Prophylaxis against venous thromboembolism in hospitalized medically ill patients: Update and practical approach

Purpose. Major updates in the medical literature for the prevention of venous thromboembolism (VTE) in medically ill patients are reviewed. A suggested approach for risk assessment is provided along with a brief review of chemical prophylaxis use in special populations of the hospitalized medically ill. Summary. Despite new and updated guidelines, the assessment of risk for both thrombosis and bleeding in medical patients continues to lack valid standardization. Pharmacologic prophylaxis with traditional low-dose anticoagulants remains the cornerstone for preventing thrombotic events in this population, but a recent randomized controlled study questioned the clinical impact of this strategy. Currently, there is no gold standard method for determining patient eligibility for pharmacologic prophylaxis for VTE. A suggested approach is to return to the pivotal studies demonstrating benefit to assist in identifying select at-risk patients. However, many populations were under-represented in these studies, including the morbidly obese, patients with chronic kidney disease requiring hemodialysis, and patients with chronic liver disease. Incorporation of evidence for special populations to augment the original studies is required. Until risk-assessment models become validated, along with outcomes data supporting clinical decision-making using such tools, clinician judgment will likely remain the standard of care. Conclusion. The use of study enrollment criteria and patient demographics, including special population considerations, can provide guidance for risk determination and allow for an evidence-based approach to identifying eligible patients for prophylaxis.