What is the recommended prophylaxis for patients at risk of developing Deep Vein Thrombosis (DVT)?

DVT Prophylaxis Recommendations

Low molecular weight heparin (LMWH) is the preferred pharmacological agent for venous thromboembolism (VTE) prophylaxis in hospitalized patients at risk of developing deep vein thrombosis (DVT). 1

Risk Assessment

Proper risk assessment is essential before initiating DVT prophylaxis:

• Validated Risk Assessment Tools:

  • Caprini Risk Assessment Model:
    • Very low (0 points; 0.5% risk)
    • Low (1-2 points; 1.5% risk)
    • Moderate (3-4 points; 3% risk)
    • High (≥5 points; 6% risk) 1
  • Padua score (high risk ≥4 points) 1
  • IMPROVE VTE Risk Assessment Model (increased risk ≥2 points) 1

• Bleeding Risk Assessment:

  • IMPROVE Bleeding RAM (high bleeding risk ≥7 points) 1

Patient-Specific Risk Factors

• Age >40 years
• Prior history of VTE
• Cancer (especially pancreatic, lung, or gastrointestinal)
• Obesity
• Pregnancy/estrogen therapy
• Immobility 1

Recommended Prophylaxis Methods

Pharmacological Prophylaxis

1. Low Molecular Weight Heparin (First-line):

   • Enoxaparin 40 mg subcutaneously once daily
   • Dalteparin 5000 IU subcutaneously once daily
   • Fondaparinux 2.5 mg subcutaneously once daily 1

2. Unfractionated Heparin (Alternative):

   • 5000 U subcutaneously three times daily 1

3. Direct Oral Anticoagulants (DOACs):

   • Rivaroxaban 10 mg orally once daily for prophylaxis following hip/knee replacement surgery 2
   • Apixaban 2.5 mg twice daily (for patients with at least two of: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 3

Mechanical Prophylaxis

• Intermittent pneumatic compression (IPC)
• Graduated compression stockings (GCS)
• Important: Should not be used as monotherapy unless pharmacological methods are contraindicated due to active bleeding or high bleeding risk 1

Special Considerations

High Bleeding Risk Patients

• Use mechanical prophylaxis (IPC) alone until bleeding risk decreases 1

Contraindications to Pharmacological Prophylaxis

• Active bleeding
• Severe thrombocytopenia (platelets <25×10⁹/L)
• Recent intracranial hemorrhage
• Heparin-induced thrombocytopenia 1

Cancer Patients

• High-risk outpatients (Khorana score ≥2) starting systemic chemotherapy may receive prophylaxis with apixaban, rivaroxaban, or LMWH if no significant bleeding risk exists 1

Neurosurgical Patients

• LMWH or UFH recommended postoperatively 1
• Non-surgical brain tumor patients should not receive primary pharmacological prophylaxis 1

Duration of Prophylaxis

• Minimum duration: 10-14 days
• Consider extending to 35 days for high-risk patients
• Extended prophylaxis (4 weeks) recommended after major abdominal or pelvic cancer surgery 1
• Continue throughout hospitalization and until the patient is fully mobile or discharged 1

Common Pitfalls to Avoid

• Inadequate risk assessment leading to inappropriate prophylaxis 1
• Inappropriate prophylaxis duration - not extending prophylaxis for high-risk patients or continuing unnecessarily in low-risk patients 1
• Overlooking contraindications such as active bleeding or severe thrombocytopenia 1
• Relying solely on mechanical prophylaxis when pharmacological methods are indicated 1
• Delayed initiation of prophylaxis - should be started as soon as possible after admission when no contraindications exist 1