WHEN IT COMES to VTE prophylaxis, the traditional therapy—heparin or LMWH—presents physicians with some challenges.
Researchers, for example, are warning of a looming shortage of heparin due to an illness that is decimating the world’s pig population. (Heparin is made from pig intestines.) That has left hospitals around the country wondering what they’re going to turn to for inpatient anticoagulation.
Hospitalist Ebrahim Barkoudah, MD, MPH, associate director of Brigham Health Hospital Medicine Unit at Boston’s Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School, says the acute effects of the heparin shortage have not affected patients negatively because of the hospital’s efforts to change practices and educate providers’ about other therapeutic alternatives. Some of those strategies, he adds, can help both conserve heparin and improve patient care.
Getting patients up and out of bed sooner rather than later, for example, isn’t only good medicine, but it can potentially reduce the amount of heparin those patients need. “The first recommendation we usually tell our providers on the front lines is to make sure they mobilize their patients when safe,” Dr. Barkoudah says.
Read our related article: How to use DOACs in extended VTE prophylaxis without raising bleeding risk.
And regularly evaluating patients to make sure that they still need heparin is likewise good for patients and for heparin conservation. “If we see patients are ambulating and they’re not at high risk any longer, continuing a decision that was made on historic data might not be the best approach,” Dr. Barkoudah says. “If we can ambulate our patients safely between admission and discharge, we may need to revisit VTE risk using one of the stratification tools.”
“We can be saving medications that could be used for high-risk patients.”
~ Ebrahim Barkoudah, MD, MPH
Brigham and Women’s Hospital
Dr. Barkoudah also says that getting patients’ preferences in terms of anticoagulation is important. By having one-on-one conversations about anticoagulation strategies (think heparin vs. direct oral anticoagulants, for example), physicians can bring patients into the decision-making process. “This is a discussion with our patients to talk about how they would like to be part of the plan,” he explains.
Dr. Barkoudah is quick to point out that these strategies are at the heart of good patient care. “Our providers need to make sure they’re doing what’s best for the patient,” he notes. “We can also be saving medications that could be used for high-risk patients. This is a call for educating everyone on risk parameters and decision-making”.
Because heparin must be injected, patients sometimes have strong preferences about anticoagulation. Geno Merli, MD, associate chief medical officer of Thomas Jefferson University Hospitals in Philadelphia, says that his health system recently saw evidence of that patient preference for injectable medication such as heparin or LMWH was an issue.
Jefferson found that over a two-week period, there was a significant number of hospitalized medically ill patients refusing to receive injections of heparin or LMWH. Think of patients awakened in the middle of the night who were asked if they were ready for their shot of heparin or LMWH.
According to Dr. Merli, the looming shortage of heparin combined with patient attitudes about injections may lead hospitalists to embrace oral alternatives. “I think we’ll see a major change in the oral use of DOACs, specifically rivaroxaban, in the inpatient setting,” he says.