From the FDA Drug Label
In patients undergoing prophylaxis following elective hip surgery or hip fracture surgery, the total clearance of fondaparinux is approximately 25% lower in patients with mild renal impairment (CrCl 50 to 80 mL/min), approximately 40% lower in patients with moderate renal impairment (CrCl 30 to 50 mL/min), and approximately 55% lower in patients with severe renal impairment (<30 mL/min) compared to patients with normal renal function.
DVT Prophylaxis with Fondaparinux in Postop Patients with Decreased GFR:
- Fondaparinux clearance is decreased in patients with renal impairment, with a 25% decrease in mild impairment, 40% decrease in moderate impairment, and 55% decrease in severe impairment.
- Dosage adjustment may be necessary in patients with decreased GFR, as the elimination of fondaparinux is prolonged in these patients 1.
- However, the exact dosage adjustment is not specified in the provided drug label.
From the Research
For DVT prophylaxis in postoperative patients with decreased GFR, mechanical prophylaxis with intermittent pneumatic compression devices is recommended, especially for those with contraindications to anticoagulation, as it reduces the risk of DVT by 60% compared to no prophylaxis 2.
Key Considerations
- The use of intermittent pneumatic compression devices is supported by a systematic review and meta-analysis, which found that these devices are effective in preventing DVT in postoperative patients 2.
- The American College of Chest Physicians recommends the use of mechanical prophylaxis with intermittent pneumatic compression devices for patients with contraindications to anticoagulation 3.
- For patients with decreased GFR, the use of low molecular weight heparin (LMWH) with dose adjustment may be considered, but the risk of bleeding must be carefully balanced against the risk of thrombosis 4.
Dose Adjustments
- For patients with GFR 30-60 mL/min, enoxaparin 30 mg subcutaneously twice daily or 40 mg once daily may be used.
- For severe renal impairment (GFR <30 mL/min), unfractionated heparin (UFH) 5000 units subcutaneously every 8-12 hours is preferred as it doesn't require renal clearance.
Monitoring and Duration
- Regular monitoring of anti-Xa levels may be necessary for patients on LMWH with severe renal impairment.
- Prophylaxis should typically continue until the patient is fully mobile or for 7-14 days post-surgery for high-risk patients.
Alternative Options
- Fondaparinux may be used at 1.5 mg daily for patients with GFR 20-50 mL/min, but should be avoided if GFR <20 mL/min.
- The use of graduated compression stockings may also be considered, but the evidence suggests that intermittent pneumatic compression devices are more effective in preventing DVT 5.