HIGH RISK>
VTE prophylaxis: Following hip or knee replacement surgery, abdominal surgery, or in medical patients with severely restricted mobility during acute illness who are at risk for thromboembolic complications. Note: Patients at risk of thromboembolic complications who undergo abdominal surgery include those with one or more of the following risk factors: age >40 years, obesity, general anesthesia lasting >30 minutes, malignancy, history of DVT or PE.
General:
Hospitalized medical patients with acute illness at moderate and high risk for VTE (including patients with active cancer):SubQ: 40 mg once daily; continue for length of hospital stay or until patient is fully ambulatory and risk of VTE has diminished (ACCP [Kahn 2012]; ASCO [Lyman 2013]; ASCO [Lyman 2015]). Note: Extended prophylaxis beyond acute hospital stay is not routinely recommended (ACCP [Kahn 2012]; Sharma 2012).
=> MULTIPLE risk= 40 BID possible.
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=> BMI >40 = Dose up to 30%
VTE prophylaxis: Note: The following recommendations may be applied to all indications for VTE prophylaxis except Bariatric Surgery, which already states specific dosing based on BMI and Pregnancy, which requires individualized dosing based on thromboembolic risk.
VTE prophylaxis: Following hip or knee replacement surgery, abdominal surgery, or in medical patients with severely restricted mobility during acute illness who are at risk for thromboembolic complications. Note: Patients at risk of thromboembolic complications who undergo abdominal surgery include those with one or more of the following risk factors: age >40 years, obesity, general anesthesia lasting >30 minutes, malignancy, history of DVT or PE.
General:
Hospitalized medical patients with acute illness at moderate and high risk for VTE (including patients with active cancer):SubQ: 40 mg once daily; continue for length of hospital stay or until patient is fully ambulatory and risk of VTE has diminished (ACCP [Kahn 2012]; ASCO [Lyman 2013]; ASCO [Lyman 2015]). Note: Extended prophylaxis beyond acute hospital stay is not routinely recommended (ACCP [Kahn 2012]; Sharma 2012).
=> MULTIPLE risk= 40 BID possible.
--------------------------------------------------------------------------------------------------------------------------
=> BMI >40 = Dose up to 30%
VTE prophylaxis: Note: The following recommendations may be applied to all indications for VTE prophylaxis except Bariatric Surgery, which already states specific dosing based on BMI and Pregnancy, which requires individualized dosing based on thromboembolic risk.
BMI 30 to 39 kg/m2: Use standard prophylaxis dosing.
BMI ≥40 kg/m2: Increase standard prophylaxis dose by 30% (Nutescu 2009); however, the ideal dose is unknown.
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VTE prophylaxis: Note: For patients assessed to be at the highest risk (eg, Caprini score >8, stroke, active cancer, multiple risk factors), many experts combine pharmacologic methods with mechanical methods or increase the dose frequency to twice daily (eg, 30 or 40 mg twice daily). Increasing the dose should always be balanced against the risk of bleeding (Malhotra 2018; Pai 2018a; Pai 2018b).
Bariatric surgery, high VTE risk (off-label use): Note: Optimal dosing strategies have not been established. Dosing regimens based on best available evidence (Birkmeyer 2012; Borkgren-Okonek 2008; Scholten 2002).
BMI ≤50 kg/m2: SubQ: 40 mg every 12 hours initiated at least 2 hours before surgery
BMI >50 kg/m2: SubQ: 60 mg every 12 hours initiated at least 2 hours before surgery
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