Duration of anti coagulation in patients who had thrombosis – Are we sure about it?

The recommended duration of anticoagulation in the VTE patients is dependent on the persisting risk of re-thrombosis and bleeding.  It was noted that in 10 years follow up after cessation of the anticoagulation nearly 50% of the patients develop a recurrent VTE episode. This indicates that there is hidden risk of thrombosis in these patients. It may be due to underlying known or unknown, old or new risk factors. In these patients may have persistent old factors (of varying intensity) or newly added risk factors. So, in the beginning it was felt that the anticoagulation should be continued even after discharge from the hospital, but they were not sure about the duration. Now, the prophylaxis guidelines recommend us to extend the thrombo-prophylaxis after hip replacement surgery for at least 35 days.  Similarly, in the treatment segment also, there was discussion about continuation anti coagulation beyond 6 months after the indexed event. Placebo controlled trials were done and they showed 82% relative risk reduction of VTE (Einstein II).  In the recent past (Einstein Choice study) in another study, the anticoagulation was extended for another 1 year to its to study effect on prevention of rec VTE! It was again found that there is benefit of anticoagulation (Relative risk reduction of recurrent VTE up to 60%) without increasing the significant bleeding risk. The relative risk reduction can be as high as 60% with rivaroxaban. That leaves us with a question that is - how far is far enough with anticoagulation therapy?  Someone can consider giving anticoagulation for 10 years with annual reviews of the risk factors for re-thrombosis and bleeding.  This means, we need to use the existing drugs optimally or find out drugs which are effective and safe across all subsets of patients with thrombotic (VTE) complications, for a period of one decade after the indexed event of VTE.

Increase in the Incidence of Diabetes and Its Implications.

Diabetes mellitus is among the most prevalent and morbid chronic diseases, affecting the health of millions of persons worldwide. According to the Global Burden of Disease (GBD) report for 2015, the prevalence of diabetes rose from approximately 333 million persons in 2005 to approximately 435 million persons in 2015, an increase of 30.6%.1 During the same interval, the annual number of deaths from diabetes rose from 1.2 million to 1.5 million.2 This increase is attributed in the GBD report to population growth and aging, with small decreases in age-specific and cause-specific mortality over the same period.

The investigators examined changes in mortality and the incidence of cardiovascular disease over time. Mortality and the incidence of cardiovascular disease both decreased significantly over the study period. All-cause mortality decreased by 31.4 deaths per 10,000 person-years among persons with type 1 diabetes and by 69.6 deaths per 10,000 person-years among those with type 2 diabetes. The incidence of death from cardiovascular disease decreased by 26.0 deaths per 10,000 person-years among persons with type 1 diabetes and by 110.0 deaths per 10,000 person-years among those with type 2 diabetes. However, the rates of fatal outcomes decreased significantly less among patients with type 2 diabetes than among matched controls.

What is the solution for this increasing prevalence of Diabetes and the associated problems! It is clear that we are far from controlling the negative effects of diabetes on health worldwide. As the prevalence increases, we clearly need new approaches to reduce the burden of this disease on public health.

Reference: Julie R. Ingelfinger, M.D.,  John A. Jarcho, M.D : Increase in the Incidence of Diabetes and Its Implications. N Engl J Med 2017; 376:1473-1474  April 13, 2017