Preventing Venous Thromboembolism in Hospitalized Patients With Cancer

Improving Compliance With Clinical Practice Guidelines

Alexandra Brown

Disclosures

Am J Health Syst Pharm. 2012;69(6):469-481. 

In This Article

Abstract and Introduction

Abstract

Purpose. The use of anticoagulants for the prevention of venous thromboembolism (VTE) in hospitalized medical and surgical oncology patients is discussed.
Summary. Hospitalized patients are often at risk for developing VTE, and risk is increased in patients who have cancer. Moreover, the incidence of VTE appears to be rising in hospitalized cancer patients, who have a 2.2-fold increased risk of mortality with a VTE compared with similar patients without VTE. The literature indicates that these patients are often inadequately anticoagulated, despite strong recommendations for prophylaxis. Although there are few studies that specifically address VTE prophylaxis in cancer patients, there are several large trials that have examined data in cancer subgroups. The trials have directly compared low-molecular-weight heparin (LMWH) with placebo, unfractionated heparin with LMWH, factor Xa inhibitor (fondaparinux) with placebo, and fondaparinux with LMWH. Three important guidelines provide current recommendations for VTE prophylaxis; the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the American College of Chest Physicians (ACCP) recommend unfractionated heparin, LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications. Pharmacists can play an essential role in ensuring that VTE prophylaxis is appropriate for individual patients. Interventions to improve compliance with guidelines are particularly important now due to financial incentives from quality-focused organizations whose mandate is to decrease preventable mortality events in hospitals.
Conclusion. Hospitalized patients with cancer often do not receive appropriate thromboprophylaxis. Guidelines from ASCO, ACCP, and NCCN recommend unfractionated heparin, an LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications to such therapy.

Introduction

An estimated 300,000 people in the United States die each year due to complications from deep vein thrombosis (DVT) or pulmonary embolism (PE), which are collectively referred to by the broader term venous thromboembolism (VTE).[1,2] Deep vein thrombi usually originate in the venous system of calf muscles and often lyse spontaneously, while pulmonary emboli appear to originate in the proximal veins due to trauma or as an extension of a calf vein thrombus.[3] VTE is often asymptomatic. In one prospective study of hospitalized patients, the rate of PE was 1%, but the diagnosis was unsuspected in 70% of patients who died from acute PE.[4] VTE is one of the most common preventable causes of inpatient mortality, making prophylaxis critical in high-risk patients.[5,6] It has been suggested that adequate VTE prophylaxis could prevent as many as 100,000 deaths in the United States each year.[7] Moreover, patients who survive a VTE are at risk for sequelae from the initial event, such as increased bleeding, postthrombotic syndrome, pulmonary hypertension, and recurrent VTE.[8–10] There is a 30% cumulative risk for recurrence, and the economic impact of VTE is significant. The Agency for Healthcare Research and Quality (AHRQ) estimates the incremental inpatient cost to be $10,000 per DVT and $20,000 per PE.[5] Clearly, the prevention of VTE is of major public health importance.

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