What are the contraindications to Deep Vein Thrombosis (DVT) prophylaxis?

From the Guidelines

Deep vein thrombosis (DVT) prophylaxis is contraindicated in patients with active bleeding, severe thrombocytopenia, heparin-induced thrombocytopenia, recent neurosurgery or ocular surgery, severe uncontrolled hypertension, and those with severe peripheral arterial disease, acute DVT, severe peripheral neuropathy, recent skin grafting, or dermatitis.

Contraindications to DVT Prophylaxis

The contraindications to DVT prophylaxis can be categorized into two main groups: pharmacological and mechanical prophylaxis.

• Pharmacological prophylaxis is contraindicated in patients with: + Active bleeding, including ongoing hemorrhage, recent intracranial bleeding, or active gastrointestinal bleeding 1 + Severe thrombocytopenia (platelet count below 50,000/μL) due to increased bleeding risk + Heparin-induced thrombocytopenia (HIT), as these patients should not receive heparin-based prophylaxis, including unfractionated heparin and low molecular weight heparins like enoxaparin + Recent neurosurgery or ocular surgery (within 24-48 hours) due to bleeding concerns + Severe, uncontrolled hypertension, which may increase bleeding risk with anticoagulants
• Mechanical prophylaxis methods, such as compression stockings or intermittent pneumatic compression devices, are contraindicated in patients with: + Severe peripheral arterial disease + Acute deep vein thrombosis + Severe peripheral neuropathy + Recent skin grafting + Dermatitis, as skin breaks were more common in the IPC group (3.1% versus 1.4%; P=0.002) 1 ### Considerations for Mechanical Prophylaxis When pharmacological prophylaxis is contraindicated, mechanical methods should be considered if appropriate. However, the use of mechanical prophylaxis should be weighed against the potential risks, such as skin breaks and discomfort.
• Intermittent pneumatic compression (IPC) devices have been shown to reduce the risk of DVT in immobile patients with acute stroke, with an adjusted OR of 0.65 (95% CI, 0.51–0.84; P=0.001) 1
• Graduated compression stockings have been demonstrated to significantly reduce VTE compared with no prophylaxis, but their effectiveness in patients able to receive more potent forms of VTE prophylaxis is limited 2, 3

From the FDA Drug Label

4 CONTRAINDICATIONS

The contraindications to DVT prophylaxis with fondaparinux are not explicitly stated in the provided drug label section. However, the label does mention several warnings and precautions that may be relevant to the decision to use fondaparinux for DVT prophylaxis, including:

• Neuraxial anesthesia and post-operative indwelling epidural catheter use
• Hemorrhage
• Renal impairment and bleeding risk
• Body weight <50 kg and bleeding risk
• Thrombocytopenia These conditions may increase the risk of bleeding or other adverse reactions when using fondaparinux for DVT prophylaxis. 4

From the Research

Contraindications to DVT Prophylaxis

• Active bleeding or severe thrombocytopenia (<50,000/cc) are contraindications to pharmacological DVT prophylaxis, as stated in the study 5
• Heparin-induced thrombocytopenia (HIT) is a contraindication to heparin use, and alternative anticoagulants such as fondaparinux, lepirudin, argatroban, or bivalirudin should be used instead 6, 7
• Intracranial hemorrhage is a relative contraindication to DVT prophylaxis, and the optimal time to resume prophylaxis is not well established, with variable practices among practitioners 8
• Bleeding dyscrasia, previously diagnosed DVT or PE, and lack of post-procedure cranial imaging or DVT screening are also contraindications to DVT prophylaxis 8

Special Considerations

• Patients with a history of HIT or those at high risk of developing HIT should be closely monitored for signs of thrombocytopenia and thrombosis 6, 7
• The use of mechanical thromboprophylaxis, such as elastic stockings or pneumatic compression, may be considered in patients with contraindications to pharmacological prophylaxis, although its effectiveness is not well established 5
• Individualized thromboprophylaxis regimens should be considered, taking into account the patient's risk factors, clinical condition, and potential contraindications 5