Guidelines VTE DVT prevention therapy is not always appropriate

Updated guidelines from the American College of Chest Physicians for the prevention of venous thromboembolism in conservatively treated patients feature a move toward individualized care.

“Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines” offers more than 600 recommendations for the diagnosis, treatment and prevention of thrombosis.

The guidelines encourage clinicians to consider a patient’s risk for venous thromboembolism (VTE) and deep vein thrombosis (DVT) before administering or prescribing a prevention therapy.

“There has been a significant push in health care to administer DVT prevention for every patient, regardless of risk. As a result, many patients are receiving unnecessary therapies that provide little benefit and could have adverse effects,” Gordon Guyatt, MD, MSc, FRCPC, chair of the guidelines panel stated in a press release. “The decision to administer DVT prevention therapy should be based on the patients’ risk and the benefits of prevention or treatment.”

Notable changes

The new guidelines recommend that acutely ill hospitalized patients at increased risk for thrombosis should receive prophylaxis with low-molecular weight heparin, low-dose unfractionated heparin twice a day or three times a day, or fondaparinux (Grade 1B). The authors also suggest against extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay (Grade 2B) in these patients.

Pharmacologic prophylaxis or mechanical prophylaxis are not recommended for acutely ill hospitalized patients at low risk for thrombosis (Grade 1B).

Patients who are acutely ill, hospitalized, at increased risk for thrombosis, and are bleeding or at a high risk for major bleeding should be treated with mechanical thromboprophylaxis with graduated compression stockings (Grade 2C) or intermittent pneumatic compression (Grade 2C).

For critically ill patients, low-molecular weight heparin or low-dose unfractionated heparin thromboprophylaxis (Grade 2C) are recommended. For those who are bleeding or at high risk for major bleeding, it is recommended that mechanical thromboprophylaxis with graduated compression stockings and/or intermittent pneumatic compression be used at least until the bleeding risk decreases (Grade 2C).

Low-molecular weight heparin or low-dose unfractionated heparin are not recommended for outpatients with cancer who have no additional risk factors for thrombosis (Grade 2B). Prophylactic use of vitamin K agonists is not recommended in this population (Grade 1B).

Discussion

The American College of Chest Physician guidelines are updated every 3 years, M. Hassan Murad, MD, MPH, an associate professor of medicine at Mayo Clinic in Rochester, Minn., and one of the guideline authors told Orthopedics Today’s sister publication HemOnc Today.

“In this case, the changes were not necessarily due to new evidence but rather due to more careful evaluation of existing evidence,” Murad said. “Newer framework and innovations in methodology, evidence-based medicine and guideline development science have occurred.”

The most significant change in the current iteration of guidelines is that evidence supporting anticoagulation to prevent venous thrombosis in medical patients is not as strong as once thought, Murad said.

“We introduced a framework to evaluate a patient’s risk for thrombosis and for bleeding, which is the key adverse effect of the treatment,” he said. “Patients with high risk of thrombosis and low risk for bleeding would benefit the most. It is not a single approach that applies to everyone, and it should be individualized.”

Reference:

Guyatt GH. Chest. 2012;141(2 Suppl):7S-47S.
Disclosure: Guyatt and Murad have no relevant financial disclosures.