Hospital Prophylaxis for Adult Inpatients

DVT Prophylaxis

The American College of Chest Physicians recommends pharmacologic prophylaxis with LMWH, low-dose unfractionated heparin (LDUH), or fondaparinux for acutely ill hospitalized medical patients at increased risk of thrombosis throughout hospitalization 1, 2
Enoxaparin 40 mg subcutaneously once daily is a recommended first-line option for DVT prophylaxis 1, 3
Unfractionated heparin 5000 units subcutaneously every 8 hours is preferred in cancer patients and provides a more consistent anticoagulant effect than twice-daily dosing 1, 2
Dalteparin 5000 IU subcutaneously once daily is an alternative option for DVT prophylaxis 3
Fondaparinux 2.5 mg subcutaneously once daily is also a recommended option for DVT prophylaxis 1, 2, 3

For patients with renal impairment (CrCl <30 mL/min), the American College of Chest Physicians recommends reducing enoxaparin to 30 mg subcutaneously once daily or using unfractionated heparin instead 4, 5
For obese patients (BMI >30 kg/m²), consider enoxaparin 40 mg subcutaneously every 12 hours or weight-based dosing at 0.5 mg/kg every 12 hours 4, 5, 6
For cancer patients, unfractionated heparin 5000 units subcutaneously every 8 hours is the preferred regimen 7, 4

The American College of Chest Physicians recommends continuing DVT prophylaxis until the patient is fully ambulatory or hospital discharge, with a minimum duration of 7-10 days for surgical patients 3, 4, 5
Do not extend prophylaxis beyond the period of immobilization or acute hospital stay for most medical patients, unless the patient has multiple VTE risk factors or elevated D-dimer 1, 2, 5

For patients who are actively bleeding or at high risk for major bleeding, anticoagulant thromboprophylaxis is contraindicated, and mechanical prophylaxis with graduated compression stockings or intermittent pneumatic compression should be used instead 1, 2
When bleeding risk decreases and VTE risk persists, substitute pharmacologic for mechanical prophylaxis 1, 2

Do not administer anticoagulants too close to neuraxial anesthesia due to increased risk of spinal hematoma 4
For surgical patients, enoxaparin should be started 2-4 hours preoperatively or 10-12 hours preoperatively 4
Routine anti-Xa monitoring is not required for prophylactic doses in most patients, but monitor platelet counts every 2-3 days from day 4 to day 14 for patients at risk of heparin-induced thrombocytopenia (HIT) 4, 6