Does thromboprophylaxis (thrombosis prevention) for surgical patients with thrombophilia (hypercoagulability disorder) require any modifications?

From the Guidelines

Thromboprophylaxis for surgical patients with thrombophilia should be modified to include more aggressive prophylaxis due to their higher baseline risk of venous thromboembolism (VTE). According to the most recent and highest quality study 1, patients undergoing major cancer surgery should receive pharmacological thromboprophylaxis for at least 10 days post-operatively, and extended post-operative VTE prophylaxis for 4 weeks with low molecular weight heparin (LMWH) is recommended for patients with cancer undergoing open abdominal or pelvic surgery or laparoscopic colorectal cancer surgery.

Key Considerations

• For most thrombophilia patients undergoing surgery, LMWH such as enoxaparin 40mg subcutaneously once daily or 30mg twice daily is recommended, starting 12-24 hours after surgery and continuing for at least 7-10 days for minor procedures and 28-35 days for major orthopedic or cancer surgeries 1.
• For high-risk thrombophilias, consider higher prophylactic doses or even therapeutic anticoagulation with enoxaparin 1mg/kg twice daily.
• Patients already on long-term anticoagulation should bridge appropriately, typically stopping warfarin 5 days pre-op and resuming LMWH until the INR is therapeutic postoperatively.
• Mechanical prophylaxis with compression stockings and intermittent pneumatic compression devices should be used in addition to pharmacological methods.
• Early mobilization remains important, as thrombophilia creates a hypercoagulable state that, when combined with the additional prothrombotic stress of surgery, significantly increases VTE risk compared to the general population.

Recommendations

• Pharmacological VTE prophylaxis with LMWH (preferred) or UFH is recommended in patients undergoing major cancer surgery, unless contraindicated due to a high risk of bleeding 1.
• Fondaparinux may be used as an alternative.
• Mechanical methods such as IPC or GCSs are suggested as an alternative when pharmacological VTE prophylaxis is contraindicated.
• Mechanical methods may be used in combination with pharmacological VTE prophylaxis in patients at exceedingly high risk of VTE.

From the FDA Drug Label

1. WARNINGS AND PRECAUTIONS 5.1 Neuraxial Anesthesia and Post-operative Indwelling Epidural Catheter Use 5.2 Hemorrhage 5.3 Renal Impairment and Bleeding Risk 5.4 Body Weight < 50 kg and Bleeding Risk 5.5 Thrombocytopenia 5.6 Monitoring: Laboratory Tests

The FDA drug label does not provide direct information on modifications for thromboprophylaxis in surgical patients with thrombophilia. However, it does discuss various warnings and precautions related to bleeding risk, which may be relevant for patients with hypercoagulability disorders.

• Thrombophilia is not explicitly mentioned in the label.
• Bleeding risk is discussed in several sections, but not in the context of thrombophilia.
• No specific modifications for thromboprophylaxis in patients with thrombophilia are provided 2.

From the Research

Thromboprophylaxis for Surgical Patients with Thrombophilia

Thromboprophylaxis, or the prevention of thrombosis, is a critical aspect of surgical care, particularly for patients with thrombophilia, a hypercoagulability disorder. The following points highlight the key considerations for thromboprophylaxis in surgical patients with thrombophilia:

• The level of venous thromboembolism (VTE) risk following surgery depends on various factors, including the type of surgery and the presence of additional risk factors, such as elderly age and cancer 3.
• Patients with inherited bleeding disorders undergoing surgery require assessment of individual risk for VTE, taking into account the nature of the surgery and anaesthetic, type and severity of bleeding disorder, age, BMI, history of thrombosis, and other high-risk comorbidities 4.
• For patients undergoing major surgery, the use of antithrombotic drugs, such as low molecular weight heparin (LMWH), low-dose unfractionated heparin, or fondaparinux, is recommended for thromboprophylaxis 3, 5.
• In patients with a high risk of thromboembolism and a high bleeding risk after surgery, administering a reduced dose of direct oral anticoagulant on the evening after surgery and on the following day may be a good practice 4.
• The management of neurosurgery patients with high risk for both thrombosis and intracranial bleeding requires careful consideration of pharmacologic thromboprophylaxis, temporary interruption of antithrombotic drugs, and possible use of substitutive medication ('bridging therapy') 6.

Modifications for Thromboprophylaxis

The following modifications may be necessary for thromboprophylaxis in surgical patients with thrombophilia:

• Reduced dosages of LMWH may be used relatively safely during transient severe thrombocytopaenia 4.
• Monitoring of anti-Xa levels may be used to adjust the doses of LMWH in patients with moderate or severe thrombocytopaenia 4.
• The delay between major gastrointestinal bleeding and resuming warfarin should be at least 7 days 4.
• Extended prophylaxis with LMWH reduces the risk of symptomatic VTE in high-risk abdominal and pelvic cancer surgery without an appreciable increase in risk of bleeding 7.