Overuse of venous thromboembolism prophylaxis among hospitalized patients with liver disease

Abstract

Introduction Patients with liver disease are at risk of venous thromboembolism (VTE); however, little is understood regarding the safety and efficacy of VTE prophylaxis in patients with cirrhosis. We examined the application of a VTE risk assessment model in VTE prophylaxis decision‐making in a closed cohort of hospitalized patients with liver disease. Methods Sequential patients admitted to an inpatient hepatology service at a tertiary care center were evaluated for need for VTE prophylaxis. Risk assessment by IMPROVE was compared with current practice patterns of VTE prophylaxis. Rates of bleeding and clotting events were noted. Results 98 patient encounters were included in our analysis. 76% of patients received VTE prophylaxis in practice. IMPROVE recommended use of VTE prophylaxis in 19% of patients. Patients who received VTE prophylaxis that was not warranted had significantly lower risk of clotting compared with patients in whom VTE prophylaxis was warranted per IMPROVE. Conclusions Application of IMPROVE risk assessment would significantly reduce VTE prophylaxis use among hospitalized patients with liver disease. Our findings challenge the “one‐size‐fits‐all” current practice pattern of VTE prophylaxis. Future studies are needed in large cohorts of hospitalized patients with liver disease that include clinical outcomes of bleeding and clotting risk.

AGA Technical Review on Coagulation in Cirrhosis

“…There were 5 retrospective cohort studies reporting VTE events in hospitalized patients with cirrhosis receiving prophylactic anticoagulation. 18,[76][77][78][79] VTE events were defined as deep vein thrombosis (DVT) or pulmonary embolism (PE) or PVT and presented as composite end points in most studies, irrespective of symptom presence. The retrospective nature of the studies without systematic screening for VTE limits robust interpretation to support clinical guidance.…”

“…There were 3 retrospective cohort studies reporting bleeding events in those with vs without prophylactic anticoagulation during hospitalization. 18,78,79 All bleeding events was defined as the overall number of major and minor bleeds reported in the study. Major bleeding (reported in 2 studies) was defined per the International Society on Thrombosis and Haemostasis.…”

“…87,88 Risk assessment models have been applied successfully to cohorts with cirrhosis in smaller retrospective observational studies. 18,89 Prior prospective RCTs examining anticoagulation for prevention of VTE in medical patients exclude patients with cirrhosis. It remains unclear whether patients with cirrhosis may benefit from medical VTE prophylaxis, given the potential for increased risk of bleeding.…”

“…Yet clinicians must make a choice daily when caring for patients with cirrhosis to administer or withhold VTE prophylaxis. 18 PVT is common in cirrhosis and it is not clear whether detection or treatment affects outcomes. 19 Yet, in certain circumstances, treatment with anticoagulation has been shown to be effective and safe.…”

AGA Clinical Practice Guideline on the Management of Coagulation Disorders in Patients With Cirrhosis

“…Despite clear evidence of increased risk for VTE, hospitalized patients with cirrhosis have not been typically included in most studies of thromboprophylaxis with anticoagulation, and no RCTs were found comparing outcomes of prophylactic anticoagulation in patients with cirrhosis. Review of the literature by the TR identified only 5 retrospective studies [57][58][59][60][61] that examined the risk of thrombotic events in patients with cirrhosis. Given the observational and retrospective design, without welldefined outcomes (all thrombotic events, ie, deep venous thrombosis, pulmonary embolism, and PVT, were considered together) and lack of systematic screening for VTE, the TR team explored data from well-done RCTs in the general medical population, as well as previously published guidelines.…”