Defining Medically Ill Patients for VTE Prophylaxis


Patient factors that can help healthcare professionals determine the appropriateness for administering a direct oral anticoagulant versus heparin for prophylaxis of venous thromboembolism.

Manesh R. Patel, MD: For medically ill patients [who] we’re prophylaxing for venous thromboembolism, there are other options. Enoxaparin or molecular weight heparin as you described is 1, although that’s getting into shortage. Betrixaban and rivaroxaban have indications here; there might be opportunities. If we thought about that, at your institution or other places, how are people thinking about the medically ill population? How are we defining the medically ill population at risk? Is there a specific thing your organization is doing? I can certainly share some of the things we’re thinking about.

Sarah A. Spinler, PharmD, FCCP, FAHA, FASHP, AACC, BCPS, AQ-Cardiology: Sure. I think what has developed over the past 3 years is that in the past the medically ill population was one [that said], “Let’s give prophylaxis to everybody who walks in the door.” Then it was like, “Well, maybe a lot of patients who don’t need prophylaxis are getting it.” So we’ve come back full circle to looking at risk scales or scores. For medical prophylaxis, there [is] the improved score or the Padua score, but basically it’s looking at things like respiratory diseases, COPD [chronic obstructive pulmonary disorder]. Heart failure is a big one [because] such a large proportion of hospitalized patients have heart failure.

In terms of patients with rheumatologic diseases, [they] tend to be at high risk, inflammatory; inflammatory bowel disorders patients tend to be at high risk. There [are] many characteristics, and you can use a risk scale or score. Also in general, critically ill patients tend to be at high risk. Again, those patients are getting a lot of procedures done as well. You’re concerned about using an anticoagulant in those types of patients who are getting procedures.

Manesh R. Patel, MD: Yeah. I certainly think at our place we would probably say, similar to how you think about it, that we have a broad group of people [who] by their sheer nature being in the hospital, you’re medically ill obviously. You may be undergoing a procedure, may have acute coronary syndrome; you may have other reasons you’re getting anticoagulated. But if you were there for heart failure [or] COPD, you have an advanced stage of other comorbidities, you’re certainly going to be a patient for...

Sarah A. Spinler, PharmD, FCCP, FAHA, FASHP, AACC, BCPS, AQ-Cardiology: Sepsis infections.

Manesh R. Patel, MD: ICU [intensive care unit] care that’s not otherwise for coronary disease or at least anticoagulation disease. Those are patients [who] would certainly meet that. Then the data would say to us [that] at least treating those patients both within that hospitalization but prolonged after that hospitalization may have a benefit. There may be other value propositions here, but certainly the drop in the availability of heparins is affecting it.

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