Venous thromboembolism PROPHYLAXIS options

The recommended dose of heparin for prophylaxis is 5000 units subcutaneously (SC) every 8 hours. No renal or hepatic dose adjustments are necessary...

Introduction

As a critical care pharmacist, it is crucial to identify patients who require venous thromboembolism (VTE) prophylaxis and those who should avoid it. According to the CHEST Guidelines, prophylaxis is recommended for acutely ill hospitalized medical patients at increased risk of thrombosis (hip replacement, obesity, cancer, advanced age, etc), unless contraindicated, such as in cases of active bleeding.

NPS-adv

Medications for VTE prophylaxis

One commonly used medication for VTE prophylaxis is heparin. The recommended dose of heparin for prophylaxis is 5000 units subcutaneously (SC) every 8 hours. No renal or hepatic dose adjustments are necessary. In some cases, a higher prophylactic dose of 7500 units every 8 hours may be considered for obese patients with a BMI of 30 kg/m². or higher.

Enoxaparin (Clexane) is another medication option for VTE prophylaxis. The usual prophylactic dose is 40 mg SC once daily. For doses in obese patients "click here". However, for patients with a CrCl < 30 mL/min, the dose should be adjusted to 30 mg SC once daily.
Fondaparinux (Arixtra) is contraindicated for prophylactic use in patients weighing less than 50 kg or with CrCl < 30 mL/min. Prophylactic dose is 2.5 mg every 24 hours.

Certain direct oral anticoagulants, such as rivaroxaban (Xarelto), offer convenience with oral administration. Rivaroxaban is FDA-approved for VTE prophylaxis at a dosage of 10 mg once daily. It's important to note that while these agents provide ease of use, cost considerations may limit their availability for some patients.

When chemical prophylaxis is contraindicated

In cases where chemical prophylaxis is contraindicated, mechanical prophylaxis can be initiated. This includes the use of graduated compression stockings or intermittent pneumatic compression devices, which work by applying pressure to the legs and enhancing blood flow to prevent clot formation. Get our article, "Note on treating venous thromboembolism (VTE)", also read "Simple guide for venous thromboembolism (VTE) prophylaxis after surgery or hospitalization" and "Using DOACs for venous thromboembolism due to cancer" for more information.

References

Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JRE, Wells P, Woller SC, Moores L. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352.
Badireddy M, Mudipalli VR. Deep Venous Thrombosis Prophylaxis. [Updated 2023 May 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534865.
Laryea J, Champagne B. Venous thromboembolism prophylaxis. Clin Colon Rectal Surg. 2013 Sep;26(3):153-9.