SLR - April 2013 - Sara Mahmood
Reference: Piazza, G., Goldhaber, S. Kroll, A. Goldberg, R., Emery, C., Spencer, F. Venous Thromboembolism in Patients with Diabetes Mellitus. The American Journal of Medicine. July 2012, 125:7, 709-16.
Scientific Journal Review
Reviewed by: Sara Mahmood, DPM
Residency Program: Sisters of Charity Hospital, Buffalo, NY
Podiatric Relevance:
Diabetic patients who develop venous thromboembolism (VTE) have an increased risk of recurrent deep vein thrombosis (DVT) and long-term major bleeding. In this study, diabetes was an independent risk factor for recurrent deep vein thrombosis. This article demonstrates the increased risk of venous thromboembolism among diabetic patients with specific evaluation of clinical characteristics, prophylaxis, treatment, and outcomes of venous thromboembolism in patients with and without previously diagnosed diabetes.
Methods:
Two thousand, four hundred and eighty-eight diabetic patients were studied in the population-based Worcester Venous Thromboembolism (VTE) Study. Patients were selected from an eligible patient list from healthcare system encounters in which diagnosis codes were consistent with VTE in 1999, 2001, 2003 and 2005, from 11 medical centers. Each potential case of VTE was independently validated by the study project coordinator using specific diagnostic criteria. Patients were classified as being definite, probable, possible or negative based on modification of the classification described by Silverstein et al.
Results:
Out of 2,488 VTE, 476 (19.1 percent) had a clinical history of diabetes. Patients with diabetes were more likely to suffer recurrent deep vein thrombosis than patients without, 14.9 percent vs. 10.7 percent, respectively. This study also states that diabetic patients have an increase in co-morbidities predisposing them to VTE including immobilization, acute infection, heart failure, chronic lung disease, ischemic heart disease, cerebrovascular disease and chronic kidney disease (CKD). These patients were also more likely to have an indwelling catheter as compared to non-diabetic patients, which increases their risk for VTE. Of the 476 patients with VTE, 33 percent were on insulin, 45.5 percent were on oral hypoglycemic drugs and 21.5 percent were diet controlled. Symptoms in diabetics were similar to non-diabetics except for the fact that diabetics had less frequent extremity pain and increased loss of consciousness. Loss of consciousness occurred exclusively in diabetic patients who suffered pulmonary embolism. Thrombophylaxis was omitted from more than one-third of diabetic patients who had been hospitalized for non-venous-thromoboembolism-related illness or those who had undergone major surgery within the past three months before diagnosis of VTE. Diabetic patients also had a longer hospital stay (38.2 percent vs. 25.8 percent) which points to a more complicated course of treatment. Intravenous heparin was used more often than low-molecular weight heparin in diabetics for treatment of VTE or DVT. Only history of diabetes was associated with a significant increase in risk of recurrent DVT (1.74). Long-term bleeding complications were 16.4 percent in diabetics vs. 11.7 percent in non-diabetics.
Conclusion:
Diabetic patients who develop a VTE are likely to have a more complicated course of treatment and diabetes is an independent risk factor for DVT development. There was an observation of low rate of thromoboprophylaxis in diabetic patients, when in fact they should be aggressively thromoboprophylaxed. This study points to the fact that all of our diabetic patients are at an increased risk for VTE and DVT and this risk warrants our increased vigilance in this patient population. Patients with diabetes who subsequently developed VTE had a 74 percent increase in the risk of recurrent DVT. Providers should emphasize VTE as a potential complication of diabetes and encourage its prevention. There is need for further studies that will focus on venous thromboembolism prevention in this vulnerable and increasingly prevalent patient population.