Meta-Analysis: Which Anticoagulant Treatments Are Best for Preventing Venous Thromboembolism in Hospital?
BACKGROUND AND PURPOSE:
- Eck et al. (BMJ, 2022) assessed the benefits and harms of different types and doses of anticoagulant drugs for the prevention of venous thromboembolism (VTE) in hospitalized patients who are acutely ill
METHODS:
- Systematic review and meta-analysis
- Inclusion criteria
- RCTs
- Studies that investigated the prevention of VTE among acutely ill adult patients in the hospital
- Eligible studies compared
- Low or intermediate dose low-molecular-weight heparin (LMWH) | Low or intermediate dose unfractionated heparin | Direct oral anticoagulants (DOACs) | Pentasaccharides | Placebo | No intervention
- Study design
- Random effects, Bayesian network meta-analyses were used to assess primary outcomes
- The quality of evidence was graded using the Confidence in Network Meta-Analysis framework
- Primary outcomes
- All-cause mortality
- Symptomatic VTE
- Major bleeding
- Serious adverse events at or closest time to 90 days
RESULTS:
- 44 RCTs | 90,095 participants
- Evidence was low to moderate quality
- None of the interventions assessed reduced all-cause mortality compared with placebo
- Some interventions were most likely to reduce symptomatic VTE
- Pentasaccharides
- OR 0.32 (95% credible interval [CrI], 0.08 to 1.07)
- Intermediate dose LMWH
- OR 0.66 (95% CrI, 0.46 to 0.93)
- DOACs
- OR 0.68 (95% CrI, 0.33 to 1.34)
- Intermediate dose unfractionated heparin
- OR 0.71 (95% CrI, 0.43 to 1.19)
- Pentasaccharides
- Two interventions were most likely to increase major bleeding
- Intermediate dose unfractionated heparin
- OR 2.63 (95% CrI, 1.00 to 6.21)
- DOACs
- OR 2.31 (95% CrI, 0.82 to 6.47)
- Low to moderate quality evidence
- Intermediate dose unfractionated heparin
- No conclusive differences were found between interventions regarding serious adverse events
- Very low to low quality evidence
- When compared with no intervention rather than placebo, all active interventions performed
- More favorably regarding risk for
- VTE
- Mortality
- Less favorably regarding risk for major bleeding
- More favorably regarding risk for
- The results were robust in prespecified sensitivity andsubgroup analyses
CONCLUSION:
- For prevention of VTE among acutely ill patients, LMWH maximized benefit while limiting major bleeding risk vs other interventions
- Interventions with the least favorable outcomes included
- Unfractionated heparin, especially intermediate dose
- DOACs
- The authors state
Our results support the National Institute for Health and Care Excellence and the American Society of Hematology guidelines on thrombosis prophylaxis in their recommendations on the use of low-molecular-weight heparins or pentasaccharides
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