Venous Thromboembolism (VTE) Prophylaxis Options
Low molecular weight heparin (LMWH) is the primary pharmacological agent recommended for VTE prophylaxis in most clinical settings, with direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban recommended for specific ambulatory cancer patients and mechanical methods reserved for when pharmacological prophylaxis is contraindicated. 1
Hospitalized Medical Patients
- LMWH (enoxaparin, dalteparin, etc.) is recommended as first-line prophylaxis for hospitalized medical patients with cancer and reduced mobility 1
- Fondaparinux is an alternative when creatinine clearance is ≥30 mL/min 1
- Unfractionated heparin (UFH) is recommended when renal function is impaired 1
- DOACs are not recommended routinely in this setting 1
- Specific dosing options include 1:
- UFH 5000 IU every 8 hours
- Enoxaparin 4000 anti-Xa IU once daily
- Dalteparin 5000 anti-Xa IU once daily
- Tinzaparin 4500 anti-Xa IU once daily
- Fondaparinux 2.5 mg once daily
Surgical Patients
- All patients with cancer undergoing major surgery should receive pharmacological thromboprophylaxis with LMWH or UFH 1
- The highest prophylactic dose of LMWH is recommended to prevent postoperative VTE 1
- Prophylaxis should be commenced preoperatively 1
- Extended prophylaxis (4 weeks) with LMWH is recommended after major abdominal or pelvic surgery in cancer patients without high bleeding risk 1
- Mechanical methods (intermittent pneumatic compression, graduated compression stockings) should not be used as monotherapy except when pharmacological methods are contraindicated 1
- A combined regimen of pharmacological and mechanical prophylaxis may improve efficacy in highest-risk patients 1
Ambulatory Cancer Patients
- Primary prophylaxis with LMWH (Grade 1A) or DOACs (rivaroxaban or apixaban; Grade 1B) is indicated in ambulatory patients with locally advanced or metastatic pancreatic cancer on systemic therapy who have low bleeding risk 1
- DOACs (rivaroxaban 10 mg daily or apixaban 2.5 mg twice daily) are recommended for ambulatory cancer patients receiving systemic therapy who are at intermediate-to-high risk of VTE (Khorana score ≥2) 1, 2
- LMWH is not recommended for patients with locally advanced or metastatic lung cancer outside of clinical trials 1
- For multiple myeloma patients on immunomodulatory drugs with steroids, VTE prophylaxis options include 1:
- LMWH at prophylactic doses
- Oral anticoagulants (vitamin K antagonists or apixaban)
- Low-dose aspirin (100 mg daily)
Special Populations
Patients with Thrombocytopenia
- Full-dose anticoagulant can be used if platelet count >50 × 10⁹/L with no evidence of bleeding 1
- For platelet count >80 × 10⁹/L, standard prophylactic dosing is recommended 3
- For platelet counts between 25-80 × 10⁹/L, consider reduced-dose prophylaxis (50% of standard dose) with careful monitoring 3
- For severe thrombocytopenia (<25 × 10⁹/L), VTE prophylaxis should generally be withheld 3
Patients with Renal Impairment
- In severe renal failure (creatinine clearance <30 mL/min), unfractionated heparin is preferred 1, 3
- Fondaparinux and LMWH are not recommended with severe renal impairment 1
Mechanical Prophylaxis Options
- Mechanical methods include intermittent pneumatic compression (IPC), graduated compression stockings (GCS), and venous foot pumps 1
- These should be used primarily when pharmacological prophylaxis is contraindicated due to bleeding risk 1
- IPC has been shown to be less effective than pharmacological prophylaxis when used alone 1
- Adding IPC to pharmacological prophylaxis may provide additional protection in high-risk patients 1
Common Pitfalls to Avoid
- Inferior vena cava filters are not recommended for routine prophylaxis 1
- Aspirin alone is not recommended as thromboprophylaxis except in specific myeloma patients 1
- Failing to extend prophylaxis for 4 weeks after major abdominal or pelvic cancer surgery 1
- Not reassessing thrombosis and bleeding risks regularly during hospitalization 3
- Continuing full-dose prophylaxis despite significant drops in platelet count 3
- Not considering mechanical prophylaxis when pharmacological prophylaxis is contraindicated 3