Continuing DAPT with DVT Prophylaxis in Hospitalized Patients
For hospitalized patients on dual antiplatelet therapy (DAPT) prior to admission, it is recommended to continue DAPT alongside DVT prophylaxis with Lovenox (enoxaparin), with individualized assessment for patients receiving therapeutic-dose anticoagulation. 1
Rationale for Continuing DAPT with Prophylactic Anticoagulation
The 2023 American College of Chest Physicians (ACCP) expert panel report provides specific guidance on this clinical scenario:
- For hospitalized patients with COVID-19 on DAPT for recent acute coronary syndrome (ACS) who are receiving prophylactic-dose anticoagulant therapy, the recommendation is to continue DAPT 1
- This recommendation can be extrapolated to non-COVID hospitalized patients as the underlying thrombotic and bleeding risk considerations are similar
DVT Prophylaxis in Hospitalized Patients
All hospitalized patients with reduced mobility should receive pharmacologic thromboprophylaxis in the absence of bleeding contraindications:
- Enoxaparin 40 mg subcutaneously once daily is the standard prophylactic dose for most patients 1
- For patients with renal impairment (CrCl <30 mL/min), dose adjustment to 20-30 mg daily may be needed 1
- For obese patients, a higher dose (60 mg daily) may be considered 1
Special Considerations for Patients on DAPT
When managing patients on DAPT who require DVT prophylaxis:
For patients on prophylactic-dose anticoagulation:
- Continue DAPT alongside prophylactic enoxaparin 1
- Monitor for signs of bleeding
For patients requiring therapeutic-dose anticoagulation:
- Individual assessment is needed based on bleeding risk 1
- Consider reducing DAPT to single antiplatelet therapy in high bleeding risk patients
- For patients with recent stent placement or very high thrombotic risk, continuation of DAPT may be warranted despite increased bleeding risk
Efficacy and Safety Considerations
- Low-molecular-weight heparins like enoxaparin have demonstrated efficacy in preventing VTE in hospitalized patients 1
- The incidence of DVT with proper prophylaxis is low (2.7%) even with standard fixed dosing 2
- Bleeding risk is increased when antiplatelet therapy is combined with anticoagulation, but remains acceptable with prophylactic doses of enoxaparin 3
Monitoring Recommendations
- Regular assessment for signs of bleeding (visible bleeding, hematuria, melena, hemoptysis)
- Monitor platelet count to detect heparin-induced thrombocytopenia
- No routine anti-Xa monitoring is required for prophylactic dosing 2
Common Pitfalls to Avoid
- Discontinuing DAPT unnecessarily: This increases risk of stent thrombosis or recurrent ACS
- Omitting DVT prophylaxis due to concerns about bleeding: The risk of VTE outweighs bleeding risk in most hospitalized patients
- Failing to adjust doses in renal impairment or obesity: Standard dosing may be inadequate or excessive in these populations
- Not recognizing drug interactions: P2Y12 inhibitors may have interactions with other medications
By following these recommendations, clinicians can effectively balance the need for continued antiplatelet therapy while providing appropriate VTE prophylaxis in hospitalized patients.