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Venous Thromboembolism in Acute Medically Ill Patients: Identifying Unmet Needs and Weighing the Value of Prophylaxis
Paul P. Dobesh, PharmD; Tania Ahuja, PharmD; George A. Davis, PharmD; Hugh Fatodu, MBA, RPh; William H. Francis, MBA, RPh; Frank P. Hull, MD; Gary L. Johnson, MD, MS, MBA; Joshua D. Lenchus, DO, BSPharm; Jacqueline Glee Lenoir, PharmD; Claudette McPherson, RN, BSN; Jeffrey Nemeth, PharmD, MPA; and Ralph J. Riello III, PharmD
Best Practices for Implementing Venous Thromboembolism Prophylaxis Across the Continuum of Care
Paul P. Dobesh, PharmD; Tania Ahuja, PharmD; George A. Davis, PharmD; Hugh Fatodu, MBA, RPh; William H. Francis, MBA, RPh; Frank P. Hull, MD; Gary L. Johnson, MD, MS, MBA; Joshua D. Lenchus, DO, BSPharm; Jacqueline Glee Lenoir, PharmD; Claudette McPherson, RN, BSN; Jeffrey Nemeth, PharmD, MPA; and Ralph J. Riello III, PharmD
Participating Faculty

Venous Thromboembolism in Acute Medically Ill Patients: Identifying Unmet Needs and Weighing the Value of Prophylaxis

Paul P. Dobesh, PharmD; Tania Ahuja, PharmD; George A. Davis, PharmD; Hugh Fatodu, MBA, RPh; William H. Francis, MBA, RPh; Frank P. Hull, MD; Gary L. Johnson, MD, MS, MBA; Joshua D. Lenchus, DO, BSPharm; Jacqueline Glee Lenoir, PharmD; Claudette McPherson, RN, BSN; Jeffrey Nemeth, PharmD, MPA; and Ralph J. Riello III, PharmD
Lenchus noted that acute medically ill patients also have significant comorbidities that increase the risk for drug interactions. Stakeholders observed that the various DOACs have varying pharmacokinetic profiles regarding metabolism and strongly recommended that clinicians screen patient profiles for concomitant medications that could increase bleeding risk.

Riello suggested that educational efforts in this arena are needed, as many practitioners may not be aware of the data supporting the use of thromboprophylaxis in acute medically ill patients. There was agreement among the panelists that education should be focused on improving inpatient VTE prophylaxis and adopting the continuum of care extending to post hospitalization.

Panelists observed that such educational initiatives would be beneficial for providers/prescribers and prescription plans since betrixaban is the first product indicated in this setting. Jeffrey Nemeth, PharmD,  MPA, explained that extended VTE prophylaxis post-hospitalization is viewed negatively at his institution because the benefits are not fully understood. Hugh Fatodu, MBA RPh, agreed that lack of utilization may be a knowledge deficit. “On the hospital side, providers and prescribers may be unwilling to address this since it is more of a chronic issue. Many systems look at acute needs, and this is simply not an acute issue,” he said. As with so many other challenges in medicine, stakeholders suggested that continuity of care may also be responsible for suboptimal use of VTE prophylaxis in acute medically ill patients. According to Jacqueline Glee Lenoir, PharmD, “Medication reconciliation is still a major challenge at in many hospitals. This task, which is often initiated by a nurse in one area and completed by a nurse in a different area, is tedious and can be extremely time-consuming. Clinicians may also utilize historical data from previous admissions and rely on patients to accurately recall their medications. To further complicate the process, because fewer family practice/internal medicine physicians are admitting their patients to the hospital, high risk for VTE may not show up on their inpatient problem list, thus outpatient medications prescribed for this indication may not be continued.”

Conclusions

Extended thromboprophylaxis represents a critical but largely unmet need for patients at risk for VTEs. The next article in this supplement explores the potential of betrixaban to address these needs. 

Author affiliations:  New York University Langone Health, New York, NY (TA); University of Kentucky College of Pharmacy, Lexington, KY (GAD); University of Nebraska Medical Center, Omaha, NE (PPD); Johns Hopkins Healthcare, Glen Burnie, Maryland (HF); MedImpact Healthcare Systems San Diego, CA (WHF); Broward Pulmonary and Sleep Specialists, Fort Lauderdale, FL (FPH); Nova South Eastern University, Fort Lauderdale, FL (FPH); Humana, Inc., Madison, WI (GLJ); University of Miami Miller School of Medicine, Miami, FL (JDL); The Medical Center, Bowling Green, KY (JGL); University of Kentucky College of Pharmacy, Lexington, KY and Louisville, KY (JGL); Pomona Valley Hospital Medical Center, Pomona, CA (CM); Englewood Hospital and Medical Center, Englewood, NJ (JN); Yale New Haven Hospital, New Haven, CT (RJR).
Funding source: Publication support provided by Portola Pharmaceuticals, Inc.
Author disclosures: Dr Davis reports to having a board membership on the Pulmonary Embolism Response Team (PERT) Consortium Board of Directors and to receiving honoraria from the American Journal of Managed Care. Dr Dobesh reports to serving as a consultant for and receiving honoraria for Boehringer Ingelheim, the Pfizer/BMS alliance, Janssen Pharmaceuticals, Daiichi Sankyo, Inc, and Portola Pharmaceuticals. Mr Fatodu reports to serving on a paid advisory board for Daiichi Sankyo, Inc. Mr Francis reports to attending a paid advisory board for the American Journal of Managed Care. Dr Lenchus reports to serving as a consultant for Portola Pharmaceuticals. Dr Lenoir reports lecture fees for serving as a consultant, receiving honoraria, and receiving lecture fees for speaking at the invitation of a commercial sponsor for Portola Pharmaceuticals and Janssen Pharmaceuticals. She also reports stock ownership with Portola Pharmaceuticals. Dr Nemeth reports to serving as a consultant, receiving honoraria, receiving lecture fees for speaking at the invitation of a commercial sponsor for Portola Roundtable. He has also reported to receipt of payment for involvement of the preparation of this manuscript as Multi-stake holder of Portola Roundtable and to attending the ASHP Midyear 2017 Portola Dinner. Dr Riello reports to serving as a consultant for Portola Pharmaceuticals, and Johnson & Johnson. He reports to receiving honoraria from Portola Pharmaceuticals, Janssen Pharmaceuticals, and Johnson & Johnson. He also reports to receiving lecture fees for speaking at the invitation of a commercial sponsor for Portola Pharmaceuticals and Janssen Pharmaceuticals. Dr Ahuja, Dr Hull, Dr Johnson, and Ms McPherson report no relationships or financial interests with any entity that would pose a conflict of interest with the subject matter of this supplement.
Authorship information: Administrative, technical, or logistic support (RJR); analysis and interpretation of data (GAD, HF, JGL, JN); concept and design (JDL, JGL, JN, PPD); critical revision of the manuscript for important intellectual content (FPH, GAD, HF, JN, PPD, RJR, TA); drafting of the manuscript (FPH, GAD, HF, JDL, JGL, JN, PPD, RJR, WHF); presentation of unmet medical need content to roundtable group (RJR); supervision (FPH, JDL, PPD).
Address correspondence to: pdobesh@unmc.edu.
 
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