Long-term thromboprophylaxis in practice: How can it be implemented?

Prolonging thromboprophylaxis after hospital discharge following surgery re duces the incidence of venographic and symptomatic venous thromboembolism ( VTE), although the effects on post-thrombotic syndrome are not yet clear. O ral anticoagulants and low-molecular-weight heparins (LMWHs) may be used fo r extended outpatient therapy, but oral anticoagulants require frequent lab oratory monitoring and may cause major gastrointestinal bleeding. Conversel y, LMWHs are effective and safe at a fixed, once-daily dosage without monit oring. Four studies have shown that extended prophylaxis with LMWHs signifi cantly reduces the incidence of post-discharge VTE following total hip repl acement. However, the need for subcutaneous injection potentially limits ho me use of LMWHs outside clinical trials because the amount of drug administ ered may vary between injections if patients self-inject, while administrat ion by nurses would be too costly. An auto-injection device is now availabl e for administering the LMWH enoxaparin. The device is simple to use and de livers a precise pre-determined dose. During studies with such devices, vol unteers successfully performed mock injections and patients with indication s for thromboprophylaxis showed high levels of acceptance with administrati on for up to 3 weeks. Ongoing studies are assessing longer periods of self- administration.