Venous Thromboembolism (VTE) prophylaxis guidelines for patients with chronic liver disease.

• Summary of Guideline
• Aims
• Background
• Treatment/Management

Summary of Guideline

 A venous thromboembolism (VTE) risk reduction guideline for patients with chronic liver disease    (CLD).

Produced and developed in response to a divisional clinical governance meeting request in 2013.

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Aims

Reduce the risk of venous thromboembolism (VTE) in patients with chronic liver disease (CLD).

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Background

The basic principle underlying this guideline is that cirrhosis and decompensated liver disease represents a highly prothrombotic state. However, it is widely recognised that prolonged prothrombin time/INR and thrombocytopenia are both frequent findings in this group of patients, which might be assumed to be protective, but actually are not. These patients are at risk of variceal bleeding, and potentially of falls if encephalopathic.

Whilst thrombotic episodes occur at a higher rate in this population compared to the general population, evidence on where risk of VTE prophylaxis outweighs risk of thrombosis at varying levels of coagulopathy and thrombocytopenia, is scarce.

Platelet counts are often low in cirrhosis due to portal hypertension and "pooling" in the spleen. Platelet function may be normal, and platelet mobilisation may be possible in the event of bleeding.

The British Society of Gastroenterology (BSG) and British Association for the Study of the Liver (BASL) have developed and published a decompensated cirrhosis care bundle which includes VTE prophylaxis. This document recommends prescribing prophylactic Low Molecular Weight Heparin (LMWH) as VTE prophylaxis, noting that patients with liver disease are at a high risk of thromboembolism even with a prolonged prothrombin time. They only advise withholding if the patient is actively bleeding or platelets are less than 50.

VTE Risk Assessment
A risk assessment should be completed for all inpatients as soon as possible after admission or by the time of first consultant review and always within 24 hours of admission. Re-risk assessment should be done 24 - 48 hours post admission, at the time of consultant review and whenever the clinical situation changes.

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Treatment/Management

These guidelines have therefore been reached by consensus by the guideline authors. Recommendations are as follows:

1. All patients should be considered for VTE prophylaxis with LMWH unless there is evidence of active bleeding. In the setting of active bleeding, the use of VTE prophylaxis may be withheld until bleeding is satisfactorily controlled.
2. Anti-embolism stockings can be used in addition to LMWH, or without if there is a contra-indication, and details regarding assessment of patients for these can be found on http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2435
3. We advise that using VTE prophylaxis with LMWH is safe in patients with platelet counts of 50 and higher and INR of 2.5 or lower.
4. This does not preclude the use of VTE prophylaxis with LMWH in patients in patients with parameters outside these limits, but it is reasonable to consider these patients the following day in discussion with a consultant within 24 hours of admission if admitted out of hours. The VTE risk assessment should be completed on admission, because level of mobility and additional factors should be considered in decision making.
5. Patients for VTE prophylaxis with LMWH should be prescribed enoxaparin. Please refer to dosing charts detailed below as this depends on renal function and weight.

     Enoxaparin Dosing for patients with creatinine clearance (CrCl) over 30mL/min

     Enoxaparin Dosing for patients with creatinine clearance (CrCl) less than 30mL/min

Note enoxaparin dosing in renal impairment is based on Creatinine Clearance not eGFR. Creatinine clearance should be calculated for elderly patients (age over 75), patients with eGFR < 30mL/min/1.73m2 and for patients with low body weight (less than 60kg). A calculator can be found at: link

VTE prophylaxis medication should be omitted the day prior to invasive procedures such as:

• Angiography, including Transarterial chemoembolization (TACE)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Transjugular liver biopsy (TJLB)
• Transjugular intrahepatic portosystemic shunt (TIPSS)
• Liver biopsy

As long as there is no sign of post-procedure bleeding, VTE prophylaxis can commence
24 hours after the procedure if the patient remains in hospital.

It is not necessary to omit VTE prophylaxis ahead of procedures such as diagnostic upper GI endoscopy, endoscopy for variceal endotherapy, diagnostic colonoscopy. Please refer to endoscopy guidelines if in doubt.

Patients with compensated chronic liver disease admitted electively for what is anticipated to be an uncomplicated procedure in the above cohort group, requiring an admission for under 48hrs can be considered exempt from VTE risk assessment. However, if they are an inpatient at 48hrs a VTE risk assessment should be completed.

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