CLINICAL NEWS
panel outlined the following six best practices based on the literature review:
• Use validated clinical prediction rules
to estimate pretest probability in
patients in whom acute PE is being
considered.
• Do not obtain D-dimer measurements or imaging studies in patients
with a low pretest probability of PE
and who meet all PE Rule-Out Criteria (PERC).
• Obtain a high-sensitivity D-dimer
measurement as the initial diagnostic
test in patients who have an intermediate pretest probability of PE or in
patients with low pretest probability
of PE who do not meet al PERC.
• Use age-adjusted D-dimer thresholds in patients older than 50 years
to determine whether imaging is
necessary.
• Do not obtain any imaging studies in
patients with a D-dimer level below
the age-adjusted cutoff.
• Obtain imaging with CT pulmonary
angiography in patients with high
pretest probability of PE.
Source: Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of
patients with suspected acute pulmonary embolism: Best practice
advice from the clinical guidelines committee of the American
College of Physicians. Ann Intern Med. 2015 September 28. [Epub
ahead of print]
ASH is in the process of developing its own
evidence-based guidelines for venous thromboembolism (VTE), as was mentioned in the feature
article “How Guidelines Happen” in the August
issue. Wendy Lim, MD, chair of the ASH guideline
panel on diagnosis of VTE, said, “The ASH guidelines will cover both pulmonary embolism (PE) and
deep-vein thrombosis (DVT), but they will differ
from the ACP guideline in that the ASH guidelines
are evaluating the evidence supporting the use of
various diagnostic tests in determining VTE, as opposed to looking at best practice recommendations.
It is likely that some ‘best practice’ recommendations will be apparent in our final recommendations
as there is increasing awareness that unnecessary
diagnostic tests are costly and can expose patients to
unnecessary risk (e.g., radiation exposure with CT
scans). As we are seeking to improve the quality of
practice, selection of appropriate diagnostic tests is
an important consideration in the assessment and
management of these patients.
FDA Approves
New Treatment for
Chemotherapy-Induced
Nausea and Vomiting
The U.S. FDA has approved rolapitant to
prevent chemotherapy-induced nausea
and vomiting that occurs from 24 hours
up to 120 hours after the start of chemotherapy (also known as delayed-phase
nausea and vomiting). The approval was
based on the results from three randomized, double-blind, controlled trials
that examined the safety and efficacy of
rolapitant (an NK-1 receptor agonist) in
combination with granisetron and dexamethasone. A total of 2,800 patients were
randomized to receive either rolapitant or
placebo with granisetron and dexamethasone. Patients had received chemotherapy
that included highly emetogenic drugs,
including cisplatin and the combination
anthracycline and cyclophosphamide, and
other moderately emetogenic chemotherapy drugs.
In these studies, patients treated with
the placebo were more likely to experience
vomiting and to need rescue medication
for nausea and vomiting during the delayed phase compared with the rolapitant
group (pooled studies: 71% vs. 60%;
p=0·0001). The most common adverse
events associated with rolapitant include
neutropenia, hiccups, decreased appetite,
and dizziness.
Rolapitant was previously approved in
combination with antiemetic agents for
the prevention of nausea and vomiting associated with initial and repeat courses of
vomit-inducing cancer chemotherapy. ●
Source: U.S. FDA press release, September 2, 2015.
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