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Understanding Pharm: VTE Prophylaxis

Please check out our article which provides a general overview of anticoagulation before reading this article!

Thromboprophylaxis based on patient group

Patient groupRecommended therapyDuration of treatment
Major traumaLMWHUntil discharge
Hip OR knee replacementDOAC (to ASA)2 – 5 weeks
General surgery LMWHUntil discharge
Major cancer surgeryLMWHUp to 30 days after discharge
Cancer medical illnessLMWH Until discharge
Acute medical illness LMWHUntil discharge
High bleeding riskBilateral, calf-length TED stockingsUntil bleeding risk allows use of anticoagulant
Credit for table to Alison Bond, PharmD, SunnyBrook Health Sciences Centre

Dosing enoxaparin based on weight

  • Weight < 40 kg OR CrCl < 30 mL/min
    • Enoxaparin 30 mg subcutaneous every night at bedtime
  • Weight 40 – 100 kg
    • Enoxaparin 40 mg subcutaneous every night at bedtime
  • Weight > 100 kg
    • Enoxaparin 40 mg subcutaneous BID
  • Weight > 125 kg
    • Enoxaparin 0.4 mg/kg subcutaneous BID

Thromboprophylactic doses of DOACs

  • Apixaban (BID dosing) (renal + liver)
    • 2.5 mg PO BID
  • Dabigatran (BID dosing) (renally cleared)
    • Avoid with CrCl < 30
    • CrCl 15 to 30 = 75 mg BID
    • CrCl 30 to 50 = between 75 – 110 mg BID
    • CrCl >50 = 110 mg BID
  • Rivaroxaban (once daily dosing) (renal + liver)
    • 10 mg PO once daily