Simple guide for venous thromboembolism (VTE) prophylaxis after surgery or hospitalization

Continue to recommend VTE prophylaxis for 14 to 35 days after knee or hip replacement. Recommend using a direct oral anticoagulant (DOAC), such as....
Abdelwahab Ward, BS Pharm, PharmD

When is venous thromboembolism (VTE) prophylaxis needed after hospitalization? Not very often. Stay alert for appropriate use.

Hip or knee replacement patients

Continue to recommend VTE prophylaxis for 14 to 35 days after knee or hip replacement.

  • Recommend using a direct oral anticoagulant (DOAC), such as Eliquis (apixaban) or Xarelto (rivaroxaban), or a low-molecular-weight heparin (Clexane [enoxaparin], etc) for most patients at higher VTE risk. This includes patients with prior VTE, CV disease, extremely limited mobility, etc.
  • For lower-VTE-risk patients, consider suggesting a DOAC for 5 days then switching to aspirin 81 mg/day to finish the course. But explain there's not good evidence for using aspirin alone from the get-go.

Nonsurgical patients

Recent evidence is raising questions about continuing VTE prophylaxis after discharge in high-risk NONsurgical patients such as an older heart failure patient with reduced mobility.

  • Explain that using Xarelto for 45 days after discharge in high-risk patients only prevents one symptomatic VTE for every 417 treated, but one in 175 have clinically important bleeding.
  • Evidence for Eliquis seems even less favourable.
  • Don't recommend this "extended-duration" VTE prophylaxis.

Also don't routinely recommend VTE prophylaxis for patients with a lower leg injury requiring immobilization, such as a cast, or in patients who are chronically immobilized, such as nursing home residents. But ensure anticoagulants are continued after discharge for appropriate indications (atrial fibrillation, recent VTE, etc). Get our note, "Optimize anticoagulants to reduce stroke risk in atrial fibrillation patients".

References

  • Thrombosis Canada - (2013). Clinical Guides[online]. Available at: https://thrombosiscanada.ca/clinicalguides

    Spyropoulos AC, Ageno W, Albers GW, Elliott CG, Halperin JL, Hiatt WR, Maynard GA, Steg PG, Weitz JI, Suh E, Spiro TE, Barnathan ES, Raskob GE; MARINER Investigators. Rivaroxaban for Thromboprophylaxis after Hospitalization for Medical Illness. N Engl J Med. 2018 Sep 20;379(12):1118-1127. Available at: https://pubmed.ncbi.nlm.nih.gov/30145946

    Cohen AT, Harrington RA, Goldhaber SZ, Hull RD, Wiens BL, Gold A, Hernandez AF, Gibson CM; APEX Investigators. Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients. N Engl J Med. 2016 Aug 11;375(6):534-44. Available at: https://pubmed.ncbi.nlm.nih.gov/27232649

    Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e195S-e226S. Available at: https://pubmed.ncbi.nlm.nih.gov/22315261

    Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. Available at: https://pubmed.ncbi.nlm.nih.gov/22315265

Abdelwahab Ward, BS Pharm, PharmD