Is it safe to prescribe heparin (unfractionated heparin) as a Venous Thromboembolism (VTE) prophylaxis in a patient with colitis and Clostridioides difficile (C. diff) infection?

Heparin for VTE Prophylaxis in Patients with Colitis and C. difficile Infection

Yes, it is safe and recommended to prescribe heparin as VTE prophylaxis in patients with colitis and C. difficile infection, as rectal bleeding is not a contraindication and the benefits outweigh the risks. 1

Increased Risk of VTE in IBD with C. difficile

• Patients with inflammatory bowel disease (IBD) have a 3-8 fold increased risk of venous thromboembolism (VTE) compared to the general population 1
• Hospitalization and steroid treatment further increase VTE risk by 1.5-2 fold 1
• C. difficile infection adds additional risk, with studies showing a 1.7-fold higher rate of VTE in IBD patients with C. difficile compared to those without (6% vs 3%) 2

Guidelines for VTE Prophylaxis

• The British Society of Gastroenterology strongly recommends that patients with acute severe ulcerative colitis should receive prophylactic low-molecular weight heparin 1
• European Crohn's and Colitis Organisation (ECCO) consensus statements recommend VTE prophylaxis for all hospitalized patients with acute severe ulcerative colitis 1
• Pharmacological prophylaxis should be administered using subcutaneous or low molecular weight heparin along with graduated compression stockings 1

Safety Considerations

• Rectal bleeding is explicitly NOT a contraindication for VTE prophylaxis in IBD patients 1
• A meta-analysis of 8 randomized controlled trials evaluating heparin in ulcerative colitis showed that while 6 of 268 patients had increased rectal bleeding, only 3 needed to be withdrawn from the study, and only one required urgent surgery 1
• The risk of major gastrointestinal bleeding with anticoagulant therapy in IBD patients is rare 1

Clinical Practice Gaps

• Despite guidelines, studies show inadequate VTE prophylaxis rates in hospitalized IBD patients:
  • Only 67.6% of UC patients receive pharmacologic prophylaxis in tertiary care centers 3
  • Only 37% of patients with severe active ulcerative colitis receive appropriate prophylaxis by 48 hours of hospitalization 4
  • Many gastroenterologists (34.6%) would not give prophylaxis to hospitalized patients with severe ulcerative colitis 5

Special Considerations for C. difficile

• C. difficile infection typically presents with profuse watery diarrhea and can progress to fulminant disease 6
• The presence of C. difficile should not prevent appropriate VTE prophylaxis, as the risk of thrombosis is actually higher in this population 2
• When C. difficile is detected in IBD patients, treatment should include appropriate antibiotics (fidaxomicin) while continuing necessary IBD management, including VTE prophylaxis 1, 6

Recommended Approach

1. Assess baseline VTE risk factors in all hospitalized IBD patients with colitis and C. difficile 1
2. Implement pharmacological VTE prophylaxis with low molecular weight heparin or unfractionated heparin 1
3. Add mechanical prophylaxis with graduated compression stockings 1
4. Monitor for bleeding complications, but understand that rectal bleeding alone is not a contraindication 1
5. Continue appropriate treatment for both the underlying IBD and C. difficile infection 1, 6

Dosing Considerations

• For unfractionated heparin, the FDA-approved dosing for VTE prophylaxis is typically 5,000 units subcutaneously every 8-12 hours 7
• Extended thromboprophylaxis following hospital discharge should be considered in high-risk IBD patients, particularly those who have undergone surgery 1