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Episode 186: 186. ACE vs ARB, Blood Clots, and Mifepristone
17 minutes Posted Nov 30, 2021 at 11:27 pm.
) both are publicly available.Key RecommendationsPatients with isolated subsegmental pulmonary embolism (PE): Rule out proximal deep venous thrombosis (e.g., with ultrasonography). If risk for recurrent VTE is low, surveillance is recommended over anticoagulation. If risk for recurrent VTE is high, anticoagulation is recommended. (Weak recommendation, low-certainty evidence)Patients with incidentally discovered asymptomatic PE (other than isolated subsegmental PE): Same initial and long-term anticoagulation that patients with symptomatic PE receive should be used. (Weak recommendation, moderate-certainty evidence)Patients with cancer-associated VTE: Direct-acting oral anticoagulants (DOACs; i.e., apixaban, edoxaban, or rivaroxaban) should be used for the treatment phase of therapy (strong recommendation, moderate-certainty evidence). Caveat: for patients with luminal gastrointestinal malignancies, apixaban or low-molecular-weight heparin is preferred to reduce bleeding risk.Patients with antiphospholipid syndrome: Warfarin (target international normalized ratio, 2.5) is recommended over DOAC therapy during the treatment phase for VTE. (Weak recommendation, low-certainty evidence)Catheter-assisted mechanical thrombectomy: Recommended for patients with PE and hypotension who also have high bleeding risk, failed systemic thrombolysis, or shock that is likely to lead to death before systemic thrombolysis can take effect. (Weak recommendation, low-certainty evidence)Initial anticoagulation setting: Outpatient treatment is recommended over hospitalization in patients with low-risk PE, if access to medications and outpatient care is available. (Strong recommendation, low-certainty evidence)Treatment-p(continued)
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Contraception 2021 Sep 20;[EPub Ahead of Print], D Grossman, S Raifman, N Morris, A Arena, L Bachrach, J Beaman, MA Biggs, C Hannum, S Ho, EB Schwarz, M GoldSTUDY DESIGNThis is an interim analysis of an ongoing prospective cohort study conducted at five sites. Clinicians assessed patients in clinic and, if they were eligible for medication abortion and ≤63 days' gestation, electronically sent prescriptions for mifepristone 200 mg orally and misoprostol 800 mcg buccally to a mail-order pharmacy, which shipped medications for next-day delivery. Participants completed surveys three and 14 days after enrollment, and we abstracted medical chart data for this interim analysis. In this prospective cohort study, researchers estimated the effectiveness, feasibility, and acceptability of medication abortion with mifepristone dispensed by a mail-order pharmacy with next-day delivery after in-person clinical assessment. The researchers found that complete medication abortion occurred for 96.9% of participants; 88.4% reported being very satisfied receiving medications by mail, and 89.6% said they would use the mail-order service again if needed. Of the 4.9% who experienced adverse events, none were related to mail-order dispensing.This research suggests that mail-order pharmacy dispensing of mifepristone is effective and acceptable to patients, providing further evidence that the in-person dispensing requirement for this medication should be removed. IMPLICATIONSThe in-person dispensing requirement for mifepristone, codified in the drug's Risk Evaluation and Mitigation Strategy, should be removed.      Stevens SM et al. Antithrombotic therapy for VTE disease: Second update of the CHEST Guideline and Expert Panel Report. Chest 2021 Aug 2; [e-pub]. (https://doi.org/10.1016/j.chest.2021.07.055)  The ninth edition of the CHEST Clinical Practice Guidelines for managing venous thromboembolism (VTE) — published in 2012 and updated in 2016 — now has a second update, which addresses 14 clinical questions and offers 32 guidance statements for clinicians who manage patients with VTE. The 2012 guideline (Chest 2012; 141:Suppl:e419S and the 2016 update (NEJM JW Emerg Med Feb 2016 and Chest 2016;
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