From the Guidelines
For first-line deep vein thrombosis (DVT) prophylaxis in hospitalized patients, anticoagulant thromboprophylaxis with low-molecular-weight heparin (LMWH) is recommended. This is based on the American College of Chest Physicians evidence-based clinical practice guidelines, which suggest that LMWH, low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux can be used for acutely ill hospitalized medical patients at increased risk of thrombosis 1.
- The choice of prophylaxis should be guided by the patient's risk of thrombosis and bleeding, with mechanical prophylaxis with graduated compression stockings (GCS) or intermittent pneumatic compression (IPC) suggested for patients at high risk of bleeding 1.
- For critically ill patients, LMWH or LDUH thromboprophylaxis is suggested, with mechanical prophylaxis with GCS and/or IPC recommended until the bleeding risk decreases 1.
- It is essential to assess the patient's risk of thrombosis using tools like the Padua or IMPROVE score to guide decisions on prophylaxis, as not all patients require pharmacological prophylaxis.
- Prophylaxis should be initiated upon admission and continued throughout the hospital stay, with dose adjustments necessary for patients with extreme body weights or impaired kidney function.
- The medications work by inhibiting clotting factors in the coagulation cascade, preventing thrombus formation in patients with reduced mobility or other risk factors during hospitalization.
- Prophylaxis should be continued until the patient regains full mobility or is discharged, with some high-risk patients potentially requiring extended prophylaxis after discharge.
From the FDA Drug Label
Prophylaxis of VTE in Acutely Ill Medical Patients at Risk for Thromboembolic Complications Not at High Risk of Bleeding: 10 mg once daily, with or without food, in hospital and after hospital discharge for a total recommended duration of 31 to 39 days ( 2.1) The first line DVT prophylaxis inpatient is rivaroxaban 10 mg once daily 2.
- Key points:
- The dose is 10 mg once daily.
- It can be taken with or without food.
- The recommended duration is 31 to 39 days.
- It is for acutely ill medical patients at risk for thromboembolic complications and not at high risk of bleeding.
From the Research
First Line DVT Prophylaxis in Inpatient
- The current standard initial therapies for deep venous thrombosis are low-molecular-weight heparin and unfractionated heparin 3.
- Fondaparinux has been shown to have efficacy and a safety profile similar to those of low-molecular-weight heparin (dalteparin) in patients with symptomatic deep venous thrombosis 3.
- A study comparing fondaparinux and enoxaparin in patients with symptomatic deep venous thrombosis found that once-daily subcutaneous fondaparinux was at least as effective and safe as twice-daily enoxaparin 3.
- Early prophylaxis can reduce patient risk of deep vein thrombosis and its complications 4.
- Low-dose low-molecular-weight heparin has been shown to reduce symptomatic and asymptomatic VTE, but the analysis of the effects on bleeding and adverse events remained inconclusive 5.
- The prevalence of deep venous thrombosis is high in elderly patients hospitalized in subacute care facilities, despite wide use of prophylaxis 6.
- Fondaparinux has been shown to have non-inferior effectiveness and a comparable tolerability profile when compared with enoxaparin in a real-world setting 7.
Treatment Options
- Fondaparinux: a factor Xa inhibitor with proven effectiveness and safety in preventing deep vein thrombosis 3, 7.
- Enoxaparin: a low-molecular-weight heparin with a twice-daily dosing regimen 3, 7.
- Low-dose low-molecular-weight heparin: a pharmacological option for the prevention of venous thromboembolism in many patient categories 5.