thrombosis are considered more likely to suffer consequences from thrombosis following discontinuation of heparin therapy than they are to suffer morbidity or mortality from procedure related hemorrhage. Timing surgery to occur around the nadir of anticoagulant effect coupled with scrupulous surgical hemostasis may mitigate the bleeding risk.
5.5 UFH/LMWH discontinuation 24 hours prior to an elective procedure versus no discontinuation (low/moderate risk)
We recommend that consideration may be given to taper (UFH) or stop (LMWH) therapy prior to a procedure.
Delphi process: 13/13 panel members responding agreed (round 2).
No veterinary studies specifically addressed the relevant PICO question. Evidence summary is as given in Section 5.5. In patients at low to moderate risk of thromboembolic disease, tapering or discontinuing heparin therapy may limit hemorrhage during procedures without significantly increasing the risk of thrombosis.
5.6 Antiplatelet agent discontinuation 5–7 days prior to surgery versus 24 hours (high risk)
24‐hour withdrawal time is unlikely:
We recommend against withdrawing antiplatelet agents within 5 days of a procedure.
Delphi process: 13/13 panel members responding agreed (round 2).
In patients receiving irreversible antiplatelet agents, a 24‐hour withdrawal time is unlikely to be different than not discontinuing the agent at all in patients at high risk for thrombosis and hence this guideline reflects as given in Section 5.2.
5.7 Antiplatelet agent discontinuation 5–7 days prior to surgery versus 24 hours (low/moderate risk)
Platelet lifespans are:
We recommend that antiplatelet agents be discontinued within 5 days of a procedure.
Delphi process: 12/12 panel members responding agreed (round 3).
Four veterinary studies (LOE3, Fair) and 3 from human medicine (LOE 6, Good) provided evidence for this guideline.
7 day human 6 dogs and possibly shorter in cats
However, platelet function may be acceptable to provide adequate surgical hemostasis prior to 5–7 days following cessation of medications, as functional platelets are introduced into the bloodstream on a continuous basis. In patients receiving irreversible antiplatelet agents, but with a low risk of thrombosis, progress toward a return of normal platelet function may be achieved prior to surgery by drug discontinuation and hence this guideline reflects 5.3 above.
- 8 Restarting antithrombotic therapy 24 hours post‐surgery versus 3–5 days (high risk patient)
- 9 Restarting antithrombotic therapy 24 hours postsurgery versus 3–5 days (low/moderate risk patient)
We recommend that in patients at high risk, antithrombotic therapy should be restarted as soon as possible after surgery provided there is no evidence of ongoing bleeding.
No evidence‐based recommendation can be made for patients at low/moderate risk.
We suggest that in patients at low/moderate risk, antithrombotic therapy be restarted once there is no evidence of ongoing bleeding.
5.10 Restarting antithrombotic therapy 24 hours postsurgery versus 3–5 days (patients that develop thrombosis)
We recommend that antithrombotic therapy should be initiated immediately in patients that develop thrombosis in the postoperative period.
Delphi process: 13/13 panel members responding agreed (round 2).
Five studies in human medicine (LOE 6, Good–Fair) High‐risk patients are more likely to be harmed by delays in administration of thromboprophylaxis than by mild postoperative bleeding.
There was insufficient evidence to make a recommendation regarding low‐risk patients, but the panel has provided a consensus recommendation for guidance. One veterinary study (LOE 5, Good) supports prompt initiation of thromboprophylaxis in patients that develop thrombosis postoperatively.274
5.11 Discontinuation of antithrombotic therapy in patients where an in situ arterial blood clot is no longer identifiable
We recommend that if the underlying causative conditions have resolved, antithrombotic therapy should be discontinued following thrombus resolution.
In patients with unknown underlying conditions or where these conditions cannot be cured or resolved, we recommend antithrombotic therapy should be continued indefinitely.
Delphi process: 13/13 panel members responding agreed (round 2).
Evidence from 2 veterinary studies (LOE 1–5, Good) suggests that patients at high risk of arterial thrombosis may have recurrent thrombi despite antithrombotic medications. Several studies (LOE 1–3, Good–Poor) suggest that patients with a noncurable predisposing condition should not have therapy discontinued
5.12 Discontinuation of antithrombotic therapy in patients where an in situ venous blood clot is no longer identifiable
We recommend that if the underlying causative conditions have resolved, that antithrombotic therapy should be discontinued following thrombus resolution.
In patients with unknown underlying conditions or where these conditions cannot be cured or resolved, we recommend antithrombotic therapy should be continued indefinitely.
In patients with a low or moderate risk of thrombosis, we suggest that the risk of hemorrhage and the ability of the animal to tolerate antithrombotic therapy should be weighed against the risk of recurrence of the prothrombotic condition.
Delphi process: 12/13 panel members responding agreed (round 2).
One panel member felt it was not clear that dogs receiving immunosuppressive corticosteroids for a condition such as IMHA that was resolving would require indefinite antithrombotics.
Multiple veterinary case reports (LOE 5, Poor) support indefinite use of antithrombotics in patients with chronic (noncurable) underlying causes particularly for the treatment of venous thromb
5.13 Weaning of UFH therapy
rebound hypercoagulable syndrome is described following abrupt discontinuation of UFH therapy in people and may increase the incidence of thrombotic events. A recent pilot study
We recommend that if UFH is administered as an IV constant rate infusion, it should be tapered (weaned) rather than abruptly discontinued.
Clinicians should consider weaning UFH therapy administered by the subcutaneous route.
Delphi process: 14/14 panel members responding agreed (round 1).
also suggested increased thrombin production following discontinuation of subcutaneous UFH in dogs
5.14 Weaning of LMWH therapy
rebound hypercoagulability described for UFH has
Clinicians do not need to wean LMWH therapy prior to discontinuation.
Delphi process: 14/14 panel members responding agreed (round 1).
not been consistently observed following enoxaparin discontinuation, although a single report was identified suggesting this might occur with dalteparin, but to a lesser extent than with UFH
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5.15 Weaning of direct Xa inhibitor therapy
3 studies from human medicine (LOE 6, Poor) were extrapolated to generate this guideline…there is insufficient evidence to confirm or refute a rebound effect following discontinuation of the direct Xa inhibitors. Several human case reports describe thrombotic events following discontinuation of rivaroxaban. Until more data are available, the panel suggests weaning of these therapies is reasonable.
Clinicians should consider weaning direct oral Xa inhibitor therapies.
Delphi process: 14/14 panel members responding agreed (round 1).
