What are the contraindications for anticoagulation therapy as deep vein thrombosis (DVT) prophylaxis in patients with a history of bleeding disorders or impaired renal function?

Contraindications to Anticoagulation for DVT Prophylaxis

Anticoagulation for DVT prophylaxis should be withheld in patients with active major bleeding, severe thrombocytopenia (<20,000-50,000/μL depending on context), severe uncontrolled hypertension, recent CNS bleeding, or high-risk intracranial lesions. 1

Absolute Contraindications

The following conditions represent situations where anticoagulation should not be administered because bleeding risk exceeds potential benefit:

• Active major, serious, or potentially life-threatening bleeding not reversible with medical or surgical intervention, including bleeding in critical sites (intracranial, pericardial, retroperitoneal, intraocular, intra-articular, intraspinal) 1
• Severe, uncontrolled malignant hypertension 1
• Severe, uncompensated coagulopathy (e.g., liver failure) 1
• Severe platelet dysfunction or inherited bleeding disorder 1
• Persistent, severe thrombocytopenia (<20,000/μL) 1
• Recent surgery or invasive procedures, including lumbar puncture, spinal anesthesia, and epidural catheter placement 1

Relative Contraindications

These situations require careful risk-benefit assessment, and anticoagulation may be administered if thrombotic risk exceeds bleeding risk:

• Intracranial or spinal lesion at high risk for bleeding 1
• Active peptic or GI ulceration at high risk of bleeding 1
• Active but non-life-threatening bleeding (e.g., trace hematuria) 1
• Intracranial or CNS bleeding within past 4 weeks 1
• Major surgery or serious bleeding within past 2 weeks 1
• Persistent thrombocytopenia (platelet count <50,000/μL) 1
• Active cerebrovascular hemorrhage 1
• Dissecting or cerebral aneurysm 1
• Bacterial endocarditis 1
• Pericarditis 1

Special Populations Requiring Modified Approach

Thrombocytopenia Management

For platelet counts 50,000-100,000/μL: Prophylactic anticoagulation can generally be administered safely 2

For platelet counts 20,000-50,000/μL: Half-dose LMWH may be considered with close monitoring for bleeding 1

For platelet counts <20,000/μL: Therapeutic anticoagulation should be held, though prophylactic doses may be tolerated in select cases 1

Renal Impairment Considerations

Severe renal impairment (creatinine clearance <30 mL/min) is a relative contraindication to LMWH, and unfractionated heparin is preferred in this setting 1

Cancer Patients with Bleeding Risk

In cancer patients with VTE and high bleeding risk, the decision requires weighing severity of thrombotic event against bleeding potential. IVC filter placement should be considered when anticoagulation is contraindicated 1

Alternative Strategies When Anticoagulation Contraindicated

When absolute contraindications exist:

• IVC filter insertion is indicated for patients with acute DVT/PE who cannot receive anticoagulation 1, 3
• Mechanical prophylaxis (graduated compression stockings, sequential compression devices) should be used 4
• Serial imaging surveillance to monitor for thrombus progression 1
• Platelet transfusions may enable anticoagulation in severe thrombocytopenia if platelet count can be maintained >50,000/μL 1

Critical Clinical Pitfalls

• Do not assume mild-moderate thrombocytopenia (>50,000/μL) is a contraindication to prophylactic anticoagulation 2
• Heparin-induced thrombocytopenia is an absolute contraindication to heparin products but not to other anticoagulant classes 1
• Pregnancy is a contraindication to warfarin but not to LMWH or unfractionated heparin 1, 5
• Epidural catheter placement requires careful timing with anticoagulation to avoid spinal/epidural hematoma 1, 6
• End-of-life/hospice care represents a situation where anticoagulation may be of uncertain benefit and should be reconsidered 1

Resumption of Anticoagulation After Bleeding

When bleeding risk resolves, conventional anticoagulant therapy should be initiated and the IVC filter (if placed) can be removed 1, 3. Typical timeframe is 7-14 days for most GI bleeding cases once hemostasis is achieved 3.