Lead authors: Kristina Island, Aparna Pal, John Newell-Price and John Wass
Lead Institution: Oxford
Deadline: 31 August 2021
Responses to: Clinical@endocrinology.org
The increased risk of thromboembolic disease in patients with Cushing’s syndrome (CS) is well recognized with the association first reported 50 years ago(1-3). Since then, several studies have confirmed the higher risk of DVT and PE in patients with CS, the majority published in case series of patients with Cushing’s disease (CD), and most often noted in the peri-operative period (4-9).
Risk of VTE in CS is thought to be in the order of a 10-fold increased risk and most notable in the first year following diagnosis (4,10). VTE accounts for 3.6-11% of all deaths in CS patients (17).
The highest risk seems to be in association with surgery and has been most studied in the context of CD post pituitary surgery (4, 10, 11). However, elevated VTE risk is also recognised post adrenalectomy for CS (12-13). Of note, VTEs have also occurred whilst on anticoagulation: in their retrospective, single centre study, Suarez et al note that 12.8% of the VTE in CS occurred in patients who were anticoagulated with prophylactic enoxaparin at the time of the event, emphasising the high risk (13). There are limited data examining the actual impact of thromboprophylaxis on VTE incidence in CS. A couple of studies have done this retrospectively and note fewer events in anticoagulated groups or after thromboprophylaxis became routine practice in their centres (7,14).
Although a previous survey by members of the Pituitary Society showed routine perioperative VTE prophylaxis had increased (15), this practice is not routine, nor is there a consensus around when, and for how long treatment should be given, nor is it clear if similar regimes should be instituted post adrenalectomy. The 2015 Endocrine Society guidelines do suggest thromboprophylaxis but no specific recommendations are made (16). They advise:
1) Evaluating CS patients for risk factors of venous thrombosis
2) In patients with CS undergoing surgery, we suggest perioperative prophylaxis for venous thromboembolism.
To establish what is the current thromboprophylaxis practice in patients with adrenal and pituitary source CS across Endocrinology centres in the UK
All UK endocrinology centres will be contacted with details of the project and a request to complete a survey of their current practice of anticoagulation in CS patients which will be collated and analysed at the SFE and Oxford.
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