The Use of Low Molecular Weight Heparin for Venous Thromboembolism Prophylaxis in Medical Patients: How Much Are We Adherent to the Guidelines?

Abstract

Background: Venous thromboembolism (VTE) is a common complication seen during or after hospitalization that manifests as deep venous thrombosis (DVT) and/or pulmonary embolism (PE). PE is considered the commonest preventable cause of death during and/or after hospitalization. Thus, pharmacological and mechanical methods are used to prevent VTE in hospitalized patients. Despite the availability of guidelines for VTE prophylaxis, it is crucial to assess the adherence and adaptation of the institution to these guidelines. Purpose: This study aimed to investigate adherence to the American College of Chest Physicians (ACCP) 2012 VTE prophylaxis guidelines in hospitalized medical patients in a tertiary care hospital in the United Arab Emirates. Methods: An observational prospective design was utilized in this study. To achieve the purpose, primary and secondary end points were identified to be the core of the investigation. The primary end points were: the incidence of bleeding, VTE, and cardiovascular events. While the secondary end points were: dose and indication validity for prophylaxis, VTE and bleeding risk assessments, adverse drug events (ADE) other than bleeding, appropriate monitoring when on low molecular weight heparin (LMWH) and the presence of contraindication at the time of prescribing LMWH. Results: 16 patients (20%) out of the total 80 met one or more of the primary end points. The vast majority of patients (81.25%) developed bleeding, while VTE was seen in one case only during hospitalization. 11 patients (13.75%) received LMWH while a contraindication was present. 15 patients (18.75%) who were prescribed LMWH had an International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score of ≥7. However, 5 out of 13 patients (38.46%) who developed bleeding had a bleeding score of ≥7, and the relationship between bleeding score of ≥7 and the development of bleeding was statistically significant (p = 0.047). When investigating the doses that were utilized, 40% were prescribed an inappropriate dose. L. AlHajri, N. Gebran 82Conclusion: Various factors played a role in the inappropriateness of VTE prophylaxis such as; poor adherence to VTE guidelines, inappropriate dosing and monitoring, and not evaluating the bleeding risk. Hence, to be able to achieve effective VTE prophylaxis, these factors need to be addressed through adherence to and adaptation of the ACCP 2012 VTE prophylaxis guidelines.

Evaluation of the use of low-molecular-weight heparin for venous thromboembolism prophylaxis in medical patients

“…In our analysis, 24 patients were at high VTE risk (according to both guidelines) and also had a contraindication, and 9 (37.5%) of these patients were prescribed LMWH. Compared with AlHajri and Gebran's [22] and Bateman et al's [28] studies, significantly fewer (n=9, 4.4%) of the total number of patients who received LMWH in the present study had a contraindication at the time of prescription.…”

“…[29] This figure was significantly higher than in a smaller cohort study of 80 patients, where 28.8% of patients received LMWH inappropriately based on the same risk predictive score (PPS). [22] Similarly, in our study a total of 37 (30.6%) of the 121 patients at low risk of VTE according to the SA guideline, and a total of 33 (28.5%) of those at low risk according to the PPS, received LMWH. A total of 28/108 (25.9%) who were at low risk of VTE according to both guidelines inappropriately received LMWH.…”

“…We also looked at the prescription of LMWH in patients who had a contraindication to administration of the drug. AlHajri and Gebran [22] reported a prevalence of 13.75% in their cohort, but this was proportional to the total of 80 of their patients who received LMWH (both lowand high-risk patients were included). This proportion was similar to those described by Bateman et al [28] in 2009 and 2010 (14% and 15%, respectively).…”

“…[11,12] It has proved to be safe [1,[13][14][15] and cost-effective and has been widely advocated [16][17][18][19][20] -a strategy that may also prove to have the unwanted consequence of overuse in low-risk patients. [21,22] In an effort to promote the safe and appropriate use of anticoagulants in VTE prophylaxis, both SA and the American College of Chest Physicians (ACCP) have published guidelines aimed at assisting clinicians in decision-making. These guidelines are based on VTE risk stratification and considering the individual bleeding risk.…”

“…[23] Objectives Some previously published non-SA studies recently showed an overall increase in adherence and improvement in the use of pharmacological prophylaxis for high-risk patients. [21,22,24] Our aim was to describe the use of LMWH at an SA tertiary institution based on adherence to local and ACCP guidelines. To achieve this, the primary study objectives were to evaluate: (i) the patients' VTE RESEARCH risk factors, quantifying them according to the PPS and the local guideline; (ii) bleeding risk according to the IMPROVE bleeding risk tool; (iii) the presence of contraindications at the time of prescription, i.e.…”