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INTERNAL MEDICINE

Venous Thromboembolism Prevention in Acutely Ill Nonsurgical Patients

Associate Professor of Pharmacy and Medicine, School of Pharmacy, Virginia Commonwealth University, Richmond, VA

John A Dougherty, MBA PharmD

Clinical Coordinator, Pharmacy Department, Orlando Regional Medical Center; Adjunct Assistant Professor, College of Pharmacy, University of Florida, Orlando, FL

James C Garrelts, PharmD

Manager, Clinical Pharmacy Services and Research, Wesley Medical Center, Wichita, KS

Roy C Parish, PharmD BCPS

Professor of Clinical Pharmacy Practice, South University, Savannah, GA

Michael P Rivey, MS BCPS

Professor, Pharmacy Practice, School of Pharmacy, University of Montana, Missoula, MT; Pharmacy Clinical Consultant, Community Medical Center, Missoula

Janice L Stumpf, PharmD

Clinical Pharmacist—Drug Information Service; Clinical Associate Professor, University of Michigan Health System and College of Pharmacy, Ann Arbor, MI

Charles T Taylor, PharmD BCPS

Division Director, Pharmacy Practice; Assistant Dean for Clinical Development, St. Louis College of Pharmacy, St. Louis, MO

A Scott Mathis, PharmD

Clinical Associate Professor, Rutgers, The State University of New Jersey, Ernest Mario School of Pharmacy; Clinical Specialist, Saint Barnabas Medical Center, Livingston, NJ

Reprints: Dr. Mathis, Saint Barnabas Medical Center—Pharmacy, 94 Old Short Hills Rd., Livingston, NJ 07039-5672, fax 973/322-5185, smathis{at}rci.rutgers.edu

Abstract

OBJECTIVE: To review recent advances in the prevention of venous thromboembolism (VTE) in acutely ill nonsurgical inpatients.

DATA SOURCES: A MEDLINE search (1966–March 2005) was done to identify relevant articles relating to prevention of VTE in acutely ill nonsurgical inpatients.

STUDY SELECTION AND DATA EXTRACTION: Four major prophylaxis trials, one registry, one guideline, and supporting articles representative of the subject matter from the last few years were included.

DATA SYNTHESIS: Enoxaparin, dalteparin, fondaparinux, and unfractionated heparin 5000 units every 8 hours are effective in reducing the risk of VTE in acutely ill medical patients, but such prophylaxis is currently underused. Barriers to be overcome include recognition of the importance of VTE in this population, definition of the optimal strategy to assess risks, optimal timing of the risk assessment, optimal prophylactic regimen for a given level of risk or disease state, and optimal duration of prophylaxis. We recommend that acutely ill medical inpatients should be risk-stratified early in their hospitalization. At this time, the specific risk-assessment protocol should be derived from the trial(s) of the available formulary agent(s). Decisions about providing prophylaxis must also be made considering anticoagulant contraindications and renal function. Mechanical methods of prophylaxis should be considered as monotherapy only if an anticoagulant contraindication exists. The optimal duration of prophylaxis is not known, but 14 days was used in recent studies.

CONCLUSIONS: Prophylaxis of VTE in acutely ill medical inpatients is underused. Data provide some guidance for increasing awareness and optimizing patient care.

Key Words: anticoagulants: fondaparinux, heparin, low-molecular-weight heparin, deep vein thrombosis, prophylaxis

Published Online, June 7, 2005. www.theannals.com, DOI 10.1345/aph.1G127