Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients

A review

Michael H. Huo, James Muntz

Research output: Contribution to journalArticle

48 Citations (Scopus)

Abstract

Background: Prophylaxis against venous thromboembolism (VTE) is routinely administered during the hospital stay in at-risk surgical and medical patients. However, in high-risk groups, the risk of deep-vein thrombosis or pulmonary embolism may persist for several weeks after discharge. The standard duration of thromboprophylaxis (6-14 days) may not provide adequate protection against such events. Objective: This article reviews published data on the efficacy and safety profile of extended-duration thromboprophylaxis in patients at high risk for VTE, the potential cost-effectiveness of such treatment, and practical aspects of ensuring an effective transition from the inpatient to the outpatient setting. Methods: MEDLINE and the Cochrane Database of Systematic Reviews were searched through January 2009 for relevant English-language reports of clinical trials, abstracts, and case reports. The search terms included, but were not limited to, venous thromboembolism, pulmonary embolism, anticoagulation, thromboprophylaxis, prolonged duration, and extended duration. The reference lists of the identified articles were reviewed for additional relevant publications. Congress Web sites were also consulted. The principal criteria for inclusion of a study were that it have a prospective, randomized design and include a control group. Case series and retrospective analyses were excluded. Results: Studies have found that extended-duration thromboprophylaxis (28-45 days) with low-molecular-weight heparins (LMWHs) can reduce the risk of VTE in high-risk patients. In separate meta-analyses, extended-duration thromboprophylaxis with LMWH was associated with significant reductions in the likelihood of symptomatic VTE compared with standard-duration thromboprophylaxis in patients undergoing major orthopedic surgery (odds ratio [OR] = 0.38; 95% CI, 0.24-0.61) or major abdominal or pelvic surgery (Peto OR = 0.22; 95% CI, 0.06-0.80). There was large heterogeneity in the reported rates of major and minor bleeding. The occurrence of clinically relevant bleeding events was generally low (<1%), particularly during extended prophylaxis. Extended-duration thromboprophylaxis was cost-effective compared with standard-duration thromboprophylaxis, with increased pharmacy costs offset by reductions in VTE and the associated costs of hospitalization. Conclusions: In high-risk surgical and medical patients, the risk of VTE may extend beyond the period of hospitalization. Such patients may benefit from extended-duration thromboprophylaxis to reduce the risk of late VTE events. LMWHs were efficacious, were associated with low rates of clinically relevant bleeding complications, and were cost-effective in patients at high risk for VTE.

Original languageEnglish (US)
Pages (from-to)1129-1141
Number of pages13
JournalClinical Therapeutics
Volume31
Issue number6
DOIs
StatePublished - Jun 2009

Fingerprint

Low Molecular Weight Heparin
Venous Thromboembolism
Costs and Cost Analysis
Hemorrhage
Pulmonary Embolism
Hospitalization
Odds Ratio
MEDLINE
Venous Thrombosis
Cost-Benefit Analysis
Orthopedics
Publications
Meta-Analysis
Inpatients
Length of Stay
Outpatients
Language
Clinical Trials
Databases
Safety

Keywords

  • heparin
  • low-molecular-weight
  • outpatient
  • prophylaxis
  • thromboembolism
  • venous thrombosis

ASJC Scopus subject areas

  • Pharmacology
  • Pharmacology (medical)

Cite this

@article{5531d54a6a6e43c7a3076dee1d5d329c,
title = "Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: A review",
abstract = "Background: Prophylaxis against venous thromboembolism (VTE) is routinely administered during the hospital stay in at-risk surgical and medical patients. However, in high-risk groups, the risk of deep-vein thrombosis or pulmonary embolism may persist for several weeks after discharge. The standard duration of thromboprophylaxis (6-14 days) may not provide adequate protection against such events. Objective: This article reviews published data on the efficacy and safety profile of extended-duration thromboprophylaxis in patients at high risk for VTE, the potential cost-effectiveness of such treatment, and practical aspects of ensuring an effective transition from the inpatient to the outpatient setting. Methods: MEDLINE and the Cochrane Database of Systematic Reviews were searched through January 2009 for relevant English-language reports of clinical trials, abstracts, and case reports. The search terms included, but were not limited to, venous thromboembolism, pulmonary embolism, anticoagulation, thromboprophylaxis, prolonged duration, and extended duration. The reference lists of the identified articles were reviewed for additional relevant publications. Congress Web sites were also consulted. The principal criteria for inclusion of a study were that it have a prospective, randomized design and include a control group. Case series and retrospective analyses were excluded. Results: Studies have found that extended-duration thromboprophylaxis (28-45 days) with low-molecular-weight heparins (LMWHs) can reduce the risk of VTE in high-risk patients. In separate meta-analyses, extended-duration thromboprophylaxis with LMWH was associated with significant reductions in the likelihood of symptomatic VTE compared with standard-duration thromboprophylaxis in patients undergoing major orthopedic surgery (odds ratio [OR] = 0.38; 95{\%} CI, 0.24-0.61) or major abdominal or pelvic surgery (Peto OR = 0.22; 95{\%} CI, 0.06-0.80). There was large heterogeneity in the reported rates of major and minor bleeding. The occurrence of clinically relevant bleeding events was generally low (<1{\%}), particularly during extended prophylaxis. Extended-duration thromboprophylaxis was cost-effective compared with standard-duration thromboprophylaxis, with increased pharmacy costs offset by reductions in VTE and the associated costs of hospitalization. Conclusions: In high-risk surgical and medical patients, the risk of VTE may extend beyond the period of hospitalization. Such patients may benefit from extended-duration thromboprophylaxis to reduce the risk of late VTE events. LMWHs were efficacious, were associated with low rates of clinically relevant bleeding complications, and were cost-effective in patients at high risk for VTE.",
keywords = "heparin, low-molecular-weight, outpatient, prophylaxis, thromboembolism, venous thrombosis",
author = "Huo, {Michael H.} and James Muntz",
year = "2009",
month = "6",
doi = "10.1016/j.clinthera.2009.06.002",
language = "English (US)",
volume = "31",
pages = "1129--1141",
journal = "Clinical Therapeutics",
issn = "0149-2918",
publisher = "Excerpta Medica",
number = "6",

}

TY - JOUR

T1 - Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients

T2 - A review

AU - Huo, Michael H.

AU - Muntz, James

PY - 2009/6

Y1 - 2009/6

N2 - Background: Prophylaxis against venous thromboembolism (VTE) is routinely administered during the hospital stay in at-risk surgical and medical patients. However, in high-risk groups, the risk of deep-vein thrombosis or pulmonary embolism may persist for several weeks after discharge. The standard duration of thromboprophylaxis (6-14 days) may not provide adequate protection against such events. Objective: This article reviews published data on the efficacy and safety profile of extended-duration thromboprophylaxis in patients at high risk for VTE, the potential cost-effectiveness of such treatment, and practical aspects of ensuring an effective transition from the inpatient to the outpatient setting. Methods: MEDLINE and the Cochrane Database of Systematic Reviews were searched through January 2009 for relevant English-language reports of clinical trials, abstracts, and case reports. The search terms included, but were not limited to, venous thromboembolism, pulmonary embolism, anticoagulation, thromboprophylaxis, prolonged duration, and extended duration. The reference lists of the identified articles were reviewed for additional relevant publications. Congress Web sites were also consulted. The principal criteria for inclusion of a study were that it have a prospective, randomized design and include a control group. Case series and retrospective analyses were excluded. Results: Studies have found that extended-duration thromboprophylaxis (28-45 days) with low-molecular-weight heparins (LMWHs) can reduce the risk of VTE in high-risk patients. In separate meta-analyses, extended-duration thromboprophylaxis with LMWH was associated with significant reductions in the likelihood of symptomatic VTE compared with standard-duration thromboprophylaxis in patients undergoing major orthopedic surgery (odds ratio [OR] = 0.38; 95% CI, 0.24-0.61) or major abdominal or pelvic surgery (Peto OR = 0.22; 95% CI, 0.06-0.80). There was large heterogeneity in the reported rates of major and minor bleeding. The occurrence of clinically relevant bleeding events was generally low (<1%), particularly during extended prophylaxis. Extended-duration thromboprophylaxis was cost-effective compared with standard-duration thromboprophylaxis, with increased pharmacy costs offset by reductions in VTE and the associated costs of hospitalization. Conclusions: In high-risk surgical and medical patients, the risk of VTE may extend beyond the period of hospitalization. Such patients may benefit from extended-duration thromboprophylaxis to reduce the risk of late VTE events. LMWHs were efficacious, were associated with low rates of clinically relevant bleeding complications, and were cost-effective in patients at high risk for VTE.

AB - Background: Prophylaxis against venous thromboembolism (VTE) is routinely administered during the hospital stay in at-risk surgical and medical patients. However, in high-risk groups, the risk of deep-vein thrombosis or pulmonary embolism may persist for several weeks after discharge. The standard duration of thromboprophylaxis (6-14 days) may not provide adequate protection against such events. Objective: This article reviews published data on the efficacy and safety profile of extended-duration thromboprophylaxis in patients at high risk for VTE, the potential cost-effectiveness of such treatment, and practical aspects of ensuring an effective transition from the inpatient to the outpatient setting. Methods: MEDLINE and the Cochrane Database of Systematic Reviews were searched through January 2009 for relevant English-language reports of clinical trials, abstracts, and case reports. The search terms included, but were not limited to, venous thromboembolism, pulmonary embolism, anticoagulation, thromboprophylaxis, prolonged duration, and extended duration. The reference lists of the identified articles were reviewed for additional relevant publications. Congress Web sites were also consulted. The principal criteria for inclusion of a study were that it have a prospective, randomized design and include a control group. Case series and retrospective analyses were excluded. Results: Studies have found that extended-duration thromboprophylaxis (28-45 days) with low-molecular-weight heparins (LMWHs) can reduce the risk of VTE in high-risk patients. In separate meta-analyses, extended-duration thromboprophylaxis with LMWH was associated with significant reductions in the likelihood of symptomatic VTE compared with standard-duration thromboprophylaxis in patients undergoing major orthopedic surgery (odds ratio [OR] = 0.38; 95% CI, 0.24-0.61) or major abdominal or pelvic surgery (Peto OR = 0.22; 95% CI, 0.06-0.80). There was large heterogeneity in the reported rates of major and minor bleeding. The occurrence of clinically relevant bleeding events was generally low (<1%), particularly during extended prophylaxis. Extended-duration thromboprophylaxis was cost-effective compared with standard-duration thromboprophylaxis, with increased pharmacy costs offset by reductions in VTE and the associated costs of hospitalization. Conclusions: In high-risk surgical and medical patients, the risk of VTE may extend beyond the period of hospitalization. Such patients may benefit from extended-duration thromboprophylaxis to reduce the risk of late VTE events. LMWHs were efficacious, were associated with low rates of clinically relevant bleeding complications, and were cost-effective in patients at high risk for VTE.

KW - heparin

KW - low-molecular-weight

KW - outpatient

KW - prophylaxis

KW - thromboembolism

KW - venous thrombosis

UR - http://www.scopus.com/inward/record.url?scp=68649085174&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=68649085174&partnerID=8YFLogxK

U2 - 10.1016/j.clinthera.2009.06.002

DO - 10.1016/j.clinthera.2009.06.002

M3 - Article

VL - 31

SP - 1129

EP - 1141

JO - Clinical Therapeutics

JF - Clinical Therapeutics

SN - 0149-2918

IS - 6

ER -