What venous thromboembolism (VTE) prophylaxis should be given to a 66-year-old patient with an intracapsular neck of femur fracture?

From the Guidelines

For a 66-year-old patient with an intracapsular neck of femur fracture, I strongly recommend venous thromboembolism (VTE) prophylaxis with low molecular weight heparin (LMWH), specifically enoxaparin 40mg subcutaneously once daily, starting as soon as possible after surgery and continuing for 28-35 days post-surgery, as this approach has been shown to significantly reduce the risk of VTE and improve outcomes in such patients 1.

Rationale for Recommendation

The recommendation is based on the high VTE risk in hip fracture patients, particularly elderly individuals, due to the combination of tissue trauma, immobility, surgery, and age-related hypercoagulability. Hip fracture patients have up to a 50% risk of developing deep vein thrombosis without prophylaxis, with significant mortality risk from pulmonary embolism. Extended prophylaxis is particularly important as the risk remains elevated for weeks after surgery.

Key Considerations

• The patient should also use mechanical prophylaxis with graduated compression stockings or intermittent pneumatic compression devices until fully mobile.
• Before starting pharmacological prophylaxis, assess for contraindications including active bleeding, severe renal impairment, or history of heparin-induced thrombocytopenia, and adjust dosing if the patient has moderate renal impairment.
• Fondaparinux 2.5mg subcutaneously once daily could be used as an alternative to enoxaparin, considering the patient's renal function and other clinical factors.

Evidence Support

The most recent and highest quality evidence supports the use of LMWH for VTE prophylaxis in patients with hip fractures, as outlined in the 2014 guidelines 1. This approach is consistent with recommendations from other reputable sources, emphasizing the importance of timely and extended VTE prophylaxis in this high-risk population.

Clinical Implications

Implementing this recommendation can significantly reduce the morbidity and mortality associated with VTE in patients with intracapsular neck of femur fractures, improving their quality of life and clinical outcomes. It is essential to individualize the approach based on patient-specific factors, such as renal function and bleeding risk, to maximize the benefits of VTE prophylaxis while minimizing potential harms.

From the FDA Drug Label

Table 9. Efficacy of Fondaparinux Sodium in the Prophylaxis of Thromboembolic Events Following Hip Replacement Surgery Endpoint Study 1 Study 2 Fondaparinux Sodium 2.5 mg SC once daily Enoxaparin Sodium 30 mg SC every 12 hr Fondaparinux Sodium 2.5 mg SC once daily Enoxaparin Sodium 40 mg SC once daily VTE 48/787 6.1% 66/797 8.3% 37/908 4.1% 85/919 9.2%

The recommended venous thromboembolism (VTE) prophylaxis for a 66-year-old patient with an intracapsular neck of femur fracture is fondaparinux sodium 2.5 mg SC once daily or enoxaparin sodium 30 mg SC every 12 hours or enoxaparin sodium 40 mg SC once daily.

• Fondaparinux sodium has been shown to have a VTE rate of 6.1% and 4.1% in two studies,
• Enoxaparin sodium 30 mg SC every 12 hours has a VTE rate of 8.3%,
• Enoxaparin sodium 40 mg SC once daily has a VTE rate of 9.2%. The choice of prophylaxis should be based on individual patient risk factors and clinical judgment 2.

From the Research

Venous Thromboembolism Prophylaxis for a 66-year-old Patient with an Intracapsular Neck of Femur Fracture

• The patient is at high risk for venous thromboembolism (VTE) due to the nature of their injury and age 3, 4, 5.
• Several studies have investigated the efficacy of different prophylactic agents in preventing VTE in patients with hip fractures or other orthopedic injuries:
  • Fondaparinux has been shown to be effective in reducing VTE in high-risk trauma patients, including those with hip fractures 6, 7.
  • Enoxaparin is also a commonly used prophylactic agent, and its administration on the morning of surgery does not appear to increase the risk of blood transfusion or wound drainage in geriatric patients undergoing femur fracture treatment 4.
  • Direct oral anticoagulants (DOACs) have also been associated with reduced odds of VTE in patients undergoing distal femur fracture fixation 5.
• The choice of prophylactic agent may depend on various factors, including the patient's individual risk factors, medical history, and the specific nature of their injury.
• It is essential to consider the patient's overall clinical picture and to weigh the potential benefits and risks of each prophylactic agent when making a decision about VTE prophylaxis 3, 7, 4, 5.
• Some studies suggest that patients with distal femur fractures may be at higher risk for VTE compared to those with hip fractures, and that enoxaparin and DOACs may be effective therapeutic options for risk mitigation 5.