From the Guidelines
For inpatient DVT prophylaxis, rivaroxaban 10mg once daily or apixaban 2.5mg twice daily are the recommended DOACs, as suggested by the American Society of Hematology 2020 guidelines 1. These medications should be initiated after admission and continued throughout the hospitalization period, with consideration for extended prophylaxis for up to 30 days post-discharge in high-risk patients.
- Key considerations before starting DOACs include:
- Assessing renal function, as dose adjustments may be needed for patients with CrCl <30 mL/min
- Avoiding use in patients with severe renal impairment, active bleeding, or those on dual antiplatelet therapy
- The mechanism of action of these medications involves directly inhibiting specific coagulation factors, with rivaroxaban and apixaban targeting Factor Xa to prevent thrombin formation and subsequent clot development 1.
- Compared to traditional prophylaxis with low molecular weight heparin, DOACs offer the advantage of oral administration and no need for routine monitoring, though they may carry a slightly higher bleeding risk in certain populations 1.
- It is essential to ensure patients are not taking other anticoagulants or medications that strongly affect CYP3A4 and P-glycoprotein pathways to avoid drug interactions.
From the FDA Drug Label
for prophylaxis of venous thromboembolism (VTE) in acutely ill medical patients Prophylaxis of VTE in Acutely Ill Medical Patients at Risk for Thromboembolic Complications Not at High Risk of Bleeding: 10 mg once daily, with or without food, in hospital and after hospital discharge for a total recommended duration of 31 to 39 days
The recommended pharmacological prophylaxis for inpatient Deep Vein Thrombosis (DVT) prevention using Direct Oral Anticoagulants (DOACs), specifically rivaroxaban, is 10 mg once daily, with or without food, in hospital and after hospital discharge for a total recommended duration of 31 to 39 days 2.
From the Research
Inpatient DOAC for DVT Prophylaxis
- The use of Direct Oral Anticoagulants (DOACs) for Deep Vein Thrombosis (DVT) prophylaxis in inpatient settings has been studied in various research papers 3, 4, 5, 6, 7.
- According to a study published in 2020, appropriate prophylaxis in high-risk medically ill patients has been shown to reduce the risk of VTE and related mortality 3.
- Another study published in 2022 compared the outcomes of patients with distal DVT treated with warfarin versus DOACs, and found that DOACs had a significantly lower incidence of pulmonary embolism (PE) and major bleeding 4.
- A review published in 2017 discussed the use of DOACs for the initial treatment of pulmonary embolism, and noted that DOACs are becoming the agents of first choice due to their practicability 5.
- A randomized clinical trial published in 2023 found that DOACs were noninferior to low-molecular-weight heparin (LMWH) for preventing recurrent VTE in patients with cancer 6.
- Extended VTE prophylaxis with DOACs, such as betrixaban and rivaroxaban, has been shown to be effective in reducing symptomatic VTE in high-risk medical patients 7.
Recommended Pharmacological Prophylaxis
- The recommended pharmacological prophylaxis for inpatient DVT prevention using DOACs depends on various factors, including patient risk factors, comorbidities, and medication interactions.
- The North American Thrombosis Forum (NATF) has launched the Anticoagulation Action Initiative, which provides practical guidance and recommendations for VTE prevention during hospitalization and after discharge 7.
- The choice of DOAC and duration of prophylaxis should be individualized based on patient-specific factors, such as renal function, liver function, and bleeding risk 3, 4, 5, 6, 7.