What are the recommendations for venous thromboembolism (VTE) prophylaxis in patients with sickle cell disease during an inpatient crisis?

VTE Prophylaxis Recommendations During Sickle Cell Crisis Inpatient

Pharmacological VTE prophylaxis is recommended for patients with sickle cell disease during inpatient crisis due to their high risk of thrombotic events, unless there are contraindications such as active bleeding. 1

Risk Assessment for VTE in Sickle Cell Disease

• Patients with sickle cell disease (SCD) have an increased baseline risk of venous thromboembolism (VTE) compared to the general population, with incidence ranging from 11.2% in all adults with SCD to 17.1% in those with more severe disease 1
• Risk factors that further increase VTE risk in SCD patients include:
  • Female sex 1
  • More severe disease (hospitalization ≥3 times per year) 1
  • Severe sickle cell genotype 1
  • Presence of central venous catheters 1, 2
  • Acute chest syndrome and pneumonia 1
  • Immobility during hospitalization 1
  • Older age 1

Prophylaxis Recommendations

First-line Approach

• Low-molecular-weight heparin (LMWH) is preferred over unfractionated heparin (UFH) for VTE prophylaxis in most hospitalized SCD patients during crisis 1
• Standard prophylactic dosing should be used initially, similar to other acutely ill medical patients 3
• Consider dose adjustments for patients with obesity (50% increase in thromboprophylaxis dose for patients with high BMI) 1

Special Considerations

• For patients with renal impairment (CrCl <30 mL/min), unfractionated heparin (UFH) may be preferred over LMWH 1
• For patients at high bleeding risk or with active bleeding, use mechanical prophylaxis with intermittent pneumatic compression devices (IPCs) instead of pharmacological prophylaxis 1, 4
• When bleeding risk decreases, transition from mechanical to pharmacological prophylaxis 1, 4

Duration of Prophylaxis

• Continue VTE prophylaxis throughout the entire hospitalization for sickle cell crisis 1
• Extended post-discharge thromboprophylaxis is not routinely recommended after sickle cell crisis unless there are other significant risk factors 1

Safety Considerations

• Monitor for bleeding complications, which may occur in approximately 4.3% of SCD patients receiving VTE prophylaxis 1
• The cumulative incidence of bleeding in SCD patients on anticoagulation is approximately 4.9% at 6 months and 7.9% at 1 year 1, 5
• More severe SCD is associated with increased bleeding risk (HR = 1.61) 5

Special Situations

Central Venous Access Devices

• SCD patients with central venous access devices (CVADs) have shown reduced VTE rates with thromboprophylaxis (RR = 4.0 without prophylaxis) 2
• Consider prophylaxis for SCD patients with long-term CVADs, especially with higher-risk catheter types 2

Considerations for Treatment of Established VTE

• If VTE is diagnosed during hospitalization, direct oral anticoagulants (DOACs) may be associated with lower bleeding risk compared to vitamin K antagonists or LMWH 6, 7
• DOACs showed fewer bleeding events (OR 0.22) compared to vitamin K antagonists (OR 1.55) in SCD patients with VTE 6

Implementation Pitfalls to Avoid

• Not providing prophylaxis to high-risk SCD patients due to unfounded concerns about bleeding 1, 3
• Failing to transition from mechanical to pharmacological prophylaxis when bleeding risk decreases 1, 4
• Using inappropriate dosing in obese patients 1
• Not considering the high recurrence rate of VTE in SCD patients when determining management strategies 5