Hematology/oncology clinics of North America
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Hematol. Oncol. Clin. North Am. · Oct 2016
ReviewUse of Direct Oral Anticoagulants in Special Populations.
Direct oral anticoagulants (DOACs) have been approved for the treatment of venous thromboembolism and atrial fibrillation based on randomized controlled trials (RCTs) of direct comparisons with vitamin K antagonists. Despite having more than 100,000 patients enrolled, safety and efficacy are debated in selected populations. Although DOACs are reviewed as a class of anticoagulant, pharmacokinetic differences exist such that different medications may be beneficial in distinct clinical settings. Synthesizing available evidence based on phase III RCTs, post hoc subgroup analyses, and pooled metaanalyses, this review provides an overview of DOACs and scrutinizes individual differences in their applications for the special populations.
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Hematol. Oncol. Clin. North Am. · Oct 2016
ReviewPerioperative Management of the Direct Oral Anticoagulants: A Case-Based Review.
The periprocedural management of patients on direct oral anticoagulants (DOACs) is a common but potentially challenging clinical problem because there are few prospective studies to guide clinical decisions. Retrospective analyses from randomized trials and observational data suggest that DOACs can be managed in a standardized manner, based on surgical and patient characteristics, that does not result in excess major bleeding or thrombosis. In a case-based manner, this article presents a perioperative DOAC management algorithm and reviews the available and emerging evidence supporting the safety and efficacy of this approach. A free online clinical guidance tool is available from Thrombosis Canada that includes the proposed management algorithm.
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Hematol. Oncol. Clin. North Am. · Oct 2016
ReviewReversal Agents for the Direct Oral Anticoagulants.
The vitamin K antagonists (VKAs) are associated with a significant rate of major and fatal bleeding complications. The new direct oral anticoagulants (DOACs), even though having a better bleeding profile than the VKAs, are still associated with serious bleeding. ⋯ Although there is controversy around the necessity of a reversal agent, most clinicians agree that having a reversal agent for the DOACs would be beneficial. Three reversal agents are currently in development.
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Hematol. Oncol. Clin. North Am. · Jun 2016
ReviewManagement of Thrombotic Microangiopathic Hemolytic Anemias with Therapeutic Plasma Exchange: When It Works and When It Does Not.
Thrombotic microangiopathies are a heterogeneous group of inherited and acquired disorders sharing a common clinical presentation of microangiopathic hemolytic anemia, thrombocytopenia, and organ damage. These disorders have been treated with plasma exchange (TPE) based on randomized controlled trials, which found this therapy to be effective in thrombotic thrombocytopenic purpura (TTP). ⋯ When TPE is applied, the treatment regimen used for TTP is usually applied. There is a need for further evaluation of the role of TPE in the treatment of thrombotic microangiopathies other than TTP.
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Surgery remains the most important effective treatment for differentiated (DTC) and medullary thyroid cancer (MTC). Radioactive iodine (RAI) is another important treatment but is reserved only for DTC whose disease captures RAI. Once patients fail primary therapy, observation is often recommended, as most DTC and MTC patients will have indolent disease. ⋯ Most patients are not surgical candidates at diagnosis due to advanced disease. External beam radiation and radiosensitizing radiation are the mainstay of therapy at this time. However, exciting new drugs and approaches to therapy are on the horizon but it will take a concerted, worldwide effort to complete clinical trials in order to find effective therapies that will improve the overall survival for this devastating disease.