Management of Venous Thromboembolism: Prophylaxis for Hospitalized and Non-Hospitalized Medical Patients

Publication Date: November 27, 2018
Last Updated: March 14, 2022

Recommendations

Acutely ill medical patients: pharmacological VTE prophylaxis

In acutely ill medical patients, the American Society of Hematology (ASH) guideline panel suggests using UFH, LMWH, or fondaparinux rather than no parenteral anticoagulant. (2, ⊕⊕oo)
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Among these anticoagulants, the panel suggests using LMWH (, ⊕⊕oo)
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  • or fondaparinux
(, ⊕ooo)
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  • rather than UFH.
(2, )
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Remark: These recommendations also apply to patients with stroke who receive VTE prophylaxis.

Critically ill medical patients: pharmacological VTE prophylaxis

In critically ill medical patients, the ASH guideline panel recommends using UFH or LMWH over no UFH or LMWH (1, ⊕⊕⊕o)
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and suggests using LMWH over UFH. (2, ⊕⊕⊕o)
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Acutely or critically ill medical patients: mechanical VTE prophylaxis vs a combination of pharmacological and mechanical or pharmacological VTE prophylaxis alone

In acutely or critically ill medical patients, the ASH guideline panel suggests using pharmacological VTE prophylaxis over mechanical VTE prophylaxis. (2, ⊕ooo)
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In acutely or critically ill medical patients who do not receive pharmacological VTE prophylaxis, the ASH guideline panel suggests using mechanical VTE prophylaxis over no VTE prophylaxis. (2, ⊕⊕⊕o)
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In acutely or critically ill medical patients, the ASH guideline panel suggests pharmacological or mechanical VTE prophylaxis alone over mechanical combined with pharmacological VTE prophylaxis. (2, ⊕ooo)
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In acutely or critically ill medical patients who are receiving mechanical VTE prophylaxis, the ASH guideline panel suggests using pneumatic compression devices or graduated compression stockings for VTE prophylaxis. (2, ⊕ooo)
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DOAC vs LMWH in acutely ill medical patients

In acutely ill hospitalized medical patients, the ASH guideline panel recommends using LMWH over DOACs for VTE prophylaxis. (1, ⊕⊕⊕o)
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In acutely ill hospitalized medical patients, the ASH guideline panel recommends inpatient VTE prophylaxis with LMWH only, rather than inpatient and extended-duration outpatient VTE prophylaxis with DOACs. (1, ⊕⊕⊕o)
Remark: If patients are on a DOAC for other reasons, this recommendation may not apply.
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Extended-duration outpatient prophylaxis vs inpatient-only prophylaxis

In acutely ill medical patients, the ASH guideline panel recommends inpatient over inpatient plus extended-duration outpatient VTE prophylaxis. (1, ⊕⊕⊕o)
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Extended-duration outpatient prophylaxis vs inpatient-only UFH or LMWH

In critically ill medical patients, the ASH guideline panel recommends inpatient over inpatient plus extended-duration outpatient VTE prophylaxis. (1, ⊕⊕⊕o)
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Chronically ill medical patients or nursing home patients

In chronically ill medical patients, including nursing home patients, the ASH guideline panel suggests not using VTE prophylaxis compared with using any VTE prophylaxis. (2, ⊕ooo)
Remark: If a patient’s status changes to acute, other recommendations would apply.
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Medical outpatients with minor provoking risk factors for VTE

In medical outpatients with minor provoking risk factors for VTE (eg, immobility, minor injury, illness, infection), the ASH guideline panel suggests not using VTE prophylaxis. (2, ⊕ooo)
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Long-distance travelers

In long-distance (>4 hours) travelers without risk factors for VTE, the ASH guideline panel suggests not using graduated compression stockings, LMWH, or aspirin for VTE prophylaxis. (2, ⊕ooo)
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In people who are at substantially increased VTE risk (eg, recent surgery, prior history of VTE, postpartum women, active malignancy, or ≥2 risk factors, including combinations of the above with hormone replacement therapy, obesity, or pregnancy), the ASH guideline panel suggests using graduated compression stockings or prophylactic LMWH for long-distance (>4 hours) travel. (2, ⊕ooo)
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In people who are at substantially increased VTE risk (eg, recent surgery, prior history of VTE, postpartum women, active malignancy, or ≥2 risk factors, including combinations of the above with hormone replacement therapy, obesity, or pregnancy), and in whom LMWH or graduated compression stockings is not feasible (eg, resource-constrained setting or aversion to other indicated anticoagulants), the ASH guideline panel suggests using aspirin rather than no VTE prophylaxis. (2, ⊕ooo)
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Recommendation Grading

Disclaimer

Overview

Title

Management of Venous Thromboembolism: Prophylaxis for Hospitalized and Non-Hospitalized Medical Patients

Authoring Organization

Publication Month/Year

November 27, 2018

Last Updated Month/Year

July 6, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about preventing VTE in these groups.

Target Patient Population

Acutely ill and critically ill medical inpatients, people in long-term care facilities, outpatients with minor injuries, and long-distance travelers.

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Long term care

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Prevention

Keywords

Venous Thromboembolism, VTE Prophylaxis

Source Citation

19 September 2018. DOI 10.1182/ bloodadvances.2018022954