Can a patient scheduled to undergo bone marrow biopsy still receive Deep Vein Thrombosis (DVT) prophylaxis?

From the Guidelines

Yes, patients scheduled for bone marrow biopsy can generally receive DVT prophylaxis, as the most recent and highest quality study suggests that the benefits of prophylaxis often outweigh the risks of bleeding complications 1.

Key Considerations

• The decision to continue or initiate DVT prophylaxis should be individualized based on the patient's thrombotic risk versus bleeding risk.
• Pharmacological prophylaxis with low molecular weight heparin (such as enoxaparin 40mg subcutaneously once daily) or unfractionated heparin (5000 units subcutaneously every 8-12 hours) can typically be continued up to the procedure, with the last dose given at least 12 hours before the biopsy for prophylactic doses and 24 hours for therapeutic doses.
• After the procedure, prophylaxis can usually be resumed 6-12 hours later if there are no signs of bleeding complications.
• Mechanical prophylaxis methods like compression stockings or intermittent pneumatic compression devices are safe alternatives that can be used without interruption.

Patient-Specific Factors

• Patients with high thrombotic risk (history of VTE, active cancer, prolonged immobility) benefit most from continued prophylaxis.
• Those with coagulopathies or very low platelet counts may need modification of the regimen or temporary discontinuation.

Guideline Recommendations

• The most recent guidelines from the European Society for Medical Oncology (ESMO) recommend pharmacological VTE prophylaxis with LMWH or UFH in patients undergoing major cancer surgery, unless contraindicated due to a high risk of bleeding 1.
• Fondaparinux may be used as an alternative, and mechanical methods such as IPC or GCSs are suggested as an alternative when pharmacological VTE prophylaxis is contraindicated.

From the FDA Drug Label

If neurological compromise is noted, urgent treatment is necessary Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: • A history of traumatic or repeated epidural or spinal punctures Epidural or spinal hematomas may occur in patients who are anticoagulated with low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture.

The patient can still receive DVT prophylaxis with dalteparin, but the benefits and risks must be carefully considered before the bone marrow biopsy, especially if it involves a spinal puncture. The risk of epidural or spinal hematomas must be weighed against the need for thromboprophylaxis. It is essential to monitor the patient frequently for signs and symptoms of neurological impairment 2.

From the Research

DVT Prophylaxis and Bone Marrow Biopsy

• Patients scheduled to undergo bone marrow biopsy can still receive DVT prophylaxis, as the incidence of significant hemorrhage after bone marrow biopsy is very low (0.007-1.1%) 3.
• Bone marrow biopsy is classified as having a low to moderate bleeding risk, and interrupting anticoagulation is not consistently recommended 3.
• Strategies exist to minimize bleeding risk for anticoagulated patients, and assessment and optimization of bleeding risk factors should be done on a patient-by-patient basis 3.
• The use of anticoagulants such as fondaparinux, enoxaparin, or dalteparin for DVT prophylaxis has been studied, and these medications have been shown to be effective in preventing venous thromboembolism 4, 5, 6, 7.
• The choice of anticoagulant for DVT prophylaxis should be based on individual patient factors, such as renal function and bleeding risk, as well as the specific clinical scenario 4, 5, 6, 7.

Anticoagulant Options

• Fondaparinux has been shown to be at least as effective as enoxaparin in the initial treatment of patients with symptomatic deep venous thrombosis, with a similar safety profile 4.
• Dalteparin has been shown to be comparable to enoxaparin in terms of effectiveness for VTE prophylaxis in a real-world cohort of patients 5.
• Enoxaparin has been shown to be effective in preventing venous thromboembolism after major orthopedic surgery, but may be associated with a higher risk of major bleeding compared to fondaparinux 7.
• The effects of these anticoagulants on human osteoblasts have also been studied, with fondaparinux showing no inhibitory effects on osteoblast-dependent fracture healing and endoprosthetic implant integration 6.