Vital VTE Interventions

The Hospitalist. 2008 April;2008(04):

April 1, 2008|The Hospitalist

Venous thromboembolism (VTE) affects more than 2 million Americans every year.1 Pulmonary embolism (PE) is one of the most common preventable causes of in-hospital deaths in the United States. Clinical manifestations of PE may be the first indication the patient has a VTE, and fatal PEs occur in at least 75% of hospitalized medical patients. More than 300,000 patients die from PE each year—an estimated incidence of 10%. This makes VTE prevention a top patient-safety goal in hospitals.2,3

Thromboprophylaxis can be accomplished with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH; e.g., enoxaparin, dalteparin, tinzaparin) or heparinoid, or a selective factor Xa inhibitor (e.g., fondaparinux).4 For long-term treatment, oral warfarin is often used. Doses and duration of prophylaxis and treatment regimens vary.

Thromboprophylaxis can prevent significant morbidity and PE and decrease resource consumption and long-term clinical and economic sequelae.

Current guidelines should be reviewed for specific recommendations. Two current guidelines are the American College of Chest Physicians (ACCP) Seventh Conference on the Prevention of VTE and the American Society of Clinical Oncology (ASCO) Guideline for VTE prophylaxis and treatment in oncology patients. Although guidelines are available, thromboprophylaxis continues to baffle many healthcare providers. There are many advantages to thromboprophylaxis including the prevention of significant morbidity, prevention of PE, decreases in resource consumption, and decreases in the long-term clinical and economic sequelae.

The ACCP notes that most surgical patients will require thromboprophylaxis. Contraindications need to be evaluated prior to antithrombotic/anticoagulant use. Additionally, all trauma patients with at least one VTE risk factor should receive thromboprophylaxis. Acutely ill patients hospitalized with congestive heart failure or severe respiratory distress or who are confined to bed and have one or more additional risk factors, should receive VTE prophylaxis. Additionally, most patients upon admission to an intensive-care unit should be assessed for VTE risk and receive thromboprophylaxis as required.

New Indications,Dosage Forms

Aripiprazole (Abilify) has been approved by the Food and Drug Administration (FDA) for a new indication, for use as adjunctive treatment to antidepressant therapy in adults with major depressive disorder.

Brimonidine tartrate 0.2%/timolol maleate 0.5% ophthalmic solution (Combigan) has been FDA-approved for lowering intraocular pressure in patients with ocular hypertension or glaucoma. It is dosed twice daily.

Carbidopa, levodopa, entacapone (Stalevo) combination tablets for treating Parkinson’s disease, were FDA approved in a new strength of 200 mg which can be dosed up to six times daily. Other available tablet strengths are 50, 100, and 150 mg. The strength is based on the levodopa component.

Duloxetine Hydrochloride (Cymbalta) has been FDA approved for maintenance treatment of major depressive disorder in adults.

Irbesartan/hydrochlorothiazide (Avalide) has been FDA approved for initial treatment of hypertensive patients who are likely to need multiple drugs to achieve blood pressure goals. This new indication is based on the results of two studies in more than 1,200 patients. The most common side effects were dizziness and headache.

Quetiapine fumarate (Seroquel XR) has been FDA approved for maintenance treatment of schizophrenia in adult patients.—MK

VTE is a major complication in up to 20% of cancer patients, with hospitalized oncology patients and those undergoing treatment at the highest risk. Some of the newer drug treatments used in these patients have higher VTE rates (e.g., bevacizumab, thalidomide, lenalidomide). These patients need to be carefully evaluated for VTE prophylaxis and closely monitored.5

Generally, in hospitalized patients with cancer, VTE prophylaxis should be considered with UFH, LMWH, or fondaparinux, in the absence of bleeding or other contraindications to anticoagulation. Relative contraindications to anticoagulation include (but are not limited to):

Active uncontrolled bleeding;
Active cerebrovascular hemorrhage;
Dissecting or cerebral aneurysm;
Bacterial endocarditis;
Pericarditis;
Active peptic or gastrointestinal ulceration;
Severe uncontrolled or malignant hypertension;
Severe head trauma;
Pregnancy (warfarin contraindication);
Heparin-induced thrombocytopenia (heparin, LMWH); and
Epidural catheter placement.