From the Guidelines
For patients hospitalized for more than one month, DVT prophylaxis should generally be continued for the duration of hospitalization as long as risk factors persist, as recommended by the American Society of Hematology 2018 guidelines 1. The decision to continue or stop prophylaxis should be based on an individualized assessment of the patient's ongoing risk factors for venous thromboembolism (VTE) versus their bleeding risk. Some key points to consider when making this decision include:
- The presence of ongoing risk factors such as immobility, active cancer, or critical illness
- The patient's bleeding risk, which may influence the choice of prophylactic agent
- The use of standard prophylactic options, including low molecular weight heparins like enoxaparin 40mg subcutaneously daily, unfractionated heparin 5000 units subcutaneously two or three times daily, or fondaparinux 2.5mg subcutaneously daily
- The consideration of mechanical methods, such as intermittent pneumatic compression devices, for patients with contraindications to pharmacological prophylaxis Regular reassessment is important, as the patient's risk factors and mobility status may change over time. If a patient becomes ambulatory and their other risk factors resolve, prophylaxis may be discontinued. Conversely, if risk factors like immobility, active cancer, or critical illness persist, prophylaxis should continue regardless of the duration of hospitalization, as the benefit of prophylaxis typically outweighs the risks in high-risk hospitalized patients, according to the American Society of Hematology 2018 guidelines 1. Key factors to consider when deciding to continue or discontinue DVT prophylaxis include:
- Ongoing risk factors for VTE
- Bleeding risk
- Patient mobility and ability to ambulate
- Presence of active cancer or critical illness By considering these factors and following the guidelines outlined by the American Society of Hematology 2018 1, clinicians can make informed decisions about DVT prophylaxis in prolonged hospitalized patients.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Guidelines for Deep Vein Thrombosis (DVT) Prophylaxis
The decision to continue or discontinue DVT prophylaxis in prolonged hospitalized patients after one month should be based on individualized risk assessment, taking into account the patient's risk of VTE and bleeding, as well as their age and life expectancy 2.
Risk Assessment
- Patient-specific risk factors, such as immobility status and acute medical illness, should be incorporated into individualized VTE risk assessment models 3.
- The Caprini score can be used to estimate the risk of thrombosis, with patients at very low risk (Caprini score 0) not requiring prophylaxis, and those at low risk (Caprini 1 to 2) receiving either mechanical or pharmacological prophylaxis 4.
- Patients at moderate to high risk of VTE (Caprini 3 to 4 or ≥5) should receive pharmacological prophylaxis, either alone or combined with mechanical prophylaxis 4.
Duration of Prophylaxis
- Prophylaxis is typically continued until the patient is ambulatory or until hospital dismissal, but longer durations can be considered in certain circumstances, such as high-risk patients undergoing malignant abdominopelvic operations, bariatric operations, or certain orthopedic operations 4.
- The decision to extend prophylaxis beyond hospital discharge should be based on the patient's individual risk factors and the potential benefits and risks of continued prophylaxis 3, 2.
Benefits and Risks of Prophylaxis
- Pharmacologic prophylaxis has been shown to be effective in preventing VTE in hospitalized medically ill patients, but it also carries a risk of bleeding 5, 6.
- The benefits and risks of prophylaxis should be carefully weighed, taking into account the patient's individual risk factors and the potential consequences of VTE or bleeding 2, 5.