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Current clinical practice for thromboprophylaxis management in patients with Cushing's syndrome across reference
F M van Haalen1, M Kaya2, I C M Pelsma2
1Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands. f.m.van_haalen@lumc.nl.
Insights
Cushing's syndrome patients face high VTE risk, yet thromboprophylaxis practices vary widely among expert centers. Standardized protocols are lacking, necessitating research for optimal anticoagulant strategies.
Area of Science:
- Endocrinology
- Hematology
- Clinical Practice Research
Background:
- Cushing's syndrome (CS) is linked to a hypercoagulable state, increasing venous thromboembolism (VTE) risk.
- Current evidence-based guidelines for thromboprophylaxis in CS patients are absent.
- This study surveyed European Reference Network on Rare Endocrine Conditions (Endo-ERN) centers specializing in CS.
Purpose of the Study:
- To map current clinical practices for thromboprophylaxis in Cushing's syndrome patients.
- To identify variations in management strategies across specialized endocrine centers.
- To inform the development of standardized thromboprophylaxis protocols for CS.
Main Methods:
- Utilized the EU survey tool for a two-stage survey (primary screening and in-depth).
- Collected data on thromboprophylaxis initiation, duration, and drug choice.
- Assessed perioperative management and hemostasis testing practices.
Main Results:
- Most centers (23/25) provide thromboprophylaxis, but only one has a standardized protocol.
- Initiation is often based on VTE history (15/23) and hypercortisolism severity (15/23).
- Low-Molecular-Weight-Heparin is the universal first-choice anticoagulant; significant practice variations exist.
Conclusions:
- Substantial practice variation in thromboprophylaxis and perioperative treatment for CS patients is evident.
- Standardized protocols are lacking even within specialized European centers.
- Randomized controlled trials are crucial to determine optimal anticoagulant regimens, balancing bleeding and thrombosis risks.
Background:
Cushing's syndrome (CS) is associated with an hypercoagulable state and an increased risk of venous thromboembolism (VTE). Evidence-based guidelines on thromboprophylaxis strategies in patients with CS are currently lacking. We aimed to map the current clinical practice for thromboprophylaxis management in patients with CS across reference centers (RCs) of the European Reference Network on Rare Endocrine Conditions (Endo-ERN), which are endorsed specifically for the diagnosis and treatment of CS. Using the EU survey tool, a primary screening survey, and subsequently a secondary, more in-depth survey were developed.
Results:
The majority of the RCs provided thromboprophylaxis to patients with CS (n = 23/25), although only one center had a standardized thromboprophylaxis protocol (n = 1/23). RCs most frequently started thromboprophylaxis from CS diagnosis onwards (n = 11/23), and the majority stopped thromboprophylaxis based on individual patient characteristics, rather than standardized treatment duration (n = 15/23). Factors influencing the initiation of thromboprophylaxis were 'medical history of VTE' (n = 15/23) and 'severity of hypercortisolism' (n = 15/23). Low-Molecular-Weight-Heparin was selected as the first-choice anticoagulant drug for thromboprophylaxis by all RCs (n = 23/23). Postoperatively, the majority of RCs reported 'severe immobilization' as an indication to start thromboprophylaxis in patients with CS (n = 15/25). Most RCs (n = 19/25) did not provide standardized testing for variables of hemostasis in the postoperative care of CS. Furthermore, the majority of the RCs provided preoperative medical treatment to patients with CS (n = 23/25). About half of these RCs (n = 12/23) took a previous VTE into account when starting preoperative medical treatment, and about two-thirds (n = 15/23) included 'reduction of VTE risk' as a goal of treatment.
Conclusions:
There is a large practice variation regarding thromboprophylaxis management and perioperative medical treatment in patients with CS, even in Endo-ERN RCs. Randomized controlled trials are needed to establish the optimal prophylactic anticoagulant regimen, carefully balancing the increased risk of (perioperative) bleeding, and the presence of additional risk factors for thrombosis.
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