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How we study and treat patients with suspected thrombophilia
G. J.. Ruiz-Argüellesa, G. J.. Ruiz-Delgadoa
a Center for Hematology and Internal Medicine, Clínica Ruiz de Puebla, Puebla, Pue., Mexico
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    "textoCompleto" => "<p class="elsevierStylePara"> Since 1999 we have been studying and treating patients with suspected inherited and&#47;or acquired thrombophilia&#46; Some of them have been referred to us by other specialists&#44; mainly ophthalmologists and neurologists&#44; but interestingly&#44; most of them have come to our clinic referred to by friends or relatives&#44; this being most likely&#44; to our regret&#44; a reflection of the importance that other specialists place on this condition&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Diagnosis </span></p><p class="elsevierStylePara"> Inherited thrombophilia is a rather common condition which explains several cases of thrombosis&#46; An inherited thrombophilic condition should be suspected in cases of&#58; Thrombosis in individuals of less than 45 years&#44; thrombosis in unusual sites&#44; thrombosis without other triggering conditions&#44; resistance to antithrombotic treatments&#44; recurrent miscarriages and a family history of thrombosis&#46; Most cases of thrombosis in these persons present themselves when exposed to other acquired thrombophilic conditions&#44; the most frequent ones being estrogen treatment&#44; puerperium and prolonged immobilization&#46;</p><p class="elsevierStylePara"> In the vast majority of cases&#44; patients coming to our clinic have been studied incompletely by other physicians and given empirically antiplatelet drugs&#44; anticoagulants or both&#46; Many of these patients have been frightened by their physicians about having a potentially mortal disease at a young age&#46;</p><p class="elsevierStylePara"> a&#41; Thrombophilic screening</p><p class="elsevierStylePara"> Stemming from our studies of more than 15 years&#44; we have designed 2 thrombophilic screening sets of studies in Mexican patients being studied for thrombophilia&#46; Table 1 shows the salient inherited thrombophilic conditions which we have identified in Mexicans and which were used to design these 2 thrombophilic profiles&#58;</p><p class="elsevierStylePara"><img alt="Table 1 Prevalence of several thrombophilic conditions in both thrombophilic Mexicans mestizos and normal controls&#46;" src="304v16n64-90367594fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">1&#46; Full thrombophilic screening profile</span>&#58; MTHFR C677T gene mutation&#44; investigation of the sticky platelet syndrome&#44; activated protein C resistance aPCR phenotype&#44; factor V Leiden mutation&#44; HR2 haplotype of the factor V gene&#44; anti-phospholipid antibodies&#44; factor II G20210A gene mutation&#44; protein C levels&#44; protein S levels&#44; antithrombin III levels&#44; PnH phenotype in red and white blood cells&#44; JAK-2 V617F gene mutation&#44; and lupus anticoagulant</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">2&#46; Limited thrombophilic screening profile</span>&#58; MTHFR C677T gene mutation&#44; investigation of the sticky platelet syndrome&#44; aPCR phenotype&#44; and anti-phospholipid antibodies&#46;</p><p class="elsevierStylePara"> We encourage all patients to have the full laboratory workup done&#44; since the chances of identifying the thrombophilic conditions are above 90&#37;&#44; provided all the workup is done&#46; We reserve the limited profile for patients who are unable to defray the cost of the full workup&#46; Before ma- king the set of studies&#44; we instruct the patients to stop both antiplatelet drugs and&#47;or anticoagulants&#44; and to switch into low molecular weight heparin 5-7 days before drawing the blood samples&#46; Most of the times we identify 2 or more inherited thrombophilic conditions which coexist with another acquired thrombophilic state in order to develop a full blown thrombotic episode&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment </span></p><p class="elsevierStylePara"> Once the diagnosis is done&#44; employing the above mentioned studies&#44; we make the following recommendations to the patients&#58;</p><p class="elsevierStylePara"> a&#41; Sticky platelet syndrome &#40;SPS&#41;</p><p class="elsevierStylePara"> This inherited condition leads into both arterial and venous thrombosis and&#44; until recently&#44; its true importance in medical literature had been neglected&#46; Patients with the SPS rethrombose when given oral anticoagulants&#59; they must be treated with antiplatelet drugs&#46; Aspirin &#40;100 mg&#47;day&#41; is adequately tolerated by more than 90&#37; of patients&#59; the rest are to be given clopidogrel or other antiplatelet drugs&#46; The test to define SPS must be repeated 4 weeks after starting aspirin&#59; if the aggregation profiles normalize it must be kept indefinitely&#59; less than 10&#37; of individuals need other antiplatelet drugs to reverse the platelet hyperaggregability&#46; SPS patients&#44; adequately treated&#44; have a less than 5&#37; chance of re-thrombosing&#46;</p><p class="elsevierStylePara"> b&#41; MTHFR C677T gene mutation</p><p class="elsevierStylePara"> This genetic condition probably is not&#44; by itself&#44; enough to create thrombophilia&#44; but added to other ones&#44; it may have significance&#46; On the other hand&#44; the prevalence of this mutation in the normal population in Mexico is extremely high&#46; Since this mutation may lead into hyperhomocystinemia which may be aggravated by folic acid deficiency&#44; we recommend folic acid&#44; 5 mg&#47;day&#44; indefinitely to individuals displaying this gene mutation and having suffered a thrombotic episode&#46;</p><p class="elsevierStylePara"> c&#41; Activated PCR aPCR phenotype</p><p class="elsevierStylePara"> This condition can be either inherited or acquired&#46; In Mexicans <span class="elsevierStyleItalic">mestizos</span> the acquired forms &#40;antiphospholipid antibodies&#44; increased factor VIII levels&#41; are considerably more frequent&#46; Patients with inherited forms of aPCR who have had a thrombosis probably need an anticoagulant indefinitely&#46; We tend to use the new oral anticoagulants &#40;NOACs&#41; more than vitamin K antagonists and prefer rivaroxaban which is used once a day&#46; Individuals with acquired forms of aPCR need the anticoagulant at least while the laboratory phenomenon is present&#46;</p><p class="elsevierStylePara"> d&#41; Oother inherited conditions</p><p class="elsevierStylePara"> Protein S deficiency&#44; protein C deficiency and anti-thrombin III deficiency&#44; all of them very infrequent in Mexicans <span class="elsevierStyleItalic">mestizos</span>&#44; probably need lifelong anticoagulation&#46; Again&#44; we tend to use the NOACs more than vitamin K antagonists and prefer rivaroxaban which is used once a day&#46; NOACs are significantly more expensive than vitamin K antagonists&#44; but in the long turn&#44; needing no laboratory control and being less related to severe hemorrhages&#44; may be a good option&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion </span></p><p class="elsevierStylePara"> With a full laboratory workup&#44; we are now able to identify inherited and acquired thrombophilic conditions in more than 90&#37; of individuals having a clinical marker of thrombophilia&#46; These studies should ideally be done in persons studied and treated by cardiologists&#44; angiologists&#44; gastroenterologists&#44; neurologists&#44; gynecologists&#44; ophthalmologists and other specialists dealing with either arterial or venous thrombosis&#44; in order to properly identify the conditions and prevent future re-thrombotic episodes&#46; Even hematologists still consider these studies and treatments as experimental or non-evidence-based&#46; As a result of studying these conditions in more than 500 Mexicans <span class="elsevierStyleItalic">mestizos</span>&#44; we have been able to define thrombophilic profiles&#44; which could be used to both identify these diseases and define the more adequate treatment&#46;<span class="elsevierStyleSup">1-16</span></p><hr></hr><p class="elsevierStylePara"> Received&#58; April 2014&#59; <br></br> Accepted&#58; June 2014</p><p class="elsevierStylePara"> &#42; Corresponding author&#58; <br></br> Center for Hematology and Internal Medicine&#46; <br></br> 3710 8B Sur Street&#44; Z&#46;P&#46; 72530&#44; Puebla&#44; Pue&#46;&#44; Mexico&#46; <br></br> Telephone&#58; 01 &#40;222&#41; 243 8100&#46; Fax&#58; 01 &#40;222&#41; 243 8428&#46; <br></br><span class="elsevierStyleItalic">E-mail address</span>&#58; <a href="mailto&#58;gruiz1&#64;clinicaruiz&#46;com" class="elsevierStyleCrossRefs">gruiz1&#64;clinicaruiz&#46;com</a> &#40;G&#46; J&#46; Ruiz-Arg&#252;elles&#41;&#46;</p>"
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ISSN: 16655796
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