Recommendations and resources
1) Do not conduct thrombophilia testing in adult patients under the age of 50 years unless the first episode of venous thromboembolism (VTE):
occurs in the absence of a major transient risk factors (surgery, trauma, immobility), or
occurs in the absence of oestrogen-provocation, or
occurs at an unusual site.
Thrombophilia testing is costly and can result in harm to patients if the duration of anticoagulation is inappropriately prolonged or if patients are incorrectly labelled as thrombophilic. Thrombophilia testing does not change the management of venous thromboembolism (VTE) occurring in the setting of major transient VTE risk factors.
2) Limit surveillance computed tomography (CT) scans in asymptomatic patients with confirmed complete remission following curative intent treatment for aggressive lymphoma – except for patients on a clinical trial.
CT surveillance in asymptomatic patients in remission from aggressive lymphoma may be harmful through a small but cumulative risk of radiation-induced malignancy. It is also costly and has not been demonstrated to improve survival. Therefore the anticipated benefits of post-treatment CT scans should be weighed against the potential harm of radiation exposure. Due to a decreasing probability of relapse with the passage of time and a lack of proven benefit, CT scans in asymptomatic patients more than 2 years beyond the completion of treatment are rarely advisable.
3) Do not extend anticoagulation beyond 3 months for a patient with a non-extensive, index venous thromboembolic event (VTE), which occurred in the setting of a major, transient risk factor.
Anticoagulation is potentially harmful and costly. Patients with a first venous thromboembolism (VTE) triggered by a major, transient risk factor are at low risk for recurrence once the risk factor has resolved and an adequate treatment regimen with anticoagulation has been completed. Evidence-based and consensus guidelines recommend three months of anticoagulation over shorter or longer periods of anticoagulation in patients with VTE in the setting of a reversible provoking factor.
4) Do not perform baseline or routine surveillance CT scans or bone marrow biopsy in patients with asymptomatic early stage chronic lymphocytic leukaemia (CLL).
In patients with asymptomatic, early-stage chronic lymphocytic leukaemia (CLL), baseline and routine surveillance computed tomography (CT) scans do not improve survival and are not necessary to stage or prognosticate patients. CT scans expose patients to small doses of radiation, and can detect incidental findings that are not clinically relevant but lead to further investigations and are costly. For asymptomatic patients with early-stage CLL, clinical staging and blood monitoring is recommended over CT scans.
5) Do not treat patients with immune thrombocytopenic purpura (ITP) in the absence of bleeding or a platelet count <30,000/L without risk factors for bleeding.
Treatment for immune thrombocytopenic purpura (ITP) should be aimed at treating and preventing bleeding episodes and improving quality of life. Unnecessary treatment exposes patients to potentially serious treatment side effects and can be costly, with little expectation of clinical benefit. Unless they are preparing for surgery or invasive procedure, or have significant additional risk factor for bleeding, ITP treatment is rarely indicated in adult patients with platelet counts greater than 30,000/L. In patients preparing for surgery or other invasive procedures, short-term treatment may be indicated to increase the platelet count prior to the planned intervention and during the immediate post-operative period.