DVT Prophylaxis Recommendations

Risk Stratification

The American College of Chest Physicians recommends pharmacologic prophylaxis with LMWH, low-dose unfractionated heparin, or fondaparinux for hospitalized medical patients at increased risk of thrombosis throughout hospitalization 1
High-risk medical patients requiring prophylaxis include acutely ill hospitalized patients with reduced mobility, patients with active malignancy, and those with a history of prior VTE 2, 1, 3
Patients with cancer hospitalized with neutropenia and presumed infection are also at high risk 5

The American College of Chest Physicians recommends LMWH (enoxaparin 40 mg subcutaneously once daily) as a first-line agent for pharmacologic prophylaxis 2, 1
Unfractionated heparin (5000 units subcutaneously twice or three times daily) and fondaparinux (2.5 mg subcutaneously once daily) are also recommended as first-line agents 2, 1
The choice between these agents should be based on once-daily versus multiple daily dosing convenience, renal function, and local formulary costs, as efficacy is equivalent 2

For patients with renal impairment, fondaparinux should be reduced to 1.5 mg once daily if creatinine clearance is 30-50 mL/min 2
Enoxaparin should be reduced to 30 mg once daily if creatinine clearance is <30 mL/min 4

For patients weighing >150 kg, consider increasing enoxaparin to 40 mg subcutaneously every 12 hours 4

The American College of Chest Physicians recommends continuing pharmacologic prophylaxis for 7-10 days postoperatively for most surgical patients 2, 4
Extended prophylaxis (4 weeks total) is strongly recommended for major abdominal or pelvic surgery, hip fracture surgery, cancer surgery patients, and patients with restricted mobility, obesity, or history of VTE 2, 3, 4, 5

For patients actively bleeding or at high risk for major bleeding, use mechanical prophylaxis only, such as graduated compression stockings or intermittent pneumatic compression devices 1, 2
Do not use anticoagulant prophylaxis in patients with high bleeding risk 1

The American Society of Clinical Oncology recommends primary prophylaxis for ambulatory cancer patients with locally advanced or metastatic pancreatic cancer receiving chemotherapy, patients with Khorana score ≥2 receiving systemic therapy, and myeloma patients on immunomodulatory drugs with steroids 3, 1
Do not use routine prophylaxis for lung cancer patients (outside clinical trials) or patients with indwelling central venous catheters 3, 1

Active bleeding, severe thrombocytopenia (platelet count <50,000/μL), active intracranial bleeding in CNS malignancy patients, and recent neurosurgery are absolute contraindications to pharmacologic prophylaxis 1, 6
Epidural or spinal hematomas may occur with anticoagulation and neuraxial procedures, potentially causing permanent paralysis 6