New Paradigms of Extended Thromboprophylaxis in Medically Ill Patients

Abstract

Extended thromboprophylaxis given to medically ill patients for up to 45 days following an acute hospitalization remains an emerging topic among many hospital-based health care providers. Recent advancements in the field of extended thromboprophylaxis using risk stratification and careful patient selection criteria have led to an improved safety profile of direct oral anticoagulants (DOACs) and established net clinical benefit when given to key patient subgroups at high risk of venous thromboembolism (VTE) and low risk of bleeding. The Food and Drug Administration (FDA) has now approved the DOACs betrixaban and rivaroxaban for both in-hospital and extended thromboprophylaxis in medically ill patients in these key subgroups, which represents more than one-quarter of hospitalized medically ill patients. This has potential to significantly reduce VTE-related morbidity and mortality for these patients. Emerging data also supports reductions in the risk of arterial thromboembolism in medically ill patients with extended thromboprophylaxis post-hospital discharge using DOACs. This article aims to review the most recent concepts of predicting and preventing VTE and to discuss emerging paradigms of extended thromboprophylaxis in hospitalized medically ill patients utilizing an individualized, risk-adapted approach.

Prevention of Venous Thromboembolism in 2020 and Beyond

“…Routine use of extended thromboprophylaxis after discharge without individualized risk assessment is not recommended [9]. A recent publication in this VTE series explores the recent trials for extended VTE prophylaxis and suggests an algorithm to determine which patients may benefit from extended prophylaxis [135].…”

Prophylaxis and treatment of COVID-19 related venous thromboembolism

“…It is known that the risk of hospital-associated VTE extends for up to 6 weeks post-discharge in medically ill patients with a high VTE risk, as those with pneumonia, sepsis and post-ICU admission [ 114 ], but the efficacy and safety of extended thromboprophylaxis in COVID-19 patients is still unclear [ 115 , 116 ]. Extended prophylaxis with LMWH or DOAC may be considered in patients with a high VTE and a low bleeding risk [ 10 , 102 , 117 ].…”

Rivaroxaban: Expanded Role in Cardiovascular Disease Management—A Literature Review

“…Most studies indicated positive health outcomes for those who took rivaroxaban, but some negative and some nonsuperior effects were also found. The FDA approved rivaroxaban to prevent VTE in acutely ill patients in October 2019, and based on this approval, rivaroxaban can be initiated during hospitalizations and continued for 31-39 days [ 35 ]. In the systematic review and meta-analysis comparing prolonged thromboprophylaxis with factor Xa inhibitors to the short-term enoxaparin, DOACs were more effective than enoxaparin but were also associated with more bleeding episodes [ 36 ].…”

“…The use of rivaroxaban in AF was also associated with a higher risk of bleeding in AF patients on hemodialysis in a systemic review of the randomized trials, cohort studies, and case series [ 60 ]. Rivaroxaban was not studied in the treatment or prophylaxis of DVT/PE in patients with CrCl < 30 mL/min, while the reduced dose of 2.5 mg twice daily was not tested in patients with CrCl < 15 mL/min [ 16 , 17 , 30 , 31 , 35 ]. Rivaroxaban is not recommended for the treatment of DVT/PE if CrCl is <30 mL/min, while the 2.5 mg twice daily dose should be used with caution in coronary artery disease and peripheral artery disease with CrCl 15-30 mL/min and is not recommended in ESRD [ 16 , 17 , 30 , 31 , 35 ].…”