Venous Thromboembolism

Question 1

Which pharmacological prophylaxis is used for patients undergoing general or orthopaedic surgery?

Answer 1

A low molecular weight heparin

Heparin (unfractionated) is preferred in patients with renal impairment

• Usually continue for at least 7 days post-surgery

Question 2

Which pharmacological prophylaxis should be considered in patients undergoing abdominal, bariatric, thoracic or cardiac surgery, or patients with lower limb immobilisation or fragility fractures of the pelvis, hip or proximal femur?

Answer 2

Fondaparinux sodium

Question 3

How long should the pharmacological prophylaxis be extended to after a major cancer surgery in the abdomen?

Answer 3

28 days

Question 4

How long should the pharmacological prophylaxis be extended to after spinal surgery?

Answer 4

30 days

Question 5

Patients undergoing an elective HIP replacement should be given which thromboprophylaxis?

Answer 5

Low molecular weight heparin administered for 10 days followed by low-dose aspirin for a further 28 days

OR

Low molecular weight heparin administered for 28 days in combination with anti-embolism stockings until discharge

OR

Rivaroxaban.

Question 6

Patients undergoing an elective KNEE replacement should be given which thromboprophylaxis?

Answer 6

Low-dose aspirin for 14 days

OR

Low molecular weight heparin administered for 14 days in combination with anti-embolism stockings until discharge

OR

Rivaroxaban

Question 7

What VTE prophylaxis should be given in acutely ill medical patients who are at high risk of VTE?

Answer 7

1st line:
- low molecular weight heparin

alt:
- fondaparinux sodium

for a minimum of 7 days

Question 8

What VTE prophylaxis should be given in acutely ill medical patients who are at high risk of VTE and who have renal impairment?

Answer 8

• low molecular weight heparin

OR

• heparin (unfractionated)

Question 9

When starting thrombolytic treatment what baseline blood tests need to be ordered? (5)

Answer 9

Full blood count

Renal function

Hepatic function

Prothrombin time

Activated partial thromboplastin time

Question 10

Which pharmacological treatment should be offered for a patient with confirmed proximal DVT or PE?

Answer 10

• Apixaban

OR

• Rivaroxaban

Question 11

If apixaban or rivaroxaban are unsuitable in patients with confirmed proximal DVT or PE, which alternatives can be given?

Answer 11

Low molecular weight heparin for at least 5 days, then dabigatran etexilate OR edoxaban

OR

LMWH given with vitamin K antagonist for at least 5 days or until the INR is at least 2.0 for 2 consecutive readings, then a vitamin K antagonist on its own

Question 12

When can the use of heparin (unfractionated) with a vitamin K to treat a confirmed proximal DVT or PE be used, which is not normally recommended?

Answer 12

If the patient has renal impairment, established renal failure, or an increased risk of bleeding

Question 13

For renally impaired patients, (estimate creatinine clearance between 15-50 ml/min) with a confirmed proximal DVT or PE, what are the options for drug management?

Answer 13

Apixaban

OR

Rivaroxaban

OR

LMWH for at least 5 days, followed by either dabigatran etexilate or edoxaban

OR

LWMH or heparin unfractionated, given concurrently with a vitamin K antagonist for at least 5 days or until the INR is at least 2.0 for 2 consecutive readings, followed by a vitamin K antagonist on its own

Question 14

How long should patients be offered anticoagulation treatment after a confirmed DVT or PE?

Answer 14

3 months

Question 15

How long should patients be offered anticoagulation treatment after a confirmed DVT or PE if they have active cancer?

Answer 15

3-6 months

Question 16

How often should patients on long-term anticoagulants or aspirin treatment be reviewed?

Answer 16

At least once a year for:

• general health
• risk of VTE recurrence
• bleeding risk
• treatment preferences

Question 17

VTE treatment in pregnancy: if VTE is suspected, what should be started immediately?

Answer 17

LWMH until VTE has been excluded. Continue if patient is confirmed with DVT and PE

Question 18

In pregnant women who are at high risk of haemorrhage and in whom continued heparin treatment is essential, what should they be treated with?

Answer 18

Heparin (unfractionated) until the risk factors for haemorrhage have resolved