A clinical focus on the use of extended-duration thromboprophylaxis in medically ill patients

This review describes and analyzes literature to provide recommendations for use of extended-duration thromboprophylaxis (EDT) in medically ill patients.

Guidelines recommend pharmacologic thromboprophylaxis for patients at increased thrombosis risk during hospitalization and recommend against extending thromboprophylaxis beyond hospitalization. Despite these recommendations, observational data demonstrate that venous thromboembolism (VTE) risk persists following hospital discharge. A MEDLINE literature search was performed to identify original research evaluating the safety and efficacy of EDT. Eight meta-analyses and 5 randomized controlled trials-each varying in the agents studied (enoxaparin, rivaroxaban, apixaban, and betrixaban)-were selected for inclusion. Collectively, the evaluated data demonstrates that EDT reduces the incidence of VTE at the expense of increasing the risk of major bleeding and without providing mortality reduction. Variations in enrollment criteria, differences in EDT strategies, and uncertainty regarding proper patient selection limit the applicability of EDT in practice. Rivaroxaban and betrixaban gained Food and Drug Administration (FDA) approval on the basis of results of the APEX and MARINER trials and a post hoc analysis of the MAGELLEN trial results. Although a number of agents are FDA approved for use in EDT, clinicians must carefully weigh the risks vs benefits of EDT with these agents until studies demonstrate a more favorable risk-benefit profile.

Evidence to support EDT in medically ill patients is inconclusive and has highlighted the need for an individualized approach. The reviewed evidence supports guideline recommendations from both the American College of Chest Physicians and the American Society of Hematology that recommend against routine use of EDT in the majority of medically ill patients. Future studies are needed to optimize the risk-benefit profile of EDT and to ensure proper patient selection.