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Options for parenteral venous thromboembolism (VTE) prophylaxis in hospitalized patients with cancer

Options for parenteral venous thromboembolism (VTE) prophylaxis in hospitalized patients with cancer
  Hospitalized medical patients Surgical patients (postoperative dosing*)
Unfractionated heparin
Unfractionated heparin
  • 5000 units once every 8 to 12 hours
  • 5000 units once every 8 to 12 hours beginning 6 to 24 hours postoperatively
Low molecular weight (LMW) heparin
Dalteparin
  • 5000 anti-Xa units once daily
  • 5000 anti-Xa units once daily beginning 12 to 24 hours postoperatively
Enoxaparin
  • 40 mg once daily
  • 40 mg once daily beginning 12 to 24 hours postoperatively
NadroparinΔ
  • ≤70 kg: 3800 anti-Xa units once daily
  • >70 kg: 5700 anti-Xa units once daily
  • Moderate risk of thrombosis (eg, general surgery): 2850 anti-Xa units beginning 12 to 24 hours postoperatively
  • High risk of thrombosis (eg, orthopedic surgery): 38 anti-Xa units/kg (maximum 3800 anti-Xa units) once daily beginning 12 to 24 hours postoperatively; on postoperative day 4 increase to 57 anti-factor Xa units/kg (maximum 5700 anti-Xa units) once daily
TinzaparinΔ
  • 4500 anti-Xa units once daily
  • Moderate risk of thrombosis (eg, general surgery): 3500 anti-Xa units once daily beginning 12 to 24 hours postoperatively
  • High risk of thrombosis (eg, orthopedic surgery): 75 anti-Xa units/kg once daily beginning 12 to 24 hours postoperatively
Fondaparinux
Fondaparinux
  • ≥50 kg: 2.5 mg once daily
  • <50 kg: Avoid use
  • ≥50 kg: 2.5 mg once daily beginning 6 to 8 hours postoperatively or beginning on the morning of the day after surgery
  • <50 kg: Avoid use

These doses apply to VTE prophylaxis (not treatment) and are appropriate for adults with active cancer. Administration is by subcutaneous injection for all agents listed. Dose adjustments may be required for kidney impairment or high body mass index. For dose adjustments, refer to separate tables in UpToDate and UpToDate Lexidrug monographs. Anti-Xa units should be calibrated to the specific product.

For surgical patients, some surgeons will start prophylaxis preoperatively, depending on the specific procedure, bleeding risk, and thrombosis risk. Refer to UpToDate topics on VTE prevention in patients with cancer for further information including suggested duration of thromboprophylaxis and use of parenteral as well as oral anticoagulants.

VTE: venous thromboembolism.

* Preoperative dosing may be appropriate in selected settings provided there is no concern about bleeding with anticoagulation (eg, due to neuraxial anesthesia or spine surgery). Refer to UpToDate for details of anticoagulation management in individuals undergoing neuraxial anesthesia or procedures involving the central nervous system.

¶ The standard unfractionated heparin dosing interval for VTE prophylaxis is once every 8 hours. In low weight patients (eg, <50 kg) standard dosing may result in overexposure and increased anticoagulant effect; consider an interval of once every 12 hour dosing in such patients.

Δ Not available in the United States.
Adapted from: Key NS, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol 2020; 38:496.
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