Prevention and Treatment of Venous Thromboembolism Key Clinical Questions
07. Who should receive extended VTE prophylaxis post-discharge, and what is the optimal strategy?
a. HOMERuN institutions
Sixty-two percent of institutions recommended consideration of post-discharge pharmacologic VTE prophylaxis. There was little consensus on recommended agent, dose, and duration. There was little agreement on criteria for selecting patients for post-discharge prophylaxis. The most common indication cited was to continue pharmacologic prophylaxis post-discharge if patients had received intensified prophylaxis dosing or empiric treatment dosing while hospitalized (38%). Other criteria included considering whether the patient had ongoing immobility or had an elevated D-dimer at discharge.
b. What is Known
Extended duration prophylaxis beyond hospitalization has been shown to benefit some high-risk surgical patients. In general, evidence to date for post-discharge prophylaxis for medically ill patients generally demonstrates no difference in overall survival or rates of pulmonary embolism but does show a reduced risk of symptomatic VTE. This is countered by an increased risk of major bleeding (RR 2.09, 95% 1.33-3.27).16
c. What is Not Known
The risks and benefits of post-discharge prophylaxis for patients with COVID-19 specifically, and whether these differ from medically ill patients generally, remain unknown. The optimal criteria for identifying patients at high risk of VTE post-discharge who warrant pharmacologic prophylaxis remain unknown. There is also uncertainty regarding the optimal regimen, including agent, dosing, and duration.
Key Clinical Questions
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- Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018;2(22):3198-3225. doi:10.1182/bloodadvances.2018022954