Thromboprophylaxis Strategies in Acute Medically Ill Patients

Abstract

We review pivotal clinical trials of extended-duration venous thromboembolism (VTE) prophylaxis strategies in acute medically ill patients. For VTE prophylaxis in medically ill patients, current guidelines recommend the use of parenteral anticoagulants during hospitalization but not for extended duration prophylaxis. In 2017, betrixaban was approved for VTE prophylaxis in acute medically ill patients based on the results of the APEX trial. The MARINER trial missed its primary endpoint of reducing the composite of symptomatic VTE and VTE-related mortality with rivaroxaban compared with placebo. It did show that rivaroxaban halved the symptomatic VTE rate compared with placebo and did achieve its secondary endpoint. The EXCLAIM, ADOPT, and MAGELLAN trials did not demonstrate a net clinical benefit in reduction of VTE events due to an increase in bleeding events. The risk of VTE remains high in acute medically ill patients after hospital discharge. Based on the results of the APEX trial which showed a reduction in VTE, the FDA approved betrixaban for use in acute medically ill patients for extended duration VTE prophylaxis. Next steps are to implement the findings from APEX and MARINER into clinical practice to reduce recurrent VTE, lower healthcare cost, and reduce rehospitalization.