From the Guidelines
For DVT prophylaxis in patients with Crohn's disease, extended thromboembolism prophylaxis following hospital discharge after surgery is recommended, with a minimal duration of 2 weeks postoperatively, as suggested by the ECCO guidelines 1.
DVT Prophylaxis Recommendations
- Low molecular weight heparin (LMWH) is a suitable option for DVT prophylaxis in patients with Crohn's disease, although the optimal dosage is not well established, with some studies suggesting that 4000 IU/day may be insufficient 1.
- Mechanical prophylaxis with intermittent pneumatic compression devices can be used initially in patients with severe active Crohn's disease with bleeding, with pharmacological prophylaxis started once bleeding risk decreases.
- For outpatients with Crohn's flares who are less mobile but not hospitalized, individual risk factors such as prior DVT/PE, obesity, hormone therapy, and smoking should be assessed before considering prophylaxis.
Rationale
- Patients with Crohn's disease have an inherently higher thrombosis risk due to chronic inflammation, which activates the coagulation cascade and increases platelet aggregation.
- Dehydration, immobility during flares, and corticosteroid treatment further increase this risk.
- Regular reassessment of bleeding risk is essential, particularly in patients with active intestinal inflammation.
Evidence Summary
- The ECCO guidelines recommend extended thromboembolism prophylaxis following hospital discharge after surgery in patients with Crohn's disease 1.
- A systematic review suggested that postoperative DVT risk was similar in IBD to that of patients with advanced CRC, with the highest risk in those who had a subtotal colectomy or a proctectomy 1.
- Other studies have demonstrated the importance of VTE prophylaxis in patients with cancer, including those with IBD 1.
From the FDA Drug Label
1.1 Prophylaxis of Deep Vein Thrombosis Fondaparinux sodium injection is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE): in patients undergoing hip fracture surgery, including extended prophylaxis; in patients undergoing hip replacement surgery; in patients undergoing knee replacement surgery; in patients undergoing abdominal surgery who are at risk for thromboembolic complications.
The patient has Crohn's disease, but the label does not provide specific guidance for DVT prophylaxis in patients with Crohn's disease.
- Dosing: The recommended dose of fondaparinux sodium injection for DVT prophylaxis is 2.5 mg administered by subcutaneous injection once daily after hemostasis has been established.
- Administration: Administer the initial dose no earlier than 6 to 8 hours after surgery. However, since the label does not directly address the use of fondaparinux in patients with Crohn's disease, caution should be exercised when considering fondaparinux for DVT prophylaxis in these patients 2.
From the Research
DVT Prophylaxis in Patients with Crohn's Disease
- The use of low-molecular-weight heparin (LMWH) for DVT prophylaxis in patients with Crohn's disease has been studied, with one study suggesting that standard dose LMWH prophylaxis may not be enough to prevent postoperative DVT in these patients 3.
- The study found that female gender, active rectal bleeding, and certain clotting parameters were associated with an increased risk of postoperative DVT in patients with inflammatory bowel disease, including Crohn's disease 3.
- Another study compared the effectiveness of fondaparinux and enoxaparin for the initial treatment of symptomatic deep venous thrombosis, and found that fondaparinux was at least as effective and safe as enoxaparin 4.
- A study on the use of once-daily LMWH prophylaxis in high-risk trauma patients found that it was feasible, safe, and effective in preventing DVT and pulmonary embolism 5.
- A systematic review with meta-analysis and trial sequential analysis found that low-dose LMWH was associated with a reduced risk of symptomatic and asymptomatic VTE, but the analysis of the effects on bleeding and adverse events remained inconclusive 6.
- A review of the use of LMWH for thrombosis prophylaxis found that it was efficient and safe for reducing the risk of DVT in patients undergoing general and visceral surgery, orthopedic surgery, and trauma, and that it had a potential role in gynecology, cancer, intensive care, and other areas 7.
Treatment Options
- LMWH, such as dalteparin and enoxaparin, may be used for DVT prophylaxis in patients with Crohn's disease 3, 4, 7.
- Fondaparinux may also be considered as an alternative to LMWH for the initial treatment of symptomatic deep venous thrombosis 4.
- The use of once-daily LMWH prophylaxis may be feasible and effective in high-risk patients, including those with Crohn's disease 5.