From the Guidelines
Intensive screening and prophylaxis for Venous Thromboembolism (VTE) in high-risk patients should involve a combination of pharmacological and mechanical methods, with low molecular weight heparins (LMWHs) and mechanical prophylaxis being the cornerstone of treatment, as recommended by the most recent guidelines 1.
Methods for Intensive Screening and Prophylaxis
- Pharmacological prophylaxis: LMWHs like enoxaparin or dalteparin are first-line options, with unfractionated heparin as an alternative in patients with renal impairment 1.
- Mechanical prophylaxis: graduated compression stockings and intermittent pneumatic compression devices should be used, particularly when pharmacological methods are contraindicated 1.
Screening and Risk Assessment
- Risk assessment using validated tools like the Caprini or Padua scores upon admission and regularly thereafter is essential 1.
- D-dimer testing and compression ultrasonography can be used for surveillance in very high-risk patients.
Duration of Prophylaxis
- Prophylaxis should typically continue throughout hospitalization and potentially 14-35 days post-discharge for high-risk surgical patients or those with active cancer, although the benefit of extended prophylaxis needs to be balanced against logistical challenges 1.
Important Considerations
- Early mobilization is essential when possible to prevent blood stasis and reduce the risk of VTE.
- The choice of prophylaxis method should be individualized based on patient risk factors and contraindications to anticoagulation.
- Direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban may be considered for extended prophylaxis after hospital discharge, but their use should be guided by the most recent evidence and guidelines 1.
From the FDA Drug Label
1.5 Prophylaxis of Deep Vein Thrombosis Following Hip or Knee Replacement Surgery XARELTO is indicated for the prophylaxis of DVT, which may lead to PE in adult patients undergoing knee or hip replacement surgery.
1.6 Prophylaxis of Venous Thromboembolism in Acutely Ill Medical Patients at Risk for Thromboembolic Complications Not at High Risk of Bleeding XARELTO is indicated for the prophylaxis of venous thromboembolism (VTE) and VTE related death during hospitalization and post hospital discharge in adult patients admitted for an acute medical illness who are at risk for thromboembolic complications due to moderate or severe restricted mobility and other risk factors for VTE and not at high risk of bleeding
The methods for intensive screening and prophylaxis of Venous Thromboembolism (VTE) in high-risk patients include:
- Pharmacological prophylaxis with rivaroxaban (XARELTO) for patients undergoing hip or knee replacement surgery, or for acutely ill medical patients at risk for thromboembolic complications.
- The recommended dosage for prophylaxis of DVT following hip or knee replacement surgery is 10 mg once daily for 35 days (hip replacement) or 12 days (knee replacement).
- The recommended dosage for prophylaxis of VTE in acutely ill medical patients is 10 mg once daily for a total recommended duration of 31 to 39 days. 2
From the Research
Intensive Screening and Prophylaxis of Venous Thromboembolism (VTE)
Methods for Intensive Screening
- Clinical evaluation with assessment of clinical pretest probability (CPTP) for VTE 3
- Use of risk assessment tools such as the modified Caprini score to assess thrombosis risk 4
- Venous ultrasound of the proximal veins, with or without examination of the distal veins, as the primary imaging test for leg and upper-extremity DVT 3
- Computed tomography pulmonary angiography (CTPA) as the primary imaging test for PE 3
Methods for Prophylaxis
- Aggressive ambulation 4
- Mechanical prophylaxis, such as intermittent pneumatic compression devices (IPC) 5
- Pharmacological prophylaxis, including:
- Extended prophylaxis with LMWH to reduce the risk of symptomatic VTE in high-risk patients 4