A systematic review of venous thromboembolism prophylaxis strategies in patients with renal insufficiency, obesity, or on antiplatelet agents

Abstract

BACKGROUND There is uncertainty about optimal strategies for venous thromboembolism (VTE) prophylaxis among select populations such as patients with renal insufficiency, obesity, or patients taking antiplatelet drugs including aspirin. Their physiologies make prophylaxis particularly challenging. PURPOSE We performed a comparative effectiveness review of the literature on efficacy and safety of VTE prophylaxis in these populations. DATA SOURCES We searched MEDLINE, EMBASE, SCOPUS, CINAHL, International Pharmaceutical Abstracts, http://clinicaltrial.gov, and the Cochrane Library through August 2012. Eligible studies included controlled trials and observational studies. DATA EXTRACTION Two reviewers evaluated studies for eligibility, serially abstracted data, and independently evaluated the risk of bias and strength of evidence supporting interventions to prevent VTE in these populations. RESULTS After a review of 30,902 citations, we identified 9 controlled studies, 5 of which were trials, and the other 4 were observational studies. Five articles addressed prophylaxis of patients with renal insufficiency, 2 addressed obese patients, and 2 addressed patients on antiplatelet agents. No study tested prophylaxis in underweight patients or those with liver disease. The majority of observational studies had a high risk of bias. The strength of evidence ranged from low to insufficient regarding the comparative effectiveness and safety of VTE prophylaxis among these patients. CONCLUSION The current evidence is insufficient regarding optimal VTE prophylaxis for patients with renal insufficiency, obesity, or those who are on antiplatelet drugs including aspirin. High‐quality studies are needed to inform clinicians about the best VTE prophylaxis for these patients. Journal of Hospital Medicine 2013;8:394–401. © 2013 Society of Hospital Medicine

Evaluation of venous thromboembolism prophylaxis in patients with chronic liver disease

“…14,15 Limited studies have evaluated the use of VTE prophylaxis in CLD patients, whether pharmacologic or mechanical. [6][7][8]16 These studies report that the utilization of VTE prophylaxis in CLD patients is suboptimal, with at least 75% of CLD patients receiving no prophylaxis. [6][7][8] The purpose of our study was to examine the use of prophylactic agents and the incidence of VTE and bleeding events in CLD patients.…”

“…Current guidelines for the prevention of VTE do not provide recommendations on the use of prophylaxis in the cirrhotic population, although recent literature reviews suggest that strong consideration for pharmacologic prophylaxis be given when the benefit outweighs the risk . Limited studies have evaluated the use of VTE prophylaxis in CLD patients, whether pharmacologic or mechanical . These studies report that the utilization of VTE prophylaxis in CLD patients is suboptimal, with at least 75% of CLD patients receiving no prophylaxis .…”

Prevention of Venous Thromboembolism in Medical Patients with Thrombocytopenia or with Platelet Dysfunction: The Last 10 Years

“…The evidence regarding prevention of VTE in this patient population is very limited, despite there being an increasing number of patients who are on chronic antiplatelet therapies, and most clinical practice guidelines do not address the care of these patients. 18,64,65 In patients with intermediate/high risk of cardiovascular events (previous cardiovascular event or recent stent implantation) hospitalized for an acute medical condition, it is reasonable to maintain antiplatelet therapy and to add UFH, LMWH, or fondaparinux for VTE prophylaxis. 18,65 In patients at low cardiovascular risk or with a high tendency to bleed, the riskbenefit ratio between cardiovascular recurrence and VTE prevention should be carefully evaluated.…”

“…66,67 The use of IPC devices has shown to prevent DVT, while GCSs do not significantly reduce VTE and are associated with high risk of skin ulceration. 65 Studies in ischemic stroke suggest that, in comparison to placebo, low-to-medium doses of UFH, LMWH, and heparinoids have all been shown to reduce VTE after stroke, in patients on aspirin treatment, although they are associated with an increased risk of bleeding complications. 68,69 The Prevention of VTE after Acute Ischemic Stroke with LMWH (PREVAIL) trial compared enoxaparin 40 mg subcutaneously daily to UFH 5,000 IU every 12 hours, within 48 hours after the event for 10 days (range: 6-10 days) in 1,762 patients with ischemic stroke and unable to walk unassisted.…”

“…18,64,65 In patients with intermediate/high risk of cardiovascular events (previous cardiovascular event or recent stent implantation) hospitalized for an acute medical condition, it is reasonable to maintain antiplatelet therapy and to add UFH, LMWH, or fondaparinux for VTE prophylaxis. 18,65 In patients at low cardiovascular risk or with a high tendency to bleed, the riskbenefit ratio between cardiovascular recurrence and VTE prevention should be carefully evaluated. In these patients, withdrawing aspirin during VTE prophylaxis with UFH, LMWH, or fondaparinux (i.e., during hospitalization or at the time of exposure to newer VTE risk conditions) may be considered.…”