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g. osteoporosis). Moreover, safe and optimal administration and monitoring of LMWH and warfarin in a predominantly elderly population may present challenges. Until the results of studies comparing the efficacy of aspirin to LMWH or warfarin in patients receiving such regimens, these recommendations appear sensible (Palumbo et?al, 2008a). Those on lenalidomide with one additional risk factor may receive aspirin 75?mg once daily but there is no evidence that this is protective for a similar group on thalidomide. The latter and those with two or more additional risk factors require greater protection in the form of prophylactic-dose LMWH. Thrombocytopenia is a frequent obstacle to safe thromboprophylaxis, http://www.selleckchem.com/products/Roscovitine.html related to both marrow infiltration and myeloma treatment. Patients with platelet counts http://www.selleckchem.com/products/bay-57-1293.html 50?��?109/l, thromboprophylaxis should be paused, except in very high-risk cases, which should be discussed with a haemostasis expert. The duration of thromboprophylaxis remains contentious. Clearly the risk of VTE falls as disease burden decreases, during which time there may be alterations in treatment (e.g. reduction in high dose dexamethasone dosing schedules). The majority of VTE in myeloma patients occur within the first 6?months of treatment. Thus, for example, thromboprophylaxis may be given for at least the first 4�C6?months of treatment until disease control of active myeloma is achieved with more intensive regimens, and may then be de-escalated or discontinued. However, it is important that the strategy is individualized according to the presence http://en.wikipedia.org/wiki/Methisazone of risk factors in each patient. 3.2.3?Treatment of VTE in myeloma patients.? As with other patients with suspected VTE, objective diagnosis should be made using appropriate imaging investigations, and treatment should follow best practice guidelines, such as those of the American College of Chest Physicians (Kearon et?al, 2008). No clear guidance can be given for the duration of anti-coagulation in myeloma patients developing VTE, but ongoing risk assessment is reasonable. There is good evidence that, in cancer patients, where the risk of VTE recurrence after discontinuation of anticoagulation is as high as 10%, long term maintenance with LMWH is significantly less frequently associated with recurrent VTE than warfarin, without an increased risk of bleeding (Lee et?al, 2003; L��pez et?al, 2004). Based on these studies, extended therapy with LMWH should be considered in myeloma patients, balancing these advantages against the inconvenience of daily injections, costs and long term complications.