The case for extended thromboprophylaxis in medically hospitalised patients - not yet made.

Abstract

The role of extended thromboprophylaxis is established for surgical patients, but not yet for hospitalised medical patients. This systematic review and meta-analysis sought to explore the role of extended thromboprophylaxis for medically ill hospitalised patients. Medline, EMBASE and Cochrane Libraries were searched and five randomised controlled trials were identified, comprising 20,046 extended and 20,078 standard duration thromboprophylaxis patients. Allocation to extended treatment, compared with standard duration therapy, significantly reduced the risk of symptomatic deep vein thrombosis (relative risk (RR) 0.47, 95% confidence interval (CI) 0.29-0.78, P = 0.003) and non-fatal pulmonary embolism (RR 0.59, 95% CI 0.39-0.91, P = 0.02). The risk of venous thromboembolism-related death was comparable between the extended and standard duration treatment groups (RR 0.81, 95% CI 0.6-1.09, P = 0.16). Extended treatment also doubled the risk of major bleeding (RR 2.04, 95% CI 1.42-2.91, P < 0.001), without significantly affecting the risk of intracranial bleeding or bleeding-associated death. The cost of preventing one symptomatic deep vein thrombosis and non-fatal pulmonary embolism was found to be £24,972 (€27,969) and £45,148 (€50,566), respectively, which outweigh the direct cost of managing established venous thromboembolism as previously reported. Extended duration thromboprophylaxis caused a reduction in the risk of venous thromboembolic events, but also a numerically comparable increase in major bleeding. Further trials are required in high-risk subpopulations who may derive mortality benefits from treatment. Only then could a change in current policy and practice be supported.