Prevention Of Venous Thromboembolism

Long-Distance Travel Flights > 8 h

Additional VTE risk factors

Long-distance travelers

Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Thromboprophylaxis

Spine Surgery

Avoidance of constrictive clothing around lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction General measures listed above; consider below-knee GCS (15 to 30 mmHg pressure at ankle), or single LMWH dose prior to departure

Multiple risk factors for VTE

Major thoracic surgery

VTE risk factors and contraindication to anticoagulant

GCS or IPC

Major trauma

High thrombosis risk Spinal Cord Injury (SCI) For acute SCI

High risk of bleeding Trauma

Thromboprophylaxis IPC Alternatives: > Postoperative LMWH or LDUH GCS and/or IPC combined with postoperative LMWH or LDUH Thromboprophylaxis LMWH (commenced once primary hemostasis evident) Alternatives: > Combined use of IPC and either LDUH or LMWH > If anticoagulant contraindicated because of high bleeding risk, use IPC and/or GCS; when bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for spinal hematoma on CT or MRI first few days For patients with SCI Rehabilitation following acute SCI

5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h

LMWH, LDUH, or fondaparinux Thromboprophylaxis

IPC or possibly GCS; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Trauma

> Recommend against routine DUS screening for asymptomatic DVT > Recommend DUS screening in high VTE risk (eg, SCI, lower-extremity or pelvic fracture, or major head injury) and suboptimal or no thromboprophylaxis > Recommend against use of IVC filter as primary prophylaxis

Urologic Surgery

Thromboprophylaxis

Transurethral or other low-risk urologic procedures

Early and frequent ambulation

Major open procedures

LDUH bid or tid, GCS and/or IPC just before surgery and used continuously while not ambulating, LMWH, fondaparinux, or combination pharmacologic (ie, LMWH, LDUH, or fondaparinux) with mechanical method (ie, GCS and/or IPC)

For patients actively bleeding or at very high-risk for bleeding Vascular Surgery

fondaparinux (Arixtra®)4

GCS and/or IPC LMWH (starting when considered safe to do so) > Continuation until hospital discharge > For impaired mobility during inpatient rehabilitation, continue LMWH or VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: > Combination LMWH and mechanical method

Optimal use of mechanical method with GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method Early and frequent ambulation

Undergoing major procedure with additional risk factors

LMWH, LDUH, or fondaparinux

Abdominal surgery Hip fracture surgery Hip replacement surgery Knee replacement surgery

2.5 mg SC once daily with initial dose 6 - 8 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): contraindicated

10 mg PO once daily with initial dose 6 - 10 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): not recommended

Hip replacement surgery Knee replacement surgery

Low-Molecular-Weight Heparins (LMWH) dalteparin (Fragmin®)6

Abdominal surgery

2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily

High risk of thromboembolic complications

Medical patients

5000 IU SC evening before surgery, then once daily 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, then 5000 IU SC once daily 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 5000 IU SC once daily

Abdominal surgery

40 mg SC once daily with initial dose 2 h prior to surgery

Hip replacement surgery Knee replacement surgery Medical patients

30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) 30 mg SC every 12 h 40 mg SC once daily

General surgery

2850 IU SC once daily, initial dose 2 - 4 h before surgery

Hip replacement surgery

38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4

General surgery

3500 IU SC 2 h before surgery, then 3500 IU once daily

Hip surgery

50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily or 75 IU/kg SC given post-operatively once daily

Knee surgery

75 IU/kg SC given post-operatively once daily

Alternative in malignancy Hip replacement surgery: Preoperative start - evening before surgery Preoperative start - day of surgery Postoperative start enoxaparin (Lovenox®, Clexane®)7

nadroparin (Fraxiparine®)8

tinzaparin (Innohep®)9

This Pocketcard edition is intended for the European and Canadian healthcare communities and contains only the European Medicines Agency (EMEA) and the Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.

Acenocoumarol (Sintrom®)10

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Warfarin (Coumadin )

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Abbreviations bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF, congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS, Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery; INR, international normalized ratio; IPC, intermittent pneumatic compression; IU, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT, prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement; tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump; VKA, vitamin K antagonist; VTE, venous thromboembolism

Prevention of Venous Thromboembolism (for use in Europe and Canada)

Expert Reviewer: William Geerts, MD, FRCPC

Severe renal dysfunction (CrCl < 30 mL/min): monitor anti-Xa levels to determine the appropriate dose

Severe renal dysfunction (CrCl < 30 mL/min): 30 mg SC once daily Severe renal dysfunction (CrCl < 30 mL/min): Reduce dose by 25 - 33% Severe renal dysfunction (CrCl < 30 mL/min): Consider dosage reduction

Vitamin K Antagonist (VKA) ® 11

INR target of 2.5 (INR range, 2.0 to 3.0) Fold

Fold

Fold

Fold

13662S R3 VTE Prevention.indd 1

110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated

Oral Direct Factor Xa Inhibitor rivaroxaban (Xarelto®)5

Thromboprophylaxis

No additional risk factors

Comments

Indirect Factor Xa Inhibitor

Thromboprophylaxis

Major trauma if LMWH contraindicated

Recommend against the use of IVC filter as primary prophylaxis Continuation of LMWH or conversion to oral VKA (INR target, 2.5; INR range 2.0 to 3.0)

Low-dose regimen for major abdominothoracic surgery

Postoperative LDUH, postoperative LMWH, or Oral Direct Thrombin Inhibitor perioperative IPC (Alternative: GCS) > VTE risk factors: advanced age, malignancy, presence of dabigatran Hip replacement surgery neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Pharmacologic prophylaxis (LDUH or LMWH) combined Knee replacement surgery with mechanical method (GCS and/or IPC)

LMWH, LDUH, or fondaparinux > Risk factors: active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease

Major neurosurgery

Dosage and Administration

Additional VTE risk

Acutely ill medical patients with CHF, severe respiratory disease, confined to bed, or ≥ 1 risk factors

Neurosurgery

Prophylaxis Indication

Early and frequent ambulation

Thoracic Surgery

Thromboprophylaxis

Drug Low Dose Unfractionated Heparin2 (LDUH)

Thromboprophylaxis

No additional VTE risk factors

Recommend against the use of aspirin for VTE prevention

Medical Conditions

Fold

Fold

Fold

Fold

Group Specific Thromboprophylaxis

Thromboembolism Program

References 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:381S-453S. 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008. 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008. 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008. 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007. 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007. 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008. 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008. 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007. 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.

Sunnybrook Health Sciences Centre University of Toronto

Rationale for Thromboprophylaxis General Risk Groups and Recommendations Group Specific Thromboprophylaxis Manufacturer Prescribing Information

Disclaimer This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgement concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. 5740 Executive Drive Suite 220 • Baltimore, MD 21228 TEL: 410-869-3332 • FAX: 410-744-2150 Orders and inquiries: [email protected] Copyright © 2009 All rights reserved For additional copies: www.myguidelinescenter.com

For additional copies: [email protected]

3/19/09 10:10:56 AM

ÎÎThe rationale for use of thromboprophylaxis is based on solid principles and scientific evidence (Table 1).

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors (see Table 2).

Table 1. Rationale for Thromboprophylaxis  in Hospitalized Patients

Table 2. Risk Factors for VTE Surgery

I. High prevalence of venous thromboembolism (VTE)

Trauma (major trauma or lower-extremity injury) Immobility, lower-extremity paresis Cancer Cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy) Venous compression (tumor, hematoma, arterial abnormality) Previous VTE Increasing age Pregnancy and the postpartum period

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent ÎÎIt is impossible to predict which at-risk patients will develop symptomatic thromboembolic complications ÎÎScreening at-risk patients using physical examination or noninvasive testing is neither cost-effective nor effective

II. Adverse consequences of unprevented VTE

Estrogen-containing oral contraceptives or hormone replacement

ÎÎSymptomatic DVT and PE ÎÎFatal PE ÎÎCosts of investigating symptomatic patients ÎÎRisks and costs of treating unprevented VTE ÎÎIncreased future risk of recurrent VTE

ÎÎImplement group-specific thromboprophylaxis routinely for all patients who belong to each of the major target groups.

Low Risk

Inpatient surgery

Minor surgery in mobile patients

Erythropoiesis-stimulating agents Acute medical illness Inflammatory bowel disease

Table 3. Approximate Risks of DVT in Hospitalized Patients* Patient Group

III. Efficacy and effectiveness of thromboprophylaxis

Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical care patients

ÎÎThromboprophylaxis is highly efficacious at preventing DVT and proximal DVT ÎÎThromboprophylaxis is highly effective at preventing symptomatic VTE and fatal PE ÎÎThe prevention of DVT also prevents PE ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Medical patients, bed rest or sick

Approximate DVT risk without thromboprophylaxis 10-40%

Moderate VTE risk plus high bleeding risk

LDUH bid or tid fondaparinux Mechanical

High Risk

DVT Prevalence, % 10 - 20 15 - 40 15 - 40 15 - 40 15 - 40 20 - 50 40 - 60 40 - 80 60 - 80 10 - 80

Early and “aggressive” ambulation

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Hip or knee arthroplasty, hip fracture surgery

fondaparinux Major trauma, Spinal cord injury

Bariatric Surgery

Burns

Approximate DVT risk without thromboprophylaxis 40-80%

High VTE risk plus high bleeding risk

Oral Factor Xa inhibitor (rivaroxaban*) Oral direct thrombin inhibitor (dabigatran*)

General Surgery

Thromboprophylaxis LMWH, LDUH tid, fondaparinux, or combination of pharmacologic prophylaxis with IPC >> Higher doses of LMWH or LDUH than for nonobese Thromboprophylaxis

Early and frequent ambulation

Major procedure for benign disease

LMWH, LDUH, or fondaparinux

Major procedure for cancer

LMWH, LDUH tid, or fondaparinux

Multiple risk factors

LMWH, LDUH tid, or fondaparinux combined with GCS and/or IPC

High risk of bleeding

GCS or IPC

High risk of bleeding

GCS and/or IPC until bleeding risk decreases

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d

Thromboprophylaxis

Surgical procedures

Refer to relevant surgical subsections

Bedridden with acute medical illness

Refer to high-risk medical patients

Indwelling central venous catheters

Do not use either prophylactic doses of LMWH or minidose warfarin to prevent catheter-related thrombosis

Receiving chemotherapy or hormonal therapy

Recommend against routine thromboprophylaxis for primary prevention of VTE

For cancer patients

Recommend against routine primary thromboprophylaxis to improve survival

Gynecologic Surgery

Early and frequent ambulation

Laparoscopic procedure

Early and frequent ambulation

Laparoscopic procedure with additional VTE risk factors

LMWH, LDUH, IPC, or GCS

Thromboprophylaxis

Major gynecologic surgery for benign disease without additional risk factors

LMWH, LDUH, or IPC started just before surgery and used continuously while not ambulating

CABG surgery

LMWH, LDUH, or bilateral GCS or IPC >> Suggest use of LMWH over LDUH to try to reduce risk of heparin-induced thrombocytopenia (HIT)

High risk of bleeding

Properly fitted bilateral GCS or IPC

Extensive surgery for malignancy and for patients with additional VTE risk factors

LMWH, or LDUH tid, or IPC started just before surgery and used continuously while not ambulating Alternatives: Combination LMWH or LDUH plus GCS or IPC fondaparinux

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d 

Coronary Artery Bypass Graft (CABG) Surgery

Critical Care

Thromboprophylaxis

Moderate risk for VTE

LMWH or LDUH >> VTE risk factors: medically ill or postoperative general surgery

Higher risk

LMWH >> VTE risk factors: following major trauma or orthopedic surgery

High risk of bleeding

Oral VKA (acenocoumarol, warfarin)

Hip Fracture Surgery (HFS) HFS

GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method

Total Hip Replacement (THR)

Surgery likely to be delayed

LMWH or LDUH initiated during time between admission and surgery

High risk of bleeding

Optimal use of mechanical methods; when high bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Thromboprophylaxis Options: >> LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA started preoperatively or the evening of the surgical day (INR target, 2.5; INR range, 2.0 to 3.0) Recommend against use of the following alone: aspirin, dextran, LDUH, GCS, or VFP

High risk of bleeding

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Knee Arthroscopy

Thromboprophylaxis

No additional risk factors

Early mobilization if appropraite

Additional risk factors or complicated procedure

LMWH

Knee Replacement Total Knee Replacement (TKR)

Thromboprophylaxis Options: >> LMWH (at usual high-risk dose) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: >> IPC Recommend against use of the following alone: aspirin, LDUH, or VFP

High risk of bleeding

Thromboprophylaxis fondaparinux, LMWH, adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0), or LDUH Recommend against use of aspirin alone

Fold

Fold

Hip Replacement

Thromboprophylaxis

Low-risk minor procedures and no risk factors

*Indicated for elective hip and knee replacement surgery. Fold

Fold

13662S R3 VTE Prevention.indd 2

Minor procedures and no risk factors

LMWH or LDUH >> VTE risk factors: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lowerextremity trauma, femoral venous catheter, and/or prolonged immobility

Mechanical * Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis.

Thromboprophylaxis

Burn patients with additional VTE risk factors

Cancer Patients

Most general, open gynecologic or urologic surgery patients

Inherited or acquired thrombophilia

Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10 to 40% among medical or general surgical patients and 40 to 60% following major orthopedic surgery (Table 3) ÎÎ Approximately 70% of all VTE is hospital acquired Therefore, prevention of VTE in hospital patients is the most appropriate method to reduce the burden of this disease

No specific thromboprophylaxis

Moderate Risk

ÎÎ

ÎÎChronic post-thrombotic syndrome

Approximate DVT risk without thromboprophylaxis < 10%

Medical patients who are fully mobile

Nephrotic syndrome

Paroxysmal nocturnal hemoglobinuria Obesity Central venous catheterization

Group Specific Thromboprophylaxis1

ÎÎSimplification of classification system to readily identify the general patient risk group and general thromboprophylaxis recommendations.

Selective estrogen receptor modulators

Myeloproliferative disorders

Fold

Fold

Fold

Fold

General Risk Groups and Recommendations1

Rationale for Thromboprophylaxis1

Laparoscopic Surgery

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method Thromboprophylaxis

No additional risk factors

Early and frequent ambulation

Additional VTE risk factors

LMWH, LDUH, fondaparinux, IPC, or GCS

*Indicated for elective hip and knee replacement surgery.

3/19/09 10:10:57 AM

ÎÎThe rationale for use of thromboprophylaxis is based on solid principles and scientific evidence (Table 1).

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors (see Table 2).

Table 1. Rationale for Thromboprophylaxis  in Hospitalized Patients

Table 2. Risk Factors for VTE Surgery

I. High prevalence of venous thromboembolism (VTE)

Trauma (major trauma or lower-extremity injury) Immobility, lower-extremity paresis Cancer Cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy) Venous compression (tumor, hematoma, arterial abnormality) Previous VTE Increasing age Pregnancy and the postpartum period

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent ÎÎIt is impossible to predict which at-risk patients will develop symptomatic thromboembolic complications ÎÎScreening at-risk patients using physical examination or noninvasive testing is neither cost-effective nor effective

II. Adverse consequences of unprevented VTE

Estrogen-containing oral contraceptives or hormone replacement

ÎÎSymptomatic DVT and PE ÎÎFatal PE ÎÎCosts of investigating symptomatic patients ÎÎRisks and costs of treating unprevented VTE ÎÎIncreased future risk of recurrent VTE

ÎÎImplement group-specific thromboprophylaxis routinely for all patients who belong to each of the major target groups.

Low Risk

Inpatient surgery

Minor surgery in mobile patients

Erythropoiesis-stimulating agents Acute medical illness Inflammatory bowel disease

Table 3. Approximate Risks of DVT in Hospitalized Patients* Patient Group

III. Efficacy and effectiveness of thromboprophylaxis

Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical care patients

ÎÎThromboprophylaxis is highly efficacious at preventing DVT and proximal DVT ÎÎThromboprophylaxis is highly effective at preventing symptomatic VTE and fatal PE ÎÎThe prevention of DVT also prevents PE ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Medical patients, bed rest or sick

Approximate DVT risk without thromboprophylaxis 10-40%

Moderate VTE risk plus high bleeding risk

LDUH bid or tid fondaparinux Mechanical

High Risk

DVT Prevalence, % 10 - 20 15 - 40 15 - 40 15 - 40 15 - 40 20 - 50 40 - 60 40 - 80 60 - 80 10 - 80

Early and “aggressive” ambulation

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Hip or knee arthroplasty, hip fracture surgery

fondaparinux Major trauma, Spinal cord injury

Bariatric Surgery

Burns

Approximate DVT risk without thromboprophylaxis 40-80%

High VTE risk plus high bleeding risk

Oral Factor Xa inhibitor (rivaroxaban*) Oral direct thrombin inhibitor (dabigatran*)

General Surgery

Thromboprophylaxis LMWH, LDUH tid, fondaparinux, or combination of pharmacologic prophylaxis with IPC >> Higher doses of LMWH or LDUH than for nonobese Thromboprophylaxis

Early and frequent ambulation

Major procedure for benign disease

LMWH, LDUH, or fondaparinux

Major procedure for cancer

LMWH, LDUH tid, or fondaparinux

Multiple risk factors

LMWH, LDUH tid, or fondaparinux combined with GCS and/or IPC

High risk of bleeding

GCS or IPC

High risk of bleeding

GCS and/or IPC until bleeding risk decreases

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d

Thromboprophylaxis

Surgical procedures

Refer to relevant surgical subsections

Bedridden with acute medical illness

Refer to high-risk medical patients

Indwelling central venous catheters

Do not use either prophylactic doses of LMWH or minidose warfarin to prevent catheter-related thrombosis

Receiving chemotherapy or hormonal therapy

Recommend against routine thromboprophylaxis for primary prevention of VTE

For cancer patients

Recommend against routine primary thromboprophylaxis to improve survival

Gynecologic Surgery

Early and frequent ambulation

Laparoscopic procedure

Early and frequent ambulation

Laparoscopic procedure with additional VTE risk factors

LMWH, LDUH, IPC, or GCS

Thromboprophylaxis

Major gynecologic surgery for benign disease without additional risk factors

LMWH, LDUH, or IPC started just before surgery and used continuously while not ambulating

CABG surgery

LMWH, LDUH, or bilateral GCS or IPC >> Suggest use of LMWH over LDUH to try to reduce risk of heparin-induced thrombocytopenia (HIT)

High risk of bleeding

Properly fitted bilateral GCS or IPC

Extensive surgery for malignancy and for patients with additional VTE risk factors

LMWH, or LDUH tid, or IPC started just before surgery and used continuously while not ambulating Alternatives: Combination LMWH or LDUH plus GCS or IPC fondaparinux

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d 

Coronary Artery Bypass Graft (CABG) Surgery

Critical Care

Thromboprophylaxis

Moderate risk for VTE

LMWH or LDUH >> VTE risk factors: medically ill or postoperative general surgery

Higher risk

LMWH >> VTE risk factors: following major trauma or orthopedic surgery

High risk of bleeding

Oral VKA (acenocoumarol, warfarin)

Hip Fracture Surgery (HFS) HFS

GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method

Total Hip Replacement (THR)

Surgery likely to be delayed

LMWH or LDUH initiated during time between admission and surgery

High risk of bleeding

Optimal use of mechanical methods; when high bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Thromboprophylaxis Options: >> LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA started preoperatively or the evening of the surgical day (INR target, 2.5; INR range, 2.0 to 3.0) Recommend against use of the following alone: aspirin, dextran, LDUH, GCS, or VFP

High risk of bleeding

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Knee Arthroscopy

Thromboprophylaxis

No additional risk factors

Early mobilization if appropraite

Additional risk factors or complicated procedure

LMWH

Knee Replacement Total Knee Replacement (TKR)

Thromboprophylaxis Options: >> LMWH (at usual high-risk dose) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: >> IPC Recommend against use of the following alone: aspirin, LDUH, or VFP

High risk of bleeding

Thromboprophylaxis fondaparinux, LMWH, adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0), or LDUH Recommend against use of aspirin alone

Fold

Fold

Hip Replacement

Thromboprophylaxis

Low-risk minor procedures and no risk factors

*Indicated for elective hip and knee replacement surgery. Fold

Fold

13662S R3 VTE Prevention.indd 2

Minor procedures and no risk factors

LMWH or LDUH >> VTE risk factors: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lowerextremity trauma, femoral venous catheter, and/or prolonged immobility

Mechanical * Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis.

Thromboprophylaxis

Burn patients with additional VTE risk factors

Cancer Patients

Most general, open gynecologic or urologic surgery patients

Inherited or acquired thrombophilia

Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10 to 40% among medical or general surgical patients and 40 to 60% following major orthopedic surgery (Table 3) ÎÎ Approximately 70% of all VTE is hospital acquired Therefore, prevention of VTE in hospital patients is the most appropriate method to reduce the burden of this disease

No specific thromboprophylaxis

Moderate Risk

ÎÎ

ÎÎChronic post-thrombotic syndrome

Approximate DVT risk without thromboprophylaxis < 10%

Medical patients who are fully mobile

Nephrotic syndrome

Paroxysmal nocturnal hemoglobinuria Obesity Central venous catheterization

Group Specific Thromboprophylaxis1

ÎÎSimplification of classification system to readily identify the general patient risk group and general thromboprophylaxis recommendations.

Selective estrogen receptor modulators

Myeloproliferative disorders

Fold

Fold

Fold

Fold

General Risk Groups and Recommendations1

Rationale for Thromboprophylaxis1

Laparoscopic Surgery

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method Thromboprophylaxis

No additional risk factors

Early and frequent ambulation

Additional VTE risk factors

LMWH, LDUH, fondaparinux, IPC, or GCS

*Indicated for elective hip and knee replacement surgery.

3/19/09 10:10:57 AM

ÎÎThe rationale for use of thromboprophylaxis is based on solid principles and scientific evidence (Table 1).

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors (see Table 2).

Table 1. Rationale for Thromboprophylaxis  in Hospitalized Patients

Table 2. Risk Factors for VTE Surgery

I. High prevalence of venous thromboembolism (VTE)

Trauma (major trauma or lower-extremity injury) Immobility, lower-extremity paresis Cancer Cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy) Venous compression (tumor, hematoma, arterial abnormality) Previous VTE Increasing age Pregnancy and the postpartum period

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent ÎÎIt is impossible to predict which at-risk patients will develop symptomatic thromboembolic complications ÎÎScreening at-risk patients using physical examination or noninvasive testing is neither cost-effective nor effective

II. Adverse consequences of unprevented VTE

Estrogen-containing oral contraceptives or hormone replacement

ÎÎSymptomatic DVT and PE ÎÎFatal PE ÎÎCosts of investigating symptomatic patients ÎÎRisks and costs of treating unprevented VTE ÎÎIncreased future risk of recurrent VTE

ÎÎImplement group-specific thromboprophylaxis routinely for all patients who belong to each of the major target groups.

Low Risk

Inpatient surgery

Minor surgery in mobile patients

Erythropoiesis-stimulating agents Acute medical illness Inflammatory bowel disease

Table 3. Approximate Risks of DVT in Hospitalized Patients* Patient Group

III. Efficacy and effectiveness of thromboprophylaxis

Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical care patients

ÎÎThromboprophylaxis is highly efficacious at preventing DVT and proximal DVT ÎÎThromboprophylaxis is highly effective at preventing symptomatic VTE and fatal PE ÎÎThe prevention of DVT also prevents PE ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Medical patients, bed rest or sick

Approximate DVT risk without thromboprophylaxis 10-40%

Moderate VTE risk plus high bleeding risk

LDUH bid or tid fondaparinux Mechanical

High Risk

DVT Prevalence, % 10 - 20 15 - 40 15 - 40 15 - 40 15 - 40 20 - 50 40 - 60 40 - 80 60 - 80 10 - 80

Early and “aggressive” ambulation

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Hip or knee arthroplasty, hip fracture surgery

fondaparinux Major trauma, Spinal cord injury

Bariatric Surgery

Burns

Approximate DVT risk without thromboprophylaxis 40-80%

High VTE risk plus high bleeding risk

Oral Factor Xa inhibitor (rivaroxaban*) Oral direct thrombin inhibitor (dabigatran*)

General Surgery

Thromboprophylaxis LMWH, LDUH tid, fondaparinux, or combination of pharmacologic prophylaxis with IPC >> Higher doses of LMWH or LDUH than for nonobese Thromboprophylaxis

Early and frequent ambulation

Major procedure for benign disease

LMWH, LDUH, or fondaparinux

Major procedure for cancer

LMWH, LDUH tid, or fondaparinux

Multiple risk factors

LMWH, LDUH tid, or fondaparinux combined with GCS and/or IPC

High risk of bleeding

GCS or IPC

High risk of bleeding

GCS and/or IPC until bleeding risk decreases

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d

Thromboprophylaxis

Surgical procedures

Refer to relevant surgical subsections

Bedridden with acute medical illness

Refer to high-risk medical patients

Indwelling central venous catheters

Do not use either prophylactic doses of LMWH or minidose warfarin to prevent catheter-related thrombosis

Receiving chemotherapy or hormonal therapy

Recommend against routine thromboprophylaxis for primary prevention of VTE

For cancer patients

Recommend against routine primary thromboprophylaxis to improve survival

Gynecologic Surgery

Early and frequent ambulation

Laparoscopic procedure

Early and frequent ambulation

Laparoscopic procedure with additional VTE risk factors

LMWH, LDUH, IPC, or GCS

Thromboprophylaxis

Major gynecologic surgery for benign disease without additional risk factors

LMWH, LDUH, or IPC started just before surgery and used continuously while not ambulating

CABG surgery

LMWH, LDUH, or bilateral GCS or IPC >> Suggest use of LMWH over LDUH to try to reduce risk of heparin-induced thrombocytopenia (HIT)

High risk of bleeding

Properly fitted bilateral GCS or IPC

Extensive surgery for malignancy and for patients with additional VTE risk factors

LMWH, or LDUH tid, or IPC started just before surgery and used continuously while not ambulating Alternatives: Combination LMWH or LDUH plus GCS or IPC fondaparinux

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d 

Coronary Artery Bypass Graft (CABG) Surgery

Critical Care

Thromboprophylaxis

Moderate risk for VTE

LMWH or LDUH >> VTE risk factors: medically ill or postoperative general surgery

Higher risk

LMWH >> VTE risk factors: following major trauma or orthopedic surgery

High risk of bleeding

Oral VKA (acenocoumarol, warfarin)

Hip Fracture Surgery (HFS) HFS

GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method

Total Hip Replacement (THR)

Surgery likely to be delayed

LMWH or LDUH initiated during time between admission and surgery

High risk of bleeding

Optimal use of mechanical methods; when high bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Thromboprophylaxis Options: >> LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA started preoperatively or the evening of the surgical day (INR target, 2.5; INR range, 2.0 to 3.0) Recommend against use of the following alone: aspirin, dextran, LDUH, GCS, or VFP

High risk of bleeding

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Knee Arthroscopy

Thromboprophylaxis

No additional risk factors

Early mobilization if appropraite

Additional risk factors or complicated procedure

LMWH

Knee Replacement Total Knee Replacement (TKR)

Thromboprophylaxis Options: >> LMWH (at usual high-risk dose) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: >> IPC Recommend against use of the following alone: aspirin, LDUH, or VFP

High risk of bleeding

Thromboprophylaxis fondaparinux, LMWH, adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0), or LDUH Recommend against use of aspirin alone

Fold

Fold

Hip Replacement

Thromboprophylaxis

Low-risk minor procedures and no risk factors

*Indicated for elective hip and knee replacement surgery. Fold

Fold

13662S R3 VTE Prevention.indd 2

Minor procedures and no risk factors

LMWH or LDUH >> VTE risk factors: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lowerextremity trauma, femoral venous catheter, and/or prolonged immobility

Mechanical * Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis.

Thromboprophylaxis

Burn patients with additional VTE risk factors

Cancer Patients

Most general, open gynecologic or urologic surgery patients

Inherited or acquired thrombophilia

Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10 to 40% among medical or general surgical patients and 40 to 60% following major orthopedic surgery (Table 3) ÎÎ Approximately 70% of all VTE is hospital acquired Therefore, prevention of VTE in hospital patients is the most appropriate method to reduce the burden of this disease

No specific thromboprophylaxis

Moderate Risk

ÎÎ

ÎÎChronic post-thrombotic syndrome

Approximate DVT risk without thromboprophylaxis < 10%

Medical patients who are fully mobile

Nephrotic syndrome

Paroxysmal nocturnal hemoglobinuria Obesity Central venous catheterization

Group Specific Thromboprophylaxis1

ÎÎSimplification of classification system to readily identify the general patient risk group and general thromboprophylaxis recommendations.

Selective estrogen receptor modulators

Myeloproliferative disorders

Fold

Fold

Fold

Fold

General Risk Groups and Recommendations1

Rationale for Thromboprophylaxis1

Laparoscopic Surgery

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method Thromboprophylaxis

No additional risk factors

Early and frequent ambulation

Additional VTE risk factors

LMWH, LDUH, fondaparinux, IPC, or GCS

*Indicated for elective hip and knee replacement surgery.

3/19/09 10:10:57 AM

ÎÎThe rationale for use of thromboprophylaxis is based on solid principles and scientific evidence (Table 1).

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors (see Table 2).

Table 1. Rationale for Thromboprophylaxis  in Hospitalized Patients

Table 2. Risk Factors for VTE Surgery

I. High prevalence of venous thromboembolism (VTE)

Trauma (major trauma or lower-extremity injury) Immobility, lower-extremity paresis Cancer Cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy) Venous compression (tumor, hematoma, arterial abnormality) Previous VTE Increasing age Pregnancy and the postpartum period

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent ÎÎIt is impossible to predict which at-risk patients will develop symptomatic thromboembolic complications ÎÎScreening at-risk patients using physical examination or noninvasive testing is neither cost-effective nor effective

II. Adverse consequences of unprevented VTE

Estrogen-containing oral contraceptives or hormone replacement

ÎÎSymptomatic DVT and PE ÎÎFatal PE ÎÎCosts of investigating symptomatic patients ÎÎRisks and costs of treating unprevented VTE ÎÎIncreased future risk of recurrent VTE

ÎÎImplement group-specific thromboprophylaxis routinely for all patients who belong to each of the major target groups.

Low Risk

Inpatient surgery

Minor surgery in mobile patients

Erythropoiesis-stimulating agents Acute medical illness Inflammatory bowel disease

Table 3. Approximate Risks of DVT in Hospitalized Patients* Patient Group

III. Efficacy and effectiveness of thromboprophylaxis

Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical care patients

ÎÎThromboprophylaxis is highly efficacious at preventing DVT and proximal DVT ÎÎThromboprophylaxis is highly effective at preventing symptomatic VTE and fatal PE ÎÎThe prevention of DVT also prevents PE ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Medical patients, bed rest or sick

Approximate DVT risk without thromboprophylaxis 10-40%

Moderate VTE risk plus high bleeding risk

LDUH bid or tid fondaparinux Mechanical

High Risk

DVT Prevalence, % 10 - 20 15 - 40 15 - 40 15 - 40 15 - 40 20 - 50 40 - 60 40 - 80 60 - 80 10 - 80

Early and “aggressive” ambulation

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Hip or knee arthroplasty, hip fracture surgery

fondaparinux Major trauma, Spinal cord injury

Bariatric Surgery

Burns

Approximate DVT risk without thromboprophylaxis 40-80%

High VTE risk plus high bleeding risk

Oral Factor Xa inhibitor (rivaroxaban*) Oral direct thrombin inhibitor (dabigatran*)

General Surgery

Thromboprophylaxis LMWH, LDUH tid, fondaparinux, or combination of pharmacologic prophylaxis with IPC >> Higher doses of LMWH or LDUH than for nonobese Thromboprophylaxis

Early and frequent ambulation

Major procedure for benign disease

LMWH, LDUH, or fondaparinux

Major procedure for cancer

LMWH, LDUH tid, or fondaparinux

Multiple risk factors

LMWH, LDUH tid, or fondaparinux combined with GCS and/or IPC

High risk of bleeding

GCS or IPC

High risk of bleeding

GCS and/or IPC until bleeding risk decreases

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d

Thromboprophylaxis

Surgical procedures

Refer to relevant surgical subsections

Bedridden with acute medical illness

Refer to high-risk medical patients

Indwelling central venous catheters

Do not use either prophylactic doses of LMWH or minidose warfarin to prevent catheter-related thrombosis

Receiving chemotherapy or hormonal therapy

Recommend against routine thromboprophylaxis for primary prevention of VTE

For cancer patients

Recommend against routine primary thromboprophylaxis to improve survival

Gynecologic Surgery

Early and frequent ambulation

Laparoscopic procedure

Early and frequent ambulation

Laparoscopic procedure with additional VTE risk factors

LMWH, LDUH, IPC, or GCS

Thromboprophylaxis

Major gynecologic surgery for benign disease without additional risk factors

LMWH, LDUH, or IPC started just before surgery and used continuously while not ambulating

CABG surgery

LMWH, LDUH, or bilateral GCS or IPC >> Suggest use of LMWH over LDUH to try to reduce risk of heparin-induced thrombocytopenia (HIT)

High risk of bleeding

Properly fitted bilateral GCS or IPC

Extensive surgery for malignancy and for patients with additional VTE risk factors

LMWH, or LDUH tid, or IPC started just before surgery and used continuously while not ambulating Alternatives: Combination LMWH or LDUH plus GCS or IPC fondaparinux

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d 

Coronary Artery Bypass Graft (CABG) Surgery

Critical Care

Thromboprophylaxis

Moderate risk for VTE

LMWH or LDUH >> VTE risk factors: medically ill or postoperative general surgery

Higher risk

LMWH >> VTE risk factors: following major trauma or orthopedic surgery

High risk of bleeding

Oral VKA (acenocoumarol, warfarin)

Hip Fracture Surgery (HFS) HFS

GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method

Total Hip Replacement (THR)

Surgery likely to be delayed

LMWH or LDUH initiated during time between admission and surgery

High risk of bleeding

Optimal use of mechanical methods; when high bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Thromboprophylaxis Options: >> LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA started preoperatively or the evening of the surgical day (INR target, 2.5; INR range, 2.0 to 3.0) Recommend against use of the following alone: aspirin, dextran, LDUH, GCS, or VFP

High risk of bleeding

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Knee Arthroscopy

Thromboprophylaxis

No additional risk factors

Early mobilization if appropraite

Additional risk factors or complicated procedure

LMWH

Knee Replacement Total Knee Replacement (TKR)

Thromboprophylaxis Options: >> LMWH (at usual high-risk dose) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: >> IPC Recommend against use of the following alone: aspirin, LDUH, or VFP

High risk of bleeding

Thromboprophylaxis fondaparinux, LMWH, adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0), or LDUH Recommend against use of aspirin alone

Fold

Fold

Hip Replacement

Thromboprophylaxis

Low-risk minor procedures and no risk factors

*Indicated for elective hip and knee replacement surgery. Fold

Fold

13662S R3 VTE Prevention.indd 2

Minor procedures and no risk factors

LMWH or LDUH >> VTE risk factors: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lowerextremity trauma, femoral venous catheter, and/or prolonged immobility

Mechanical * Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis.

Thromboprophylaxis

Burn patients with additional VTE risk factors

Cancer Patients

Most general, open gynecologic or urologic surgery patients

Inherited or acquired thrombophilia

Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10 to 40% among medical or general surgical patients and 40 to 60% following major orthopedic surgery (Table 3) ÎÎ Approximately 70% of all VTE is hospital acquired Therefore, prevention of VTE in hospital patients is the most appropriate method to reduce the burden of this disease

No specific thromboprophylaxis

Moderate Risk

ÎÎ

ÎÎChronic post-thrombotic syndrome

Approximate DVT risk without thromboprophylaxis < 10%

Medical patients who are fully mobile

Nephrotic syndrome

Paroxysmal nocturnal hemoglobinuria Obesity Central venous catheterization

Group Specific Thromboprophylaxis1

ÎÎSimplification of classification system to readily identify the general patient risk group and general thromboprophylaxis recommendations.

Selective estrogen receptor modulators

Myeloproliferative disorders

Fold

Fold

Fold

Fold

General Risk Groups and Recommendations1

Rationale for Thromboprophylaxis1

Laparoscopic Surgery

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method Thromboprophylaxis

No additional risk factors

Early and frequent ambulation

Additional VTE risk factors

LMWH, LDUH, fondaparinux, IPC, or GCS

*Indicated for elective hip and knee replacement surgery.

3/19/09 10:10:57 AM

ÎÎThe rationale for use of thromboprophylaxis is based on solid principles and scientific evidence (Table 1).

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors (see Table 2).

Table 1. Rationale for Thromboprophylaxis  in Hospitalized Patients

Table 2. Risk Factors for VTE Surgery

I. High prevalence of venous thromboembolism (VTE)

Trauma (major trauma or lower-extremity injury) Immobility, lower-extremity paresis Cancer Cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy) Venous compression (tumor, hematoma, arterial abnormality) Previous VTE Increasing age Pregnancy and the postpartum period

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent ÎÎIt is impossible to predict which at-risk patients will develop symptomatic thromboembolic complications ÎÎScreening at-risk patients using physical examination or noninvasive testing is neither cost-effective nor effective

II. Adverse consequences of unprevented VTE

Estrogen-containing oral contraceptives or hormone replacement

ÎÎSymptomatic DVT and PE ÎÎFatal PE ÎÎCosts of investigating symptomatic patients ÎÎRisks and costs of treating unprevented VTE ÎÎIncreased future risk of recurrent VTE

ÎÎImplement group-specific thromboprophylaxis routinely for all patients who belong to each of the major target groups.

Low Risk

Inpatient surgery

Minor surgery in mobile patients

Erythropoiesis-stimulating agents Acute medical illness Inflammatory bowel disease

Table 3. Approximate Risks of DVT in Hospitalized Patients* Patient Group

III. Efficacy and effectiveness of thromboprophylaxis

Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical care patients

ÎÎThromboprophylaxis is highly efficacious at preventing DVT and proximal DVT ÎÎThromboprophylaxis is highly effective at preventing symptomatic VTE and fatal PE ÎÎThe prevention of DVT also prevents PE ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Medical patients, bed rest or sick

Approximate DVT risk without thromboprophylaxis 10-40%

Moderate VTE risk plus high bleeding risk

LDUH bid or tid fondaparinux Mechanical

High Risk

DVT Prevalence, % 10 - 20 15 - 40 15 - 40 15 - 40 15 - 40 20 - 50 40 - 60 40 - 80 60 - 80 10 - 80

Early and “aggressive” ambulation

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Hip or knee arthroplasty, hip fracture surgery

fondaparinux Major trauma, Spinal cord injury

Bariatric Surgery

Burns

Approximate DVT risk without thromboprophylaxis 40-80%

High VTE risk plus high bleeding risk

Oral Factor Xa inhibitor (rivaroxaban*) Oral direct thrombin inhibitor (dabigatran*)

General Surgery

Thromboprophylaxis LMWH, LDUH tid, fondaparinux, or combination of pharmacologic prophylaxis with IPC >> Higher doses of LMWH or LDUH than for nonobese Thromboprophylaxis

Early and frequent ambulation

Major procedure for benign disease

LMWH, LDUH, or fondaparinux

Major procedure for cancer

LMWH, LDUH tid, or fondaparinux

Multiple risk factors

LMWH, LDUH tid, or fondaparinux combined with GCS and/or IPC

High risk of bleeding

GCS or IPC

High risk of bleeding

GCS and/or IPC until bleeding risk decreases

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d

Thromboprophylaxis

Surgical procedures

Refer to relevant surgical subsections

Bedridden with acute medical illness

Refer to high-risk medical patients

Indwelling central venous catheters

Do not use either prophylactic doses of LMWH or minidose warfarin to prevent catheter-related thrombosis

Receiving chemotherapy or hormonal therapy

Recommend against routine thromboprophylaxis for primary prevention of VTE

For cancer patients

Recommend against routine primary thromboprophylaxis to improve survival

Gynecologic Surgery

Early and frequent ambulation

Laparoscopic procedure

Early and frequent ambulation

Laparoscopic procedure with additional VTE risk factors

LMWH, LDUH, IPC, or GCS

Thromboprophylaxis

Major gynecologic surgery for benign disease without additional risk factors

LMWH, LDUH, or IPC started just before surgery and used continuously while not ambulating

CABG surgery

LMWH, LDUH, or bilateral GCS or IPC >> Suggest use of LMWH over LDUH to try to reduce risk of heparin-induced thrombocytopenia (HIT)

High risk of bleeding

Properly fitted bilateral GCS or IPC

Extensive surgery for malignancy and for patients with additional VTE risk factors

LMWH, or LDUH tid, or IPC started just before surgery and used continuously while not ambulating Alternatives: Combination LMWH or LDUH plus GCS or IPC fondaparinux

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d 

Coronary Artery Bypass Graft (CABG) Surgery

Critical Care

Thromboprophylaxis

Moderate risk for VTE

LMWH or LDUH >> VTE risk factors: medically ill or postoperative general surgery

Higher risk

LMWH >> VTE risk factors: following major trauma or orthopedic surgery

High risk of bleeding

Oral VKA (acenocoumarol, warfarin)

Hip Fracture Surgery (HFS) HFS

GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method

Total Hip Replacement (THR)

Surgery likely to be delayed

LMWH or LDUH initiated during time between admission and surgery

High risk of bleeding

Optimal use of mechanical methods; when high bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Thromboprophylaxis Options: >> LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA started preoperatively or the evening of the surgical day (INR target, 2.5; INR range, 2.0 to 3.0) Recommend against use of the following alone: aspirin, dextran, LDUH, GCS, or VFP

High risk of bleeding

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Knee Arthroscopy

Thromboprophylaxis

No additional risk factors

Early mobilization if appropraite

Additional risk factors or complicated procedure

LMWH

Knee Replacement Total Knee Replacement (TKR)

Thromboprophylaxis Options: >> LMWH (at usual high-risk dose) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: >> IPC Recommend against use of the following alone: aspirin, LDUH, or VFP

High risk of bleeding

Thromboprophylaxis fondaparinux, LMWH, adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0), or LDUH Recommend against use of aspirin alone

Fold

Fold

Hip Replacement

Thromboprophylaxis

Low-risk minor procedures and no risk factors

*Indicated for elective hip and knee replacement surgery. Fold

Fold

13662S R3 VTE Prevention.indd 2

Minor procedures and no risk factors

LMWH or LDUH >> VTE risk factors: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lowerextremity trauma, femoral venous catheter, and/or prolonged immobility

Mechanical * Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis.

Thromboprophylaxis

Burn patients with additional VTE risk factors

Cancer Patients

Most general, open gynecologic or urologic surgery patients

Inherited or acquired thrombophilia

Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10 to 40% among medical or general surgical patients and 40 to 60% following major orthopedic surgery (Table 3) ÎÎ Approximately 70% of all VTE is hospital acquired Therefore, prevention of VTE in hospital patients is the most appropriate method to reduce the burden of this disease

No specific thromboprophylaxis

Moderate Risk

ÎÎ

ÎÎChronic post-thrombotic syndrome

Approximate DVT risk without thromboprophylaxis < 10%

Medical patients who are fully mobile

Nephrotic syndrome

Paroxysmal nocturnal hemoglobinuria Obesity Central venous catheterization

Group Specific Thromboprophylaxis1

ÎÎSimplification of classification system to readily identify the general patient risk group and general thromboprophylaxis recommendations.

Selective estrogen receptor modulators

Myeloproliferative disorders

Fold

Fold

Fold

Fold

General Risk Groups and Recommendations1

Rationale for Thromboprophylaxis1

Laparoscopic Surgery

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method Thromboprophylaxis

No additional risk factors

Early and frequent ambulation

Additional VTE risk factors

LMWH, LDUH, fondaparinux, IPC, or GCS

*Indicated for elective hip and knee replacement surgery.

3/19/09 10:10:57 AM

ÎÎThe rationale for use of thromboprophylaxis is based on solid principles and scientific evidence (Table 1).

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors (see Table 2).

Table 1. Rationale for Thromboprophylaxis  in Hospitalized Patients

Table 2. Risk Factors for VTE Surgery

I. High prevalence of venous thromboembolism (VTE)

Trauma (major trauma or lower-extremity injury) Immobility, lower-extremity paresis Cancer Cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy) Venous compression (tumor, hematoma, arterial abnormality) Previous VTE Increasing age Pregnancy and the postpartum period

ÎÎAlmost all hospitalized patients have at least one risk factor for VTE ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent ÎÎIt is impossible to predict which at-risk patients will develop symptomatic thromboembolic complications ÎÎScreening at-risk patients using physical examination or noninvasive testing is neither cost-effective nor effective

II. Adverse consequences of unprevented VTE

Estrogen-containing oral contraceptives or hormone replacement

ÎÎSymptomatic DVT and PE ÎÎFatal PE ÎÎCosts of investigating symptomatic patients ÎÎRisks and costs of treating unprevented VTE ÎÎIncreased future risk of recurrent VTE

ÎÎImplement group-specific thromboprophylaxis routinely for all patients who belong to each of the major target groups.

Low Risk

Inpatient surgery

Minor surgery in mobile patients

Erythropoiesis-stimulating agents Acute medical illness Inflammatory bowel disease

Table 3. Approximate Risks of DVT in Hospitalized Patients* Patient Group

III. Efficacy and effectiveness of thromboprophylaxis

Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical care patients

ÎÎThromboprophylaxis is highly efficacious at preventing DVT and proximal DVT ÎÎThromboprophylaxis is highly effective at preventing symptomatic VTE and fatal PE ÎÎThe prevention of DVT also prevents PE ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Medical patients, bed rest or sick

Approximate DVT risk without thromboprophylaxis 10-40%

Moderate VTE risk plus high bleeding risk

LDUH bid or tid fondaparinux Mechanical

High Risk

DVT Prevalence, % 10 - 20 15 - 40 15 - 40 15 - 40 15 - 40 20 - 50 40 - 60 40 - 80 60 - 80 10 - 80

Early and “aggressive” ambulation

LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)

Hip or knee arthroplasty, hip fracture surgery

fondaparinux Major trauma, Spinal cord injury

Bariatric Surgery

Burns

Approximate DVT risk without thromboprophylaxis 40-80%

High VTE risk plus high bleeding risk

Oral Factor Xa inhibitor (rivaroxaban*) Oral direct thrombin inhibitor (dabigatran*)

General Surgery

Thromboprophylaxis LMWH, LDUH tid, fondaparinux, or combination of pharmacologic prophylaxis with IPC >> Higher doses of LMWH or LDUH than for nonobese Thromboprophylaxis

Early and frequent ambulation

Major procedure for benign disease

LMWH, LDUH, or fondaparinux

Major procedure for cancer

LMWH, LDUH tid, or fondaparinux

Multiple risk factors

LMWH, LDUH tid, or fondaparinux combined with GCS and/or IPC

High risk of bleeding

GCS or IPC

High risk of bleeding

GCS and/or IPC until bleeding risk decreases

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d

Thromboprophylaxis

Surgical procedures

Refer to relevant surgical subsections

Bedridden with acute medical illness

Refer to high-risk medical patients

Indwelling central venous catheters

Do not use either prophylactic doses of LMWH or minidose warfarin to prevent catheter-related thrombosis

Receiving chemotherapy or hormonal therapy

Recommend against routine thromboprophylaxis for primary prevention of VTE

For cancer patients

Recommend against routine primary thromboprophylaxis to improve survival

Gynecologic Surgery

Early and frequent ambulation

Laparoscopic procedure

Early and frequent ambulation

Laparoscopic procedure with additional VTE risk factors

LMWH, LDUH, IPC, or GCS

Thromboprophylaxis

Major gynecologic surgery for benign disease without additional risk factors

LMWH, LDUH, or IPC started just before surgery and used continuously while not ambulating

CABG surgery

LMWH, LDUH, or bilateral GCS or IPC >> Suggest use of LMWH over LDUH to try to reduce risk of heparin-induced thrombocytopenia (HIT)

High risk of bleeding

Properly fitted bilateral GCS or IPC

Extensive surgery for malignancy and for patients with additional VTE risk factors

LMWH, or LDUH tid, or IPC started just before surgery and used continuously while not ambulating Alternatives: Combination LMWH or LDUH plus GCS or IPC fondaparinux

Major procedure

Continue until hospital discharge High-risk (eg, major cancer surgery or previous VTE), consider continuation after hospital discharge with LMWH for ≤ 28 d 

Coronary Artery Bypass Graft (CABG) Surgery

Critical Care

Thromboprophylaxis

Moderate risk for VTE

LMWH or LDUH >> VTE risk factors: medically ill or postoperative general surgery

Higher risk

LMWH >> VTE risk factors: following major trauma or orthopedic surgery

High risk of bleeding

Oral VKA (acenocoumarol, warfarin)

Hip Fracture Surgery (HFS) HFS

GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method

Total Hip Replacement (THR)

Surgery likely to be delayed

LMWH or LDUH initiated during time between admission and surgery

High risk of bleeding

Optimal use of mechanical methods; when high bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Thromboprophylaxis Options: >> LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA started preoperatively or the evening of the surgical day (INR target, 2.5; INR range, 2.0 to 3.0) Recommend against use of the following alone: aspirin, dextran, LDUH, GCS, or VFP

High risk of bleeding

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Knee Arthroscopy

Thromboprophylaxis

No additional risk factors

Early mobilization if appropraite

Additional risk factors or complicated procedure

LMWH

Knee Replacement Total Knee Replacement (TKR)

Thromboprophylaxis Options: >> LMWH (at usual high-risk dose) >> fondaparinux >> Oral Factor Xa inhibitor (rivaroxaban*) >> Oral direct thrombin inhibitor (dabigatran*) >> Adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: >> IPC Recommend against use of the following alone: aspirin, LDUH, or VFP

High risk of bleeding

Thromboprophylaxis fondaparinux, LMWH, adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0), or LDUH Recommend against use of aspirin alone

Fold

Fold

Hip Replacement

Thromboprophylaxis

Low-risk minor procedures and no risk factors

*Indicated for elective hip and knee replacement surgery. Fold

Fold

13662S R3 VTE Prevention.indd 2

Minor procedures and no risk factors

LMWH or LDUH >> VTE risk factors: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lowerextremity trauma, femoral venous catheter, and/or prolonged immobility

Mechanical * Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis.

Thromboprophylaxis

Burn patients with additional VTE risk factors

Cancer Patients

Most general, open gynecologic or urologic surgery patients

Inherited or acquired thrombophilia

Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10 to 40% among medical or general surgical patients and 40 to 60% following major orthopedic surgery (Table 3) ÎÎ Approximately 70% of all VTE is hospital acquired Therefore, prevention of VTE in hospital patients is the most appropriate method to reduce the burden of this disease

No specific thromboprophylaxis

Moderate Risk

ÎÎ

ÎÎChronic post-thrombotic syndrome

Approximate DVT risk without thromboprophylaxis < 10%

Medical patients who are fully mobile

Nephrotic syndrome

Paroxysmal nocturnal hemoglobinuria Obesity Central venous catheterization

Group Specific Thromboprophylaxis1

ÎÎSimplification of classification system to readily identify the general patient risk group and general thromboprophylaxis recommendations.

Selective estrogen receptor modulators

Myeloproliferative disorders

Fold

Fold

Fold

Fold

General Risk Groups and Recommendations1

Rationale for Thromboprophylaxis1

Laparoscopic Surgery

IPC or VFP; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method Thromboprophylaxis

No additional risk factors

Early and frequent ambulation

Additional VTE risk factors

LMWH, LDUH, fondaparinux, IPC, or GCS

*Indicated for elective hip and knee replacement surgery.

3/19/09 10:10:57 AM

Long-Distance Travel Flights > 8 h

Additional VTE risk factors

Long-distance travelers

Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Thromboprophylaxis

Spine Surgery

Avoidance of constrictive clothing around lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction General measures listed above; consider below-knee GCS (15 to 30 mmHg pressure at ankle), or single LMWH dose prior to departure

Multiple risk factors for VTE

Major thoracic surgery

VTE risk factors and contraindication to anticoagulant

GCS or IPC

Major trauma

High thrombosis risk Spinal Cord Injury (SCI) For acute SCI

High risk of bleeding Trauma

Thromboprophylaxis IPC Alternatives: > Postoperative LMWH or LDUH GCS and/or IPC combined with postoperative LMWH or LDUH Thromboprophylaxis LMWH (commenced once primary hemostasis evident) Alternatives: > Combined use of IPC and either LDUH or LMWH > If anticoagulant contraindicated because of high bleeding risk, use IPC and/or GCS; when bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for spinal hematoma on CT or MRI first few days For patients with SCI Rehabilitation following acute SCI

5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h

LMWH, LDUH, or fondaparinux Thromboprophylaxis

IPC or possibly GCS; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Trauma

> Recommend against routine DUS screening for asymptomatic DVT > Recommend DUS screening in high VTE risk (eg, SCI, lower-extremity or pelvic fracture, or major head injury) and suboptimal or no thromboprophylaxis > Recommend against use of IVC filter as primary prophylaxis

Urologic Surgery

Thromboprophylaxis

Transurethral or other low-risk urologic procedures

Early and frequent ambulation

Major open procedures

LDUH bid or tid, GCS and/or IPC just before surgery and used continuously while not ambulating, LMWH, fondaparinux, or combination pharmacologic (ie, LMWH, LDUH, or fondaparinux) with mechanical method (ie, GCS and/or IPC)

For patients actively bleeding or at very high-risk for bleeding Vascular Surgery

fondaparinux (Arixtra®)4

GCS and/or IPC LMWH (starting when considered safe to do so) > Continuation until hospital discharge > For impaired mobility during inpatient rehabilitation, continue LMWH or VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: > Combination LMWH and mechanical method

Optimal use of mechanical method with GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method Early and frequent ambulation

Undergoing major procedure with additional risk factors

LMWH, LDUH, or fondaparinux

Abdominal surgery Hip fracture surgery Hip replacement surgery Knee replacement surgery

2.5 mg SC once daily with initial dose 6 - 8 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): contraindicated

10 mg PO once daily with initial dose 6 - 10 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): not recommended

Hip replacement surgery Knee replacement surgery

Low-Molecular-Weight Heparins (LMWH) dalteparin (Fragmin®)6

Abdominal surgery

2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily

High risk of thromboembolic complications

Medical patients

5000 IU SC evening before surgery, then once daily 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, then 5000 IU SC once daily 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 5000 IU SC once daily

Abdominal surgery

40 mg SC once daily with initial dose 2 h prior to surgery

Hip replacement surgery Knee replacement surgery Medical patients

30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) 30 mg SC every 12 h 40 mg SC once daily

General surgery

2850 IU SC once daily, initial dose 2 - 4 h before surgery

Hip replacement surgery

38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4

General surgery

3500 IU SC 2 h before surgery, then 3500 IU once daily

Hip surgery

50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily or 75 IU/kg SC given post-operatively once daily

Knee surgery

75 IU/kg SC given post-operatively once daily

Alternative in malignancy Hip replacement surgery: Preoperative start - evening before surgery Preoperative start - day of surgery Postoperative start enoxaparin (Lovenox®, Clexane®)7

nadroparin (Fraxiparine®)8

tinzaparin (Innohep®)9

This Pocketcard edition is intended for the European and Canadian healthcare communities and contains only the European Medicines Agency (EMEA) and the Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.

Acenocoumarol (Sintrom®)10

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Warfarin (Coumadin )

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Abbreviations bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF, congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS, Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery; INR, international normalized ratio; IPC, intermittent pneumatic compression; IU, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT, prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement; tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump; VKA, vitamin K antagonist; VTE, venous thromboembolism

Prevention of Venous Thromboembolism (for use in Europe and Canada)

Expert Reviewer: William Geerts, MD, FRCPC

Severe renal dysfunction (CrCl < 30 mL/min): monitor anti-Xa levels to determine the appropriate dose

Severe renal dysfunction (CrCl < 30 mL/min): 30 mg SC once daily Severe renal dysfunction (CrCl < 30 mL/min): Reduce dose by 25 - 33% Severe renal dysfunction (CrCl < 30 mL/min): Consider dosage reduction

Vitamin K Antagonist (VKA) ® 11

INR target of 2.5 (INR range, 2.0 to 3.0) Fold

Fold

Fold

Fold

13662S R3 VTE Prevention.indd 1

110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated

Oral Direct Factor Xa Inhibitor rivaroxaban (Xarelto®)5

Thromboprophylaxis

No additional risk factors

Comments

Indirect Factor Xa Inhibitor

Thromboprophylaxis

Major trauma if LMWH contraindicated

Recommend against the use of IVC filter as primary prophylaxis Continuation of LMWH or conversion to oral VKA (INR target, 2.5; INR range 2.0 to 3.0)

Low-dose regimen for major abdominothoracic surgery

Postoperative LDUH, postoperative LMWH, or Oral Direct Thrombin Inhibitor perioperative IPC (Alternative: GCS) > VTE risk factors: advanced age, malignancy, presence of dabigatran Hip replacement surgery neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Pharmacologic prophylaxis (LDUH or LMWH) combined Knee replacement surgery with mechanical method (GCS and/or IPC)

LMWH, LDUH, or fondaparinux > Risk factors: active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease

Major neurosurgery

Dosage and Administration

Additional VTE risk

Acutely ill medical patients with CHF, severe respiratory disease, confined to bed, or ≥ 1 risk factors

Neurosurgery

Prophylaxis Indication

Early and frequent ambulation

Thoracic Surgery

Thromboprophylaxis

Drug Low Dose Unfractionated Heparin2 (LDUH)

Thromboprophylaxis

No additional VTE risk factors

Recommend against the use of aspirin for VTE prevention

Medical Conditions

Fold

Fold

Fold

Fold

Group Specific Thromboprophylaxis

Thromboembolism Program

References 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:381S-453S. 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008. 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008. 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008. 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007. 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007. 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008. 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008. 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007. 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.

Sunnybrook Health Sciences Centre University of Toronto

Rationale for Thromboprophylaxis General Risk Groups and Recommendations Group Specific Thromboprophylaxis Manufacturer Prescribing Information

Disclaimer This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgement concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. 5740 Executive Drive Suite 220 • Baltimore, MD 21228 TEL: 410-869-3332 • FAX: 410-744-2150 Orders and inquiries: [email protected] Copyright © 2009 All rights reserved For additional copies: www.myguidelinescenter.com

For additional copies: [email protected]

3/19/09 10:10:56 AM

Long-Distance Travel Flights > 8 h

Additional VTE risk factors

Long-distance travelers

Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Thromboprophylaxis

Spine Surgery

Avoidance of constrictive clothing around lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction General measures listed above; consider below-knee GCS (15 to 30 mmHg pressure at ankle), or single LMWH dose prior to departure

Multiple risk factors for VTE

Major thoracic surgery

VTE risk factors and contraindication to anticoagulant

GCS or IPC

Major trauma

High thrombosis risk Spinal Cord Injury (SCI) For acute SCI

High risk of bleeding Trauma

Thromboprophylaxis IPC Alternatives: > Postoperative LMWH or LDUH GCS and/or IPC combined with postoperative LMWH or LDUH Thromboprophylaxis LMWH (commenced once primary hemostasis evident) Alternatives: > Combined use of IPC and either LDUH or LMWH > If anticoagulant contraindicated because of high bleeding risk, use IPC and/or GCS; when bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for spinal hematoma on CT or MRI first few days For patients with SCI Rehabilitation following acute SCI

5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h

LMWH, LDUH, or fondaparinux Thromboprophylaxis

IPC or possibly GCS; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Trauma

> Recommend against routine DUS screening for asymptomatic DVT > Recommend DUS screening in high VTE risk (eg, SCI, lower-extremity or pelvic fracture, or major head injury) and suboptimal or no thromboprophylaxis > Recommend against use of IVC filter as primary prophylaxis

Urologic Surgery

Thromboprophylaxis

Transurethral or other low-risk urologic procedures

Early and frequent ambulation

Major open procedures

LDUH bid or tid, GCS and/or IPC just before surgery and used continuously while not ambulating, LMWH, fondaparinux, or combination pharmacologic (ie, LMWH, LDUH, or fondaparinux) with mechanical method (ie, GCS and/or IPC)

For patients actively bleeding or at very high-risk for bleeding Vascular Surgery

fondaparinux (Arixtra®)4

GCS and/or IPC LMWH (starting when considered safe to do so) > Continuation until hospital discharge > For impaired mobility during inpatient rehabilitation, continue LMWH or VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: > Combination LMWH and mechanical method

Optimal use of mechanical method with GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method Early and frequent ambulation

Undergoing major procedure with additional risk factors

LMWH, LDUH, or fondaparinux

Abdominal surgery Hip fracture surgery Hip replacement surgery Knee replacement surgery

2.5 mg SC once daily with initial dose 6 - 8 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): contraindicated

10 mg PO once daily with initial dose 6 - 10 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): not recommended

Hip replacement surgery Knee replacement surgery

Low-Molecular-Weight Heparins (LMWH) dalteparin (Fragmin®)6

Abdominal surgery

2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily

High risk of thromboembolic complications

Medical patients

5000 IU SC evening before surgery, then once daily 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, then 5000 IU SC once daily 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 5000 IU SC once daily

Abdominal surgery

40 mg SC once daily with initial dose 2 h prior to surgery

Hip replacement surgery Knee replacement surgery Medical patients

30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) 30 mg SC every 12 h 40 mg SC once daily

General surgery

2850 IU SC once daily, initial dose 2 - 4 h before surgery

Hip replacement surgery

38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4

General surgery

3500 IU SC 2 h before surgery, then 3500 IU once daily

Hip surgery

50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily or 75 IU/kg SC given post-operatively once daily

Knee surgery

75 IU/kg SC given post-operatively once daily

Alternative in malignancy Hip replacement surgery: Preoperative start - evening before surgery Preoperative start - day of surgery Postoperative start enoxaparin (Lovenox®, Clexane®)7

nadroparin (Fraxiparine®)8

tinzaparin (Innohep®)9

This Pocketcard edition is intended for the European and Canadian healthcare communities and contains only the European Medicines Agency (EMEA) and the Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.

Acenocoumarol (Sintrom®)10

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Warfarin (Coumadin )

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Abbreviations bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF, congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS, Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery; INR, international normalized ratio; IPC, intermittent pneumatic compression; IU, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT, prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement; tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump; VKA, vitamin K antagonist; VTE, venous thromboembolism

Prevention of Venous Thromboembolism (for use in Europe and Canada)

Expert Reviewer: William Geerts, MD, FRCPC

Severe renal dysfunction (CrCl < 30 mL/min): monitor anti-Xa levels to determine the appropriate dose

Severe renal dysfunction (CrCl < 30 mL/min): 30 mg SC once daily Severe renal dysfunction (CrCl < 30 mL/min): Reduce dose by 25 - 33% Severe renal dysfunction (CrCl < 30 mL/min): Consider dosage reduction

Vitamin K Antagonist (VKA) ® 11

INR target of 2.5 (INR range, 2.0 to 3.0) Fold

Fold

Fold

Fold

13662S R3 VTE Prevention.indd 1

110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated

Oral Direct Factor Xa Inhibitor rivaroxaban (Xarelto®)5

Thromboprophylaxis

No additional risk factors

Comments

Indirect Factor Xa Inhibitor

Thromboprophylaxis

Major trauma if LMWH contraindicated

Recommend against the use of IVC filter as primary prophylaxis Continuation of LMWH or conversion to oral VKA (INR target, 2.5; INR range 2.0 to 3.0)

Low-dose regimen for major abdominothoracic surgery

Postoperative LDUH, postoperative LMWH, or Oral Direct Thrombin Inhibitor perioperative IPC (Alternative: GCS) > VTE risk factors: advanced age, malignancy, presence of dabigatran Hip replacement surgery neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Pharmacologic prophylaxis (LDUH or LMWH) combined Knee replacement surgery with mechanical method (GCS and/or IPC)

LMWH, LDUH, or fondaparinux > Risk factors: active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease

Major neurosurgery

Dosage and Administration

Additional VTE risk

Acutely ill medical patients with CHF, severe respiratory disease, confined to bed, or ≥ 1 risk factors

Neurosurgery

Prophylaxis Indication

Early and frequent ambulation

Thoracic Surgery

Thromboprophylaxis

Drug Low Dose Unfractionated Heparin2 (LDUH)

Thromboprophylaxis

No additional VTE risk factors

Recommend against the use of aspirin for VTE prevention

Medical Conditions

Fold

Fold

Fold

Fold

Group Specific Thromboprophylaxis

Thromboembolism Program

References 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:381S-453S. 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008. 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008. 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008. 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007. 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007. 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008. 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008. 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007. 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.

Sunnybrook Health Sciences Centre University of Toronto

Rationale for Thromboprophylaxis General Risk Groups and Recommendations Group Specific Thromboprophylaxis Manufacturer Prescribing Information

Disclaimer This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgement concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. 5740 Executive Drive Suite 220 • Baltimore, MD 21228 TEL: 410-869-3332 • FAX: 410-744-2150 Orders and inquiries: [email protected] Copyright © 2009 All rights reserved For additional copies: www.myguidelinescenter.com

For additional copies: [email protected]

3/19/09 10:10:56 AM

Long-Distance Travel Flights > 8 h

Additional VTE risk factors

Long-distance travelers

Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Thromboprophylaxis

Spine Surgery

Avoidance of constrictive clothing around lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction General measures listed above; consider below-knee GCS (15 to 30 mmHg pressure at ankle), or single LMWH dose prior to departure

Multiple risk factors for VTE

Major thoracic surgery

VTE risk factors and contraindication to anticoagulant

GCS or IPC

Major trauma

High thrombosis risk Spinal Cord Injury (SCI) For acute SCI

High risk of bleeding Trauma

Thromboprophylaxis IPC Alternatives: > Postoperative LMWH or LDUH GCS and/or IPC combined with postoperative LMWH or LDUH Thromboprophylaxis LMWH (commenced once primary hemostasis evident) Alternatives: > Combined use of IPC and either LDUH or LMWH > If anticoagulant contraindicated because of high bleeding risk, use IPC and/or GCS; when bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for spinal hematoma on CT or MRI first few days For patients with SCI Rehabilitation following acute SCI

5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h

LMWH, LDUH, or fondaparinux Thromboprophylaxis

IPC or possibly GCS; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Trauma

> Recommend against routine DUS screening for asymptomatic DVT > Recommend DUS screening in high VTE risk (eg, SCI, lower-extremity or pelvic fracture, or major head injury) and suboptimal or no thromboprophylaxis > Recommend against use of IVC filter as primary prophylaxis

Urologic Surgery

Thromboprophylaxis

Transurethral or other low-risk urologic procedures

Early and frequent ambulation

Major open procedures

LDUH bid or tid, GCS and/or IPC just before surgery and used continuously while not ambulating, LMWH, fondaparinux, or combination pharmacologic (ie, LMWH, LDUH, or fondaparinux) with mechanical method (ie, GCS and/or IPC)

For patients actively bleeding or at very high-risk for bleeding Vascular Surgery

fondaparinux (Arixtra®)4

GCS and/or IPC LMWH (starting when considered safe to do so) > Continuation until hospital discharge > For impaired mobility during inpatient rehabilitation, continue LMWH or VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: > Combination LMWH and mechanical method

Optimal use of mechanical method with GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method Early and frequent ambulation

Undergoing major procedure with additional risk factors

LMWH, LDUH, or fondaparinux

Abdominal surgery Hip fracture surgery Hip replacement surgery Knee replacement surgery

2.5 mg SC once daily with initial dose 6 - 8 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): contraindicated

10 mg PO once daily with initial dose 6 - 10 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): not recommended

Hip replacement surgery Knee replacement surgery

Low-Molecular-Weight Heparins (LMWH) dalteparin (Fragmin®)6

Abdominal surgery

2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily

High risk of thromboembolic complications

Medical patients

5000 IU SC evening before surgery, then once daily 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, then 5000 IU SC once daily 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 5000 IU SC once daily

Abdominal surgery

40 mg SC once daily with initial dose 2 h prior to surgery

Hip replacement surgery Knee replacement surgery Medical patients

30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) 30 mg SC every 12 h 40 mg SC once daily

General surgery

2850 IU SC once daily, initial dose 2 - 4 h before surgery

Hip replacement surgery

38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4

General surgery

3500 IU SC 2 h before surgery, then 3500 IU once daily

Hip surgery

50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily or 75 IU/kg SC given post-operatively once daily

Knee surgery

75 IU/kg SC given post-operatively once daily

Alternative in malignancy Hip replacement surgery: Preoperative start - evening before surgery Preoperative start - day of surgery Postoperative start enoxaparin (Lovenox®, Clexane®)7

nadroparin (Fraxiparine®)8

tinzaparin (Innohep®)9

This Pocketcard edition is intended for the European and Canadian healthcare communities and contains only the European Medicines Agency (EMEA) and the Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.

Acenocoumarol (Sintrom®)10

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Warfarin (Coumadin )

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Abbreviations bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF, congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS, Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery; INR, international normalized ratio; IPC, intermittent pneumatic compression; IU, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT, prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement; tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump; VKA, vitamin K antagonist; VTE, venous thromboembolism

Prevention of Venous Thromboembolism (for use in Europe and Canada)

Expert Reviewer: William Geerts, MD, FRCPC

Severe renal dysfunction (CrCl < 30 mL/min): monitor anti-Xa levels to determine the appropriate dose

Severe renal dysfunction (CrCl < 30 mL/min): 30 mg SC once daily Severe renal dysfunction (CrCl < 30 mL/min): Reduce dose by 25 - 33% Severe renal dysfunction (CrCl < 30 mL/min): Consider dosage reduction

Vitamin K Antagonist (VKA) ® 11

INR target of 2.5 (INR range, 2.0 to 3.0) Fold

Fold

Fold

Fold

13662S R3 VTE Prevention.indd 1

110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated

Oral Direct Factor Xa Inhibitor rivaroxaban (Xarelto®)5

Thromboprophylaxis

No additional risk factors

Comments

Indirect Factor Xa Inhibitor

Thromboprophylaxis

Major trauma if LMWH contraindicated

Recommend against the use of IVC filter as primary prophylaxis Continuation of LMWH or conversion to oral VKA (INR target, 2.5; INR range 2.0 to 3.0)

Low-dose regimen for major abdominothoracic surgery

Postoperative LDUH, postoperative LMWH, or Oral Direct Thrombin Inhibitor perioperative IPC (Alternative: GCS) > VTE risk factors: advanced age, malignancy, presence of dabigatran Hip replacement surgery neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Pharmacologic prophylaxis (LDUH or LMWH) combined Knee replacement surgery with mechanical method (GCS and/or IPC)

LMWH, LDUH, or fondaparinux > Risk factors: active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease

Major neurosurgery

Dosage and Administration

Additional VTE risk

Acutely ill medical patients with CHF, severe respiratory disease, confined to bed, or ≥ 1 risk factors

Neurosurgery

Prophylaxis Indication

Early and frequent ambulation

Thoracic Surgery

Thromboprophylaxis

Drug Low Dose Unfractionated Heparin2 (LDUH)

Thromboprophylaxis

No additional VTE risk factors

Recommend against the use of aspirin for VTE prevention

Medical Conditions

Fold

Fold

Fold

Fold

Group Specific Thromboprophylaxis

Thromboembolism Program

References 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:381S-453S. 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008. 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008. 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008. 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007. 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007. 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008. 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008. 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007. 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.

Sunnybrook Health Sciences Centre University of Toronto

Rationale for Thromboprophylaxis General Risk Groups and Recommendations Group Specific Thromboprophylaxis Manufacturer Prescribing Information

Disclaimer This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgement concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. 5740 Executive Drive Suite 220 • Baltimore, MD 21228 TEL: 410-869-3332 • FAX: 410-744-2150 Orders and inquiries: [email protected] Copyright © 2009 All rights reserved For additional copies: www.myguidelinescenter.com

For additional copies: [email protected]

3/19/09 10:10:56 AM

Long-Distance Travel Flights > 8 h

Additional VTE risk factors

Long-distance travelers

Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Thromboprophylaxis

Spine Surgery

Avoidance of constrictive clothing around lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction General measures listed above; consider below-knee GCS (15 to 30 mmHg pressure at ankle), or single LMWH dose prior to departure

Multiple risk factors for VTE

Major thoracic surgery

VTE risk factors and contraindication to anticoagulant

GCS or IPC

Major trauma

High thrombosis risk Spinal Cord Injury (SCI) For acute SCI

High risk of bleeding Trauma

Thromboprophylaxis IPC Alternatives: > Postoperative LMWH or LDUH GCS and/or IPC combined with postoperative LMWH or LDUH Thromboprophylaxis LMWH (commenced once primary hemostasis evident) Alternatives: > Combined use of IPC and either LDUH or LMWH > If anticoagulant contraindicated because of high bleeding risk, use IPC and/or GCS; when bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for spinal hematoma on CT or MRI first few days For patients with SCI Rehabilitation following acute SCI

5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h

LMWH, LDUH, or fondaparinux Thromboprophylaxis

IPC or possibly GCS; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Trauma

> Recommend against routine DUS screening for asymptomatic DVT > Recommend DUS screening in high VTE risk (eg, SCI, lower-extremity or pelvic fracture, or major head injury) and suboptimal or no thromboprophylaxis > Recommend against use of IVC filter as primary prophylaxis

Urologic Surgery

Thromboprophylaxis

Transurethral or other low-risk urologic procedures

Early and frequent ambulation

Major open procedures

LDUH bid or tid, GCS and/or IPC just before surgery and used continuously while not ambulating, LMWH, fondaparinux, or combination pharmacologic (ie, LMWH, LDUH, or fondaparinux) with mechanical method (ie, GCS and/or IPC)

For patients actively bleeding or at very high-risk for bleeding Vascular Surgery

fondaparinux (Arixtra®)4

GCS and/or IPC LMWH (starting when considered safe to do so) > Continuation until hospital discharge > For impaired mobility during inpatient rehabilitation, continue LMWH or VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: > Combination LMWH and mechanical method

Optimal use of mechanical method with GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method Early and frequent ambulation

Undergoing major procedure with additional risk factors

LMWH, LDUH, or fondaparinux

Abdominal surgery Hip fracture surgery Hip replacement surgery Knee replacement surgery

2.5 mg SC once daily with initial dose 6 - 8 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): contraindicated

10 mg PO once daily with initial dose 6 - 10 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): not recommended

Hip replacement surgery Knee replacement surgery

Low-Molecular-Weight Heparins (LMWH) dalteparin (Fragmin®)6

Abdominal surgery

2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily

High risk of thromboembolic complications

Medical patients

5000 IU SC evening before surgery, then once daily 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, then 5000 IU SC once daily 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 5000 IU SC once daily

Abdominal surgery

40 mg SC once daily with initial dose 2 h prior to surgery

Hip replacement surgery Knee replacement surgery Medical patients

30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) 30 mg SC every 12 h 40 mg SC once daily

General surgery

2850 IU SC once daily, initial dose 2 - 4 h before surgery

Hip replacement surgery

38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4

General surgery

3500 IU SC 2 h before surgery, then 3500 IU once daily

Hip surgery

50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily or 75 IU/kg SC given post-operatively once daily

Knee surgery

75 IU/kg SC given post-operatively once daily

Alternative in malignancy Hip replacement surgery: Preoperative start - evening before surgery Preoperative start - day of surgery Postoperative start enoxaparin (Lovenox®, Clexane®)7

nadroparin (Fraxiparine®)8

tinzaparin (Innohep®)9

This Pocketcard edition is intended for the European and Canadian healthcare communities and contains only the European Medicines Agency (EMEA) and the Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.

Acenocoumarol (Sintrom®)10

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Warfarin (Coumadin )

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Abbreviations bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF, congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS, Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery; INR, international normalized ratio; IPC, intermittent pneumatic compression; IU, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT, prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement; tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump; VKA, vitamin K antagonist; VTE, venous thromboembolism

Prevention of Venous Thromboembolism (for use in Europe and Canada)

Expert Reviewer: William Geerts, MD, FRCPC

Severe renal dysfunction (CrCl < 30 mL/min): monitor anti-Xa levels to determine the appropriate dose

Severe renal dysfunction (CrCl < 30 mL/min): 30 mg SC once daily Severe renal dysfunction (CrCl < 30 mL/min): Reduce dose by 25 - 33% Severe renal dysfunction (CrCl < 30 mL/min): Consider dosage reduction

Vitamin K Antagonist (VKA) ® 11

INR target of 2.5 (INR range, 2.0 to 3.0) Fold

Fold

Fold

Fold

13662S R3 VTE Prevention.indd 1

110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated

Oral Direct Factor Xa Inhibitor rivaroxaban (Xarelto®)5

Thromboprophylaxis

No additional risk factors

Comments

Indirect Factor Xa Inhibitor

Thromboprophylaxis

Major trauma if LMWH contraindicated

Recommend against the use of IVC filter as primary prophylaxis Continuation of LMWH or conversion to oral VKA (INR target, 2.5; INR range 2.0 to 3.0)

Low-dose regimen for major abdominothoracic surgery

Postoperative LDUH, postoperative LMWH, or Oral Direct Thrombin Inhibitor perioperative IPC (Alternative: GCS) > VTE risk factors: advanced age, malignancy, presence of dabigatran Hip replacement surgery neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Pharmacologic prophylaxis (LDUH or LMWH) combined Knee replacement surgery with mechanical method (GCS and/or IPC)

LMWH, LDUH, or fondaparinux > Risk factors: active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease

Major neurosurgery

Dosage and Administration

Additional VTE risk

Acutely ill medical patients with CHF, severe respiratory disease, confined to bed, or ≥ 1 risk factors

Neurosurgery

Prophylaxis Indication

Early and frequent ambulation

Thoracic Surgery

Thromboprophylaxis

Drug Low Dose Unfractionated Heparin2 (LDUH)

Thromboprophylaxis

No additional VTE risk factors

Recommend against the use of aspirin for VTE prevention

Medical Conditions

Fold

Fold

Fold

Fold

Group Specific Thromboprophylaxis

Thromboembolism Program

References 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:381S-453S. 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008. 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008. 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008. 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007. 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007. 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008. 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008. 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007. 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.

Sunnybrook Health Sciences Centre University of Toronto

Rationale for Thromboprophylaxis General Risk Groups and Recommendations Group Specific Thromboprophylaxis Manufacturer Prescribing Information

Disclaimer This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgement concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. 5740 Executive Drive Suite 220 • Baltimore, MD 21228 TEL: 410-869-3332 • FAX: 410-744-2150 Orders and inquiries: [email protected] Copyright © 2009 All rights reserved For additional copies: www.myguidelinescenter.com

For additional copies: [email protected]

3/19/09 10:10:56 AM

Long-Distance Travel Flights > 8 h

Additional VTE risk factors

Long-distance travelers

Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Thromboprophylaxis

Spine Surgery

Avoidance of constrictive clothing around lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction General measures listed above; consider below-knee GCS (15 to 30 mmHg pressure at ankle), or single LMWH dose prior to departure

Multiple risk factors for VTE

Major thoracic surgery

VTE risk factors and contraindication to anticoagulant

GCS or IPC

Major trauma

High thrombosis risk Spinal Cord Injury (SCI) For acute SCI

High risk of bleeding Trauma

Thromboprophylaxis IPC Alternatives: > Postoperative LMWH or LDUH GCS and/or IPC combined with postoperative LMWH or LDUH Thromboprophylaxis LMWH (commenced once primary hemostasis evident) Alternatives: > Combined use of IPC and either LDUH or LMWH > If anticoagulant contraindicated because of high bleeding risk, use IPC and/or GCS; when bleeding risk decreases, pharmacologic prophylaxis substituted for or added to mechanical method

Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for spinal hematoma on CT or MRI first few days For patients with SCI Rehabilitation following acute SCI

5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h

LMWH, LDUH, or fondaparinux Thromboprophylaxis

IPC or possibly GCS; when high bleeding risk decreases, then pharmacologic prophylaxis substituted for or added to mechanical method

Trauma

> Recommend against routine DUS screening for asymptomatic DVT > Recommend DUS screening in high VTE risk (eg, SCI, lower-extremity or pelvic fracture, or major head injury) and suboptimal or no thromboprophylaxis > Recommend against use of IVC filter as primary prophylaxis

Urologic Surgery

Thromboprophylaxis

Transurethral or other low-risk urologic procedures

Early and frequent ambulation

Major open procedures

LDUH bid or tid, GCS and/or IPC just before surgery and used continuously while not ambulating, LMWH, fondaparinux, or combination pharmacologic (ie, LMWH, LDUH, or fondaparinux) with mechanical method (ie, GCS and/or IPC)

For patients actively bleeding or at very high-risk for bleeding Vascular Surgery

fondaparinux (Arixtra®)4

GCS and/or IPC LMWH (starting when considered safe to do so) > Continuation until hospital discharge > For impaired mobility during inpatient rehabilitation, continue LMWH or VKA (INR target, 2.5; INR range, 2.0 to 3.0) Alternative: > Combination LMWH and mechanical method

Optimal use of mechanical method with GCS and/or IPC until bleeding risk decreases; then pharmacologic prophylaxis substituted for or added to mechanical method Early and frequent ambulation

Undergoing major procedure with additional risk factors

LMWH, LDUH, or fondaparinux

Abdominal surgery Hip fracture surgery Hip replacement surgery Knee replacement surgery

2.5 mg SC once daily with initial dose 6 - 8 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): contraindicated

10 mg PO once daily with initial dose 6 - 10 h after surgery

Severe renal dysfunction (CrCl < 30 mL/min): not recommended

Hip replacement surgery Knee replacement surgery

Low-Molecular-Weight Heparins (LMWH) dalteparin (Fragmin®)6

Abdominal surgery

2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily

High risk of thromboembolic complications

Medical patients

5000 IU SC evening before surgery, then once daily 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, then 5000 IU SC once daily 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 5000 IU SC once daily

Abdominal surgery

40 mg SC once daily with initial dose 2 h prior to surgery

Hip replacement surgery Knee replacement surgery Medical patients

30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) 30 mg SC every 12 h 40 mg SC once daily

General surgery

2850 IU SC once daily, initial dose 2 - 4 h before surgery

Hip replacement surgery

38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4

General surgery

3500 IU SC 2 h before surgery, then 3500 IU once daily

Hip surgery

50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily or 75 IU/kg SC given post-operatively once daily

Knee surgery

75 IU/kg SC given post-operatively once daily

Alternative in malignancy Hip replacement surgery: Preoperative start - evening before surgery Preoperative start - day of surgery Postoperative start enoxaparin (Lovenox®, Clexane®)7

nadroparin (Fraxiparine®)8

tinzaparin (Innohep®)9

This Pocketcard edition is intended for the European and Canadian healthcare communities and contains only the European Medicines Agency (EMEA) and the Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.

Acenocoumarol (Sintrom®)10

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Warfarin (Coumadin )

Venous thrombosis and its extension

Individualized; dose adjusted by INR response

Abbreviations bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF, congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS, Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery; INR, international normalized ratio; IPC, intermittent pneumatic compression; IU, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT, prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement; tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump; VKA, vitamin K antagonist; VTE, venous thromboembolism

Prevention of Venous Thromboembolism (for use in Europe and Canada)

Expert Reviewer: William Geerts, MD, FRCPC

Severe renal dysfunction (CrCl < 30 mL/min): monitor anti-Xa levels to determine the appropriate dose

Severe renal dysfunction (CrCl < 30 mL/min): 30 mg SC once daily Severe renal dysfunction (CrCl < 30 mL/min): Reduce dose by 25 - 33% Severe renal dysfunction (CrCl < 30 mL/min): Consider dosage reduction

Vitamin K Antagonist (VKA) ® 11

INR target of 2.5 (INR range, 2.0 to 3.0) Fold

Fold

Fold

Fold

13662S R3 VTE Prevention.indd 1

110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated

Oral Direct Factor Xa Inhibitor rivaroxaban (Xarelto®)5

Thromboprophylaxis

No additional risk factors

Comments

Indirect Factor Xa Inhibitor

Thromboprophylaxis

Major trauma if LMWH contraindicated

Recommend against the use of IVC filter as primary prophylaxis Continuation of LMWH or conversion to oral VKA (INR target, 2.5; INR range 2.0 to 3.0)

Low-dose regimen for major abdominothoracic surgery

Postoperative LDUH, postoperative LMWH, or Oral Direct Thrombin Inhibitor perioperative IPC (Alternative: GCS) > VTE risk factors: advanced age, malignancy, presence of dabigatran Hip replacement surgery neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Pharmacologic prophylaxis (LDUH or LMWH) combined Knee replacement surgery with mechanical method (GCS and/or IPC)

LMWH, LDUH, or fondaparinux > Risk factors: active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease

Major neurosurgery

Dosage and Administration

Additional VTE risk

Acutely ill medical patients with CHF, severe respiratory disease, confined to bed, or ≥ 1 risk factors

Neurosurgery

Prophylaxis Indication

Early and frequent ambulation

Thoracic Surgery

Thromboprophylaxis

Drug Low Dose Unfractionated Heparin2 (LDUH)

Thromboprophylaxis

No additional VTE risk factors

Recommend against the use of aspirin for VTE prevention

Medical Conditions

Fold

Fold

Fold

Fold

Group Specific Thromboprophylaxis

Thromboembolism Program

References 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:381S-453S. 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008. 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008. 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008. 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007. 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007. 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008. 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008. 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007. 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.

Sunnybrook Health Sciences Centre University of Toronto

Rationale for Thromboprophylaxis General Risk Groups and Recommendations Group Specific Thromboprophylaxis Manufacturer Prescribing Information

Disclaimer This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgement concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. 5740 Executive Drive Suite 220 • Baltimore, MD 21228 TEL: 410-869-3332 • FAX: 410-744-2150 Orders and inquiries: [email protected] Copyright © 2009 All rights reserved For additional copies: www.myguidelinescenter.com

For additional copies: [email protected]

3/19/09 10:10:56 AM