What is the recommended prophylaxis for patients at high risk of Venous Thromboembolism (VTE)?

From the Guidelines

For patients at high risk of Venous Thromboembolism (VTE), pharmacologic prophylaxis with low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin is recommended over no prophylaxis. The choice of prophylaxis should be based on the patient's individual risk factors and bleeding risk. According to the American College of Chest Physicians evidence-based clinical practice guidelines 1, for patients at high risk for VTE (≥ 6%) who are not at high risk for major bleeding complications, LMWH or low-dose unfractionated heparin is recommended.

Key Considerations

• The risk of VTE should be assessed on admission using validated tools to identify high-risk patients who would benefit most from prophylaxis.
• Prophylaxis should typically begin within 24 hours of admission or post-surgery and continue until the patient is fully mobile or discharged.
• For certain high-risk patients, extended prophylaxis for 4 weeks post-discharge is recommended, especially those undergoing abdominal or pelvic surgery for cancer 1.
• Mechanical prophylaxis with intermittent pneumatic compression devices should be employed for patients with contraindications to anticoagulation.
• The American Society of Clinical Oncology clinical practice guideline update 2014 also recommends thromboprophylaxis for most hospitalized patients with active cancer throughout hospitalization 1.

Recommended Prophylaxis Regimens

• LMWH, such as enoxaparin 40mg subcutaneously once daily or 30mg twice daily, is a commonly used regimen.
• Low-dose unfractionated heparin is also recommended for patients at high risk of VTE.
• Fondaparinux 2.5mg subcutaneously once daily can be used as an alternative to LMWH.
• Mechanical prophylaxis with intermittent pneumatic compression devices should be used for patients with contraindications to anticoagulation.

Additional Measures

• Adequate hydration, early mobilization, and addressing modifiable risk factors should accompany pharmacological prophylaxis for optimal VTE prevention.
• Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should educate patients about the signs and symptoms of VTE 1.

From the FDA Drug Label

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 ( 2.1)

The recommended prophylaxis for patients at high risk of Venous Thromboembolism (VTE) is 10 mg of rivaroxaban once daily, with or without food, for a total recommended duration of 31 to 39 days in acutely ill medical patients. However, it is noted that this is for patients not at high risk of bleeding. For patients at high risk of VTE, the label does not explicitly state the recommended prophylaxis, but it can be inferred that 10 mg once daily may be considered, but this should be done with caution and careful consideration of the patient's bleeding risk. 2

From the Research

VTE Risk and Prophylaxis

The risk of Venous Thromboembolism (VTE) is a significant concern in various patient populations, including those undergoing orthopedic surgery, hospitalized patients with cancer, and medically ill patients.

Recommended Prophylaxis

• The recommended prophylaxis for patients at high risk of VTE includes the use of anticoagulants such as low-molecular-weight heparin (LMWH), unfractionated heparin, fondaparinux, and direct oral anticoagulants (DOACs) 3, 4, 5, 6.
• The American College of Chest Physicians guidelines recommend LMWH, unfractionated heparin, or fondaparinux for VTE prophylaxis in medically ill patients 6.
• Enoxaparin, a low-molecular-weight heparin, has been shown to be effective in preventing VTE in medical patients, with a significant reduction in the incidence of deep vein thrombosis and pulmonary embolism compared to placebo 7.

Patient-Specific Considerations

• The selection of anticoagulant for VTE prophylaxis should be individualized based on patient characteristics, risks, and preferences, as well as specific pharmacokinetic and pharmacodynamic considerations 6.
• The use of graduated compression stockings and serial compression devices (SCDs) may also be considered as non-pharmacological measures for VTE prophylaxis 4.

Clinical Trials and Evidence

• Clinical trials have demonstrated the effectiveness of thromboprophylaxis in reducing the incidence of VTE in various patient populations 3, 4, 5, 6, 7.
• A mixed treatment comparison meta-analysis found that UFH, LMWHs, and DOACs are comparable in preventing VTE, DVT, PE, and death from any cause, and in association with minor and major bleeding 6.