Choosing the appropriate antithrombotic agent for the prevention and treatment of VTE: a case-based approach.
OBJECTIVE
To review the risk of venous thromboembolism (VTE) in various patient populations and evaluate the agents available for the prevention and treatment of VTE using a case-based approach.


METHODS
A MEDLINE search (1995-July 2006) was conducted to identify relevant literature. Additional references were reviewed from selected articles.


METHODS
Articles related to the prevention of VTE in orthopedic surgery, general surgery, and medically ill patients, as well as the treatment of VTE, were reviewed.


RESULTS
Pharmacologic options for the prevention and treatment of VTE include warfarin, unfractionated heparin (UFH), low-molecular-weight heparins (LMWH), and fondaparinux. Current guidelines support the use of warfarin, LMWH, or fondaparinux for VTE prophylaxis following lower limb major orthopedic surgery. For VTE prophylaxis in hospitalized medical patients or patients undergoing general surgery, use of UFH and LMWH is supported; however, recent data on fondaparinux suggest that it is also effective in these patient populations. The use of UFH or LMWH (both in conjunction with warfarin) for treatment of acute deep venous thrombosis or nonmassive pulmonary embolism is recommended. Recent data suggest that fondaparinux (in conjunction with warfarin) is also effective for the treatment of VTE. A variety of pharmacokinetic, pharmacodynamic, and pharmacoeconomic factors differentiate each agent for the various indications.


CONCLUSIONS
Currently, a "one-size-fits-all" anticoagulant is not available for treatment of VTE. A variety of patient factors, including type of surgery, medical indication, thrombotic risk factors, bleeding risk, history of heparin-induced thrombocytopenia, and a variety of comorbid conditions can affect the safety, efficacy, and selection of appropriate VTE therapy.
Nutescu
Edith A
EA
Antithrombosis Center, Department of Pharmacy Practice, College of Pharmacy, The University of Illinois at Chicago, Chicago, IL 60612-7230, USA. enutescu@uic.edu
Wittkowsky
Ann K
AK
Dobesh
Paul P
PP
Hawkins
David W
DW
Dager
William E
WE
D000368:Aged; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000188:drug therapy* / Q000517:prevention & control*; D013923:Thromboembolism / Q000188:drug therapy / Q000517:prevention & control; D020246:Venous Thrombosis / Q000188:drug therapy* / Q000517:prevention & control*
D005343:Fibrinolytic Agents