Can extended anticoagulation prophylaxis after discharge prevent thromboembolism?
A meta-analysis confirmed the benefit of thromboprophylaxis with a direct oral anticoagulant for high-risk nonsurgical patients after hospital discharge.
PRACTICE CHANGER
Treat seriously ill patients with a
STRENGTH OF RECOMMENDATION
A: Meta-analysis of randomized clinical trials1
Bhalla V, Lamping OF, Abdel-Latif A, et al. Contemporary meta-analysis of extended direct-acting oral anticoagulant thromboprophylaxis to prevent venous thromboembolism. Am J Med. 2020;133:1074-1081.e8. doi: 10.1016/j.amjmed.2020.01.037
WHAT’S NEW
Mortality and morbidity benefit with small bleeding risk
Based on this study, for every 300 high-risk patients hospitalized with nonsurgical diagnoses who are given 6 weeks of DOAC prophylaxis, there will be 2 fewer cases of VTE and VTE-related death. In this same group of patients, there will be approximately 1 major bleeding event and 3 less serious bleeds.
Patients with preexisting medical conditions such as congestive heart failure, cancer, and sepsis and those admitted to an intensive care unit are at increased risk for DVT after discharge.5 Extending DOAC prophylaxis in nonsurgical patients with serious medical conditions for 6 weeks after discharge reduces the risk of VTE or VTE-related death by 0.7% compared with placebo. Treatment in this population does incur a small increased risk of major bleeding by 0.3% in the DOAC group compared with placebo.
CAVEATS
Results cannot be generalized to all patient populations
Many high-risk patients have chronic kidney disease, and because DOACs (including apixaban, rivaroxaban, and dabigatran) are renally cleared, there are limited data to establish their safety in patients with creatinine clearance ≤ 30 mL/min. Benefits seen with DOACs cannot be extrapolated to other anticoagulation agents, including warfarin or LMWH.
In accordance with new guidelines, some of the patients in this study would now receive antiplatelet therapy, eg, poststroke patients, cancer patients, and—with the ease of DOAC use—patients with atrial fibrillation. If these patients were excluded, it is not known whether the benefit would remain. Patients included in these trials were at particularly high risk for VTE, and the benefits seen in this study cannot be generalized to a patient population with fewer VTE risk factors.
CHALLENGES TO IMPLEMENTATION
High cost and lack of updated guidelines may limit DOAC thromboprophylaxis
Cost is a concern. All the new DOACs are expensive; for example, rivaroxaban costs a little less than $500 per month.6 Obtaining insurance coverage for a novel indication may be challenging. The American Society of Hematology and others have not yet endorsed extended posthospital thromboprophylaxis in nonsurgical patients, although the use of DOACs has expanded since the last guideline revisions.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
