VTE Prophylaxis. Serving an unmet need in high-risk acute stroke patients.

Transcription

1 VTE Prophylaxis Serving an unmet need in high-risk acute stroke patients

2 Providing venous thromboembolism (VTE) prophylaxis to at-risk stroke patients The risk of venous thromboembolism (VTE) after stroke is increased in patients with restricted mobility and associated increase in venous stasis 1. The alteration in blood flow in weakened limbs may lead to vessel wall injury, whilst there is also an abnormal tendency for the blood to clot more after stroke 9. Current strategies for managing VTE risk in immobile stroke patients are 2 : Intermittent Pneumatic Compression (IPC). Add prophylactic-dose LMWH when bleed risk reduces. Anti-embolism stockings are contraindicated for stroke patients. Potential contraindications to the above treatment options: Patients with fragile or broken skin contraindicated for IPC. Patients with peripheral arterial disease contraindicated for IPC. Patients with a high bleed risk contraindicated for chemical VTE prophylaxis. Patients may develop an intolerance to IPC in the acute phase. The geko device Easy to use, geko is a battery powered, disposable, neuromuscular electrostimulation device designed to increase blood flow in the deep veins of the leg 4. 60% The increase in blood flow is equal to 60% 5 of walking without a patient having to move. Zero No wires or leads. Small, light and comfortable to wear. Silent in operation. The geko device gently stimulates the common peroneal nerve activating the calf and foot muscle pumps resulting in increased blood flow 5, and the reduction of oedema 6. 10g Weighs just 10g. Quick and easy to fit. The definition of Venous Thrombo-Embolism (VTE) includes deep vein thrombosis (DVT) and Pulmonary embolism (PE) caused by a DVT. Patients are at risk because they are often highly immobile resulting in temporary paralysis of the calf and foot muscle pumps. It is reported that the loss of gastrocnemius muscle pump results in a 47% reduction in venous flow velocity 3 thereby increasing the risk of VTE.

3 The unmet need Providing venous thromboembolism (VTE) prophylaxis to at-risk stroke patients. Current practice for DVT prophylaxis in acute stroke patients is based upon the data from the CLOTS 3 7 study summarised below: CLOTS 3 study summary DVT risk Incidence of any DVT (meaning asymptomatic and symptomatic) Incidence of symptomatic DVT Incidence of skin breaks Full adherence to IPC Mean adherence to IPC Median adherence to IPC Standard of care with no IPC Standard of care with IPC 14.9% 11.3% 6.3% 4.5% 1.4% 3.0% N/A 31.0% N/A 59.0% N/A 65.0% A new approach 11 The use of the geko device to manage VTE risk in stroke patients. Firstkind has worked with The University Hospital of North Midlands NHS Trust to introduce geko into the stroke pathway when patients are unsuitable for drug prophylaxis and/or contraindicated or intolerant to IPC. The use of the geko device has been assessed through a prospective 400 patient audit of clinical practice, covering patients who have been admitted for either ischemic or haemorrhagic stroke. Patients who were unsuitable for VTE drug prophylaxis or contraindicated or intolerant to IPC were given the geko device. Interim analysis highlights that the majority of high risk immobile acute stroke patients who could not tolerate IPC managed to tolerate geko. These patients would have not been treated as effectively otherwise, with the potential that geko will reduce the risk of morbidity and mortality in stroke patients. Outcomes: Patients who are contraindicated or become intolerant to IPC have a 6.3% increased risk of developing a symptomatic DVT. These results suggest a significant level of unmet need in this patient group. Up to 69% of acute stroke patients could benefit from using the geko device for DVT prophylaxis i.e. those who are contraindicated or intolerant for IPC. The University Hospital of North Midlands NHS Trust

4 Clinically proven The geko device is proven to prevent stasis in the deep veins of the calf. A DVT is a blood clot that forms most commonly in the deep veins of the calf muscles 8. Blood stasis is a critical factor in the formation of a DVT 4. A recent study 4 has measured the effect of geko on blood flow in the deep veins of the calf. Peak Velocity (cm/sec) Baseline Stimulation % * The study has shown statistical significance, through its mode of action to activate the calf muscle pumps, to increase blood volume velocity within the gastrocnemius, peroneal and posterior tibial veins 4 (P< ). These findings are of clinical relevance to the unmet need for DVT prophylaxis in stroke patients. The effect of the geko device on peak velocity and volume flow within the 3 calf veins studied are shown below. 112% * 137% * Health and social economic rationale in serving the unmet VTE prophylactic need in acute stroke patients Immobilised acute stroke patients, especially in the circumstance of calf pump paralysis, suffer from stasis of venous blood in the deep veins of the calf and an increased risk of DVT 9. The geko device is proven 3,4 to create conditions where this risk will be reduced: The geko device increases blood flow significantly and prevents stasis including in the clinically important deep veins of the calf (P< ) 4,10. The geko device is being used in stroke patients who would otherwise have no prophylactic intervention available to them and carry a 6.3% risk of a symptomatic DVT 7. The average use of the geko device in stroke patients at UHNM NHS Trust is 5 days per patient 11. *p<0.001 Volume flow during muscle contraction Baseline Stimulation *p< Peroneal vein 113% * Peroneal vein Posterior tibial vein 38% * Posterior tibial vein Gastrocnemius vein 50% * Gastrocnemius vein It is recognised that when compared to IPC, the proven superior anti-stasis capability of the geko device will result in at least an equivalent reduction of DVT incidence 12. In this scenario and when compared to no treatment, the use of the geko device for 5 days will save 36 per patient 13 and provides VTE prophylaxis to patients who would have no other form of prevention. Other studies report that geko delivers superior augmentation of lower limb blood flow and is a leading device for the prevention of stasis 5.

5 References 1. L. Jaap Kappelle, Preventing Deep Vein Thrombosis After Stroke: Strategies and Recommendations. Curr Treat Options Neurol Dec; 13(6): NICE guidelines (CG92). Published date January 2010, update June V.N.Obolenskiy, A.V.Karpenko. Efficacy of electrical muscle stimulation in the treatment of patients with shin bone fractures. Wound Medicine 5 (2014) A.Nicolaides, M Griffin, Measurement of blood flow in the deep veins of the lower limb using the geko neuromuscular electro-stimulation device. Journal of International Angiology August Tucker A, Maass A, Bain D, Chen LH, Azzam M, Dawson H, et al. Augmentation of venous, arterial and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. The International journal of angiology: official publication of the International College of Angiology, Inc Spring; 19(1): e Wainwright TW, Immins T, Middleton RG, Poster Physiotherapy UK, October 2014, Birmingham. 7. M. Dennis; P. Sandercock; J. Reid; C. Graham; J. Forbes; G. Murray. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet. 2013; 382(9891): Malone PC, Agutter PS. The aetiology of deep venous thrombosis. Q J Med 2006; 99: Bayer AG. 1. Why a Blood Clot is Serious. Published September Jawad, H., Bain, D., Dawson, H., Crawford, K., Johnston, A., Tucker, A.T. The effectiveness of a novel neuromuscular electrostimulation method versus intermittent pneumatic 11. Stoke, prospective data on file, prospective April 2017, Firstkind 12. NICE Guidelines (MTG19). Published date June Independent economic analysis by Mtech Access UK Ltd, April Available on NHS supply chain: EGD9020 NHSSC number: EGD9020 Firstkind Ltd, Hawk House, Peregrine Business Park, High Wycombe, Buckinghamshire, HP13 7DL, United Kingdom. T: +44 (0) W: MPSTK0356