Outpatient management of venous thromboembolism

Low molecular weight heparins (LMWHs) have provided the necessary pharmacologic tool to facilitate the outpatient management of selected patients presenting with acute venous thromboembolism. A growing collection of clinical trial results supports the safety and efficacy of this cost-efficient management strategy. However, this approach requires careful patient selection and meticulous care planning. Several randomized multicenter trials have compared a primarily outpatient approach to treating uncomplicated proximal venous thrombosis with a LMWH administered subcutaneously once or twice daily to the inpatient use of unfractionated heparin (UFH). The results have been very encouraging and suggest that the use of subcutaneous LMWH in highly selected, uncomplicated venous thrombosis patients is as safe and effective as intravenous UFH, and that most patients can be treated as outpatient or be discharged early. Irrespective of parenteral anticoagulant approach, warfarin therapy was commenced on day 1 and continued for 3 months. A recent publication by Dedden and colleagues describes a 1-year experience with a pharmacy-managed program for the home treatment of patients presenting with proximal deep vein thrombosis. A plan for coordinated patient care was implemented which included a process for patient referrals, standardized protocol orders, a plan for holding area processing and home healthcare agency follow-up, and subsequent oral anticoagulation management. Results of the program demonstrate a significant healthcare savings (as compared with standard inpatient management) with no significant compromise in patient outcomes. Recently published trials by the Columbus Investigators and Simonneau and colleagues have looked beyond uncomplicated proximal venous thromboembolism to include patients presenting with recurrent venous thrombosis and pulmonary embolism. Results suggest the subcutaneous use of LMWH is as safe and effective as intravenous UFH. Such data begin to lay the scientific foundation for the expanded clinical base of patients who may be candidates for an outpatient management approach. In today's cost-conscience environment, managing the treatment of select venous thromboembolism patients with LMWH(s) and warfarin therapy in an outpatient environment represents an evolving approach that is economically logical, does not compromise patient outcomes, but requires considerable planning to address a myriad of logistical issues.