The drug is absorbed in the gastrointestinal tract, is metabolised in the liver by cythocrome-dependent and -independent mechanisms and it is eliminated through both the renal and the faecal routes [29]

The drug is absorbed in the gastrointestinal tract, is metabolised in the liver by cythocrome-dependent and -independent mechanisms and it is eliminated through both the renal and the faecal routes [29]. Apixaban has been assessed for the treatment of DVT in a dose finding study (Botticelli DVT study) [30]. these drugs are admistered at fixed daily doses and do not require laboratory monitoring. The positive results of the first completed clinical trials suggest that a new era in the management of VTE is about to begin. Keywords: Deep vein thrombosis, Pulmonary embolism, Anticoagulants, Treatment STATE OF THE ART IN THE TREATMENT OF VENOUS THROMBOEMBOLISM Deep vein thrombosis (DVT) and pulmonary embolism (PE) are important pathologies that impact apparently healthy individuals as well as medical or surgical patients. Therapeutic objectives are essentially the prevention of thrombus extension and embolization, and the prevention of recurrent episodes of venous thromboembolism (VTE) to reduce the risk of fatal pulmonary emboli. Despite the availability of different treatment strategies, the large majority of patients generally receive a comparable therapeutic approach, and the choice of the Ibuprofen piconol treatment is usually Ibuprofen piconol eventually influenced by the severity of the presentation of the disease. Anticoagulation is the main therapy for acute VTE and the evidence for the need for anticoagulation in these patients is based Ibuprofen piconol on the results of clinical studies performed more than 40 years ago [1]. Patients need to start treatment as soon as the diagnosis is usually confirmed by objective screening, and because anticoagulant drugs with a rapid onset of action are needed in this phase, three parenteral therapeutic options are currently available for initial treatment: unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and fondaparinux [2]. Fondaparinux is a synthetic pentasaccharide that inhibits factor Xa indirectly by binding to antithrombin with high affinity and was recommended for the first time in the 8th edition of the American College of Chest Physicians (ACCP) Guidelines on Antithrombotic and Thrombolytic Therapy, which is the most recent and was published in 2008 [2]. This recommendation was based on the results of the MATISSE studies [3, 4]. In the MATISSE DVT study [3], 2205 patients with DVT were treated with a once daily subcutaneous dose of fondaparinux (7.5 mg for patients weighting 50 to 100 kg, 5.0 mg for patients weighting less than 50 kg and 10.0 mg for patients weighting more than 100 kg) or with a twice daily subcutaneous dose of enoxaparin (1 mg/kg) for at least five days. There were no differences in the incidence of recurrent VTE at 3 months (3.9% vs 4.1%), major bleeding while on treatment (1.1% vs 1.2%), and mortality at 3 months (3.8% vs 3.0%). In the MATISSE PE study [4], 2213 patients Ibuprofen piconol with acute PE were randomly allocated to treatment with subcutaneous fondaparinux or intravenous UHF. Recurrence of VTE at 3 months (3.8% vs 5.0%) and major bleeding while on treatment (1.3% vs 1.1%) were again comparable between the two groups. In selected cases, more aggressive treatment strategies are required. There is common agreement that patients with PE resulting in cardiogenic shock in the beginning treated with thrombolysis plus Ibuprofen piconol anticoagulation have better short- and long-term clinical outcomes than those who receive anticoagulation alone [5]. More recently, some authors have proposed that thrombolysis should be administered to patients with normal blood pressure (and no contraindications) when clinical or echocardiographic evidence of right ventricular dysfunction is present. In the most recent ACCP guidelines [2], the use of thrombolytic therapy, which was previously recommended for hemodynamically unstable patients (massive PE) only, is now also suggested LW-1 antibody for selected high-risk patients without hemodynamic instability and with a low risk of bleeding, with a grade 2B recommendation. However, this remains a controversial issue, and the controversy is likely to remain at least until the results of an ongoing European trial, in which 1,000 PE patients with preserved systolic blood pressure, elevated troponin levels,.

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