Recommendation on Anticoagulants Part of Latest Round of ASH Choosing Wisely Initiative

A call for limiting how long to use anticoagulants after an initial venous thromboembolism was included on the second list of tests and treatments to question as the American Society of Hematology (ASH) issued a fresh set of recommendations under the Choosing Wisely initiative.¹

This year’s list was announced at the start of the 2014 ASH Annual Meeting that convened at the Moscone Center in San Francisco, California. The first round of recommendations,

numbers 1 through 5, were announced December 4, 2013, at the last ASH meeting in New Orleans, Louisiana. Details of recommendations 6 through 10 were presented at a

session December 8, 2014.

Mark Crowther, MD, MSc, of McMaster University in Hamilton, Ontario, Canada, discussed the recommendation, “Don’t use anticoagulants for more than 3 months in patients with a first venous thromboembolism (VTE) occurring in the setting of a major transient risk factor.” Crowther described this recommendation as a basic calculation of benefit-versus-risk: a VTE triggered by a major

event, such as surgery, presents a low risk for recurrence once the major event has passed and recovery has occurred, assuming adequate care and anticoagulant therapy. Subsequently, such

patients have a low risk of thrombosis, “and have the same risk of bleeding as other patients.”

The ASH recommendation does not apply to VTE linked to non-major risks, such as pregnancy or travel-associated immobility. Choosing Wisely is the initiative of the American Board of Internal Medicine Foundation that asks each specialty to identify tests or treatments that might be overused and unnecessary, with the potential to harm patients. While saving healthcare dollars is not the only consideration of Choosing Wisely, its efforts will have that effect if patients and their doctors are more judicious in their medical decisions. Other ASH Choosing Wisely recommendations

are:

• Don’t perform baseline or routine surveillance computed tomography scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia. This recommendation

incorporates a theme heard this year at ASH about overuse of scans, which has been a broad theme across managed care and cancer care especially.

• Don’t test or treat for suspected heparin-induced thrombocytopenia in patients with a low pre-test probability. Adam C. Cuker, MD, MS, of the University of Pennsylvania, described the “4T” score, a widely used system that allows clinicians to evaluate the timing of a degree of thrombocytopenia and whether it might be caused by heparin. Cuker said this is one of the tough calls in

medicine: for one, a patient is taken off heparin and other anticoagulants are much more expensive.

• Don’t treat patients with immune thrombocytopenic purpura in the absence of bleeding or low platelet count. Cindy R. Neunert, MD, of Georgia Regents University, noted that this ASH recommendation applies to adults and that pediatric cases have difficult criteria. Treatment should be aimed at improving quality of life without exposing patients to unnecessary risks and is

always conditioned on prior bleeding episodes, activity levels, and social factors.

Reference

1. Hicks LK, Bering H, Carson KR et al. Five hematologic tests and treatments to question. Hematology. 2014;2014:599-604.

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