Reducing the risk of venous thromboembolism in patients admitted to hospital: summary of NICE guidance

Hill, Jennifer; Treasure, Tom

doi:10.1136/bmj.c95

Cited by 92 publications

(82 citation statements)

References 6 publications

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“…3 Using this estimate, the contemporary offprophylaxis rates are ‫ف‬ 1.8% for symptomatic DVT and 1% for PE for the fi rst 7 to 14 days (the initial prophylaxis period most RCTs used and that correspond to the nonextended prophylaxis period). trials before 2000 used asymptomatic DVT detected by screening tests as a primary end point.…”

Section: Baseline Risk For Vtementioning

confidence: 99%

“…If existing reviews were unavailable or not up to date or the outcomes of interest were not reported, we performed additional analyses. For example, we relied on a recent, well-done systematic review 3 to inform relative effects of low-dose unfractionated heparin (LDUH) vs no prophylaxis because studies were performed in the 1970s and 1980s and critical appraisal of the search strategy made it unlikely that studies would have been missed. However, we performed an update of the same comprehensive literature search for all interventions listed in Table 1 to include the time frame from January 2008 to December 2010.…”

Section: Evaluating and Summarizing Evidencementioning

confidence: 99%

“…This is, however, consistent with a systematic review that estimated the absolute untreated bleeding risk to be between 1% and 2%. 3 Second, we selected the major bleeding event rate for LMWH from a recent review that examined the reporting defi nitions and event rates from the enoxaparin control arm of recent trials. 40 We chose a rate of 1.5%, which was slightly higher than the average (1.4%) and higher than 12 of 14 trials that enrolled .…”

Section: Evaluating and Summarizing Evidencementioning

confidence: 99%

“…A systematic review involving close to 7,000 patients demonstrated a relative risk reduction of 58% (RR, 0.42; 95% CI, 0.36-0.50) in the incidence of asymptomatic DVT found by screening across 57 trials from surgical and nonsurgical populations. 3 Only four of the 12 studies in orthopedic surgery used venography to confi rm thrombotic events; the others used fi brinogen uptake . The relative effect estimates were similar for the eight studies involving .…”

Section: Lduh Vs No Prophylaxis-initial Prophylaxismentioning

confidence: 99%

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Prevention of VTE in Orthopedic Surgery Patients

Falck‐Ytter

Francis²,

Johanson³

et al. 2012

Chest

1,693

963

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Background: VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT. Methods: The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava fi lter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lowerextremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B). Conclusions: Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches. CHEST 2012; 141(2)(Suppl):e278S-e325SAbbreviations: DUS 5 Doppler (or duplex) ultrasonography; GCS 5 graduated compression stockings; HFS 5 hip fracture surgery; INR 5 international normalized ratio; IPCD 5 intermittent pneumatic compression device; IVC 5 inferior vena cava; LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-weight heparin; PE 5 pulmonary embolism; PEP 5 Pulmonary Embolism Prevention trial; RCT 5 randomized controlled trial; RR 5 risk ratio; THA 5 total hip arthroplasty; TKA 5 total knee arthroplasty; UFH 5 unfractionated heparin; VFP 5 venous foot pump; VKA 5 vitamin K antagonist

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Section: Baseline Risk For Vtementioning

confidence: 99%

Section: Evaluating and Summarizing Evidencementioning

confidence: 99%

Section: Evaluating and Summarizing Evidencementioning

confidence: 99%

Section: Lduh Vs No Prophylaxis-initial Prophylaxismentioning

confidence: 99%

See 2 more Smart Citations

Prevention of VTE in Orthopedic Surgery Patients

Falck‐Ytter

Francis²,

Johanson³

et al. 2012

Chest

1,693

963

View full text Add to dashboard Cite

show abstract

“…Primary prevention with thromboprophylactic treatment around orthopedic surgery reduces the risk of non-symptomatic and symptomatic VTE considerably 1,3,4 . International guidelines recommend thromboprophylaxis for patients undergoing total hip replacement (THR) or total knee replacement (TKR) with low molecular weight heparins (LMWHs), fondaparinux, or vitamin K antagonists (VKAs) 1,5,6 . From national and international surveys it seems that most orthopedic patients receive thromboprophylactic therapy with LMWHs [7][8][9][10] .…”

Section: I a L D I S T R I B U T I O N U N A U T H O R I Z E D U S mentioning

confidence: 99%

Economic evaluation of dabigatran etexilate for the primary prevention of venous tromboembolic events following major orthopedic surgery in the Netherlands

Postma

Kappelhoff

Hulst

et al. 2012

Journal of Medical Economics

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c i a l D i s t r i b u t i o n U n a u t h o r i z e d u s e p r o h i b i t e d . A u t h o r i s e d u s e r s c a n d o w n l o a d , d i s p l a y , v i e w a n d p r i n t a s i n g l e c o p y f o r p e r s o n a l u s eJournal of Medical Economics Vol. 15, No. 5, 2012, 878-886 Dabigatran etexilate is a new oral direct thrombin inhibitor for prophylaxis of venous thromboembolism (VTE) in patients who have elective surgery for total hip replacement (THR) or total knee replacement (TKR). Among the advantages of dabigatran etexilate over subcutaneous prophylaxis with Low Molecular Weight Heparin (LMWH) are reduced resource uses for (i) teaching patients to self-inject; (ii) home-care visits for subcutaneous administration; and (iii) absence of heparin-induced thrombocytopenia (HIT). Based on the demonstrated non-inferiority, the aim of this study was to conduct a cost-minimization analysis of oral dabigatran etexilate vs subcutaneous low-molecular weight heparin (LMWH) and fondaparinux from the Dutch healthcare perspective. Methods:A retrospective cohort study was conducted to measure resource use associated with subcutaneous prophylaxis. Results of this study were used in the model to elucidate specific advantages of dabigatran etexilate, next to reduced needs for self-inject teaching and lack of Heparin-Induced Thrombocytopenia. Drug and other resource utilization data were combined with local unit costs. Probabilistic sensitivity analysis was performed to account for uncertainty around relevant parameters included. Results:Home-care visits for subcutaneous administration problems were needed in 9.9% (95% CI ¼ 6.4-13.4) and 9.6% (95% CI ¼ 5.8-13.4) of THR and TKR patients, respectively. Based on costs for 1000 patients treated with dabigatran etexilate vs LMWHs, per patient cost-savings with dabigatran etexilate were estimated at E30.68 (95% CI ¼ 2.01-65.52) and E23.19 (95% CI ¼ 0.69-48.48) for THR and TKR, respectively. The probability that dabigatran etexilate would be cost-saving was estimated at 98.3% and 97.9% for THR and TKR, respectively. These cost-savings were even higher when including fondaparinux in the analysis, with per patient cost-savings of E69.87 (43.42-106.10) and E18.33 (1.63-41.26) for THR and TKR, respectively. Separate calculations for dabigatran etexilate vs nadroparin and dalteparin in THR resulted in probabilities of achieving cost-savings with dabigatran etexilate of 36.2% and 100%, respectively. For TKR these probabilities were estimated at 54.3% and 100%, respectively. Conclusions:Thromboprophylaxis with dabigatran etexilate is cost-saving in patients undergoing THR and TKR from the Dutch healthcare perspective, compared to subcutaneous LMWHs.878 Economic evaluation of dabigatran etexilate Postma et al.

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Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period

Bain

Wilson

Tooher

et al. 2014

Cochrane Database of Systematic Reviews

132

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BackgroundVenous thromboembolism (VTE), although rare, is a major cause of maternal mortality and morbidity, and methods of prophylaxis are therefore often used for women considered to be at risk. This may include women who have given birth by caesarean section, those with a personal or family history of VTE and women with inherited or acquired thrombophilias (conditions that predispose people to thrombosis). Many methods of prophylaxis carry risks of adverse effects, and as the risk of VTE is often low, it is possible that the benefits of thromboprophylaxis may be outweighed by harms. Guidelines for clinical practice have been based on expert opinion rather than high-quality evidence from randomised trials. ObjectivesTo assess the effects of thromboprophylaxis in women who are pregnant or have recently given birth and are at increased risk of VTE on the incidence of VTE and adverse effects of treatment. Search methodsWe searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 November 2013). Selection criteriaRandomised trials comparing one method of thromboprophylaxis with placebo or no treatment, and randomised trials comparing two (or more) methods of thromboprophylaxis. Data collection and analysisAt least two review authors assessed trial eligibility and quality and extracted the data.1 Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period (Review)

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Reducing the risk of venous thromboembolism in patients admitted to hospital: summary of NICE guidance

Cited by 92 publications

References 6 publications

Prevention of VTE in Orthopedic Surgery Patients

Prevention of VTE in Orthopedic Surgery Patients

Economic evaluation of dabigatran etexilate for the primary prevention of venous tromboembolic events following major orthopedic surgery in the Netherlands

Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period

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